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B-2016-2754CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2754 21543 TERRACE DR CUPERTINO, CA 95014-4741 (356 20 013) CHUEN YANG YANG SAN LEANDRO, CA 94579 OWNER'S NAME: XU WEIZHONG AND NG MIU FUN DATE ISSUED: 09/30/2016 OWNER'S PHONE: 408-771-8339 PHONE NO: (510) 213-9981 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic. #897965 Contractor CHUEN YANG YANG Date 06/30/2017 X BLDG —ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 :(commencing MECH X RESIDENTIAL _ COMMERCIAL _ with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: 1 ST FLOOR ADDITION (362 S.F.) - BEDROOM #3 AND MASTER I hereby affirm under penalty of perjury one of the following two declarations: BEDROOM CLOSET. 1. I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: 362 Valuation: $35000.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances APN Number: Occupancy Type: and state laws relating to building construction, and hereby authorize 356 20 013 R-3 (Custom) representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature,,_ v1,A Date 09/30/2016 Issued by: SEAN HATCH ' Date: 09/30/2016 ONVNER-BUILDERDEC I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1. 1, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for inspection. sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 09/30/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER " s. I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. = HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date: 09/30/2016 certify that I have read this application and state that the above information is CONST TIONLENDIe"GENCY I hereby affirm that there is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ G.). relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal DECLARATION AR e used a I understand my plans sha1ll1 bbe sas public records. Code, Section 9.18. Licensed Signature Date 09/30/2016 professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVIMN '10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPER'T'INO (4:08) 777-3228 • FAX (408) 777-3333 • buildingc4cupertino.orci n 7qt~tu.rn>\1cTRI IrTInTi U AnnrrIfIX1 IF A 1 T n A-11 Rldvff nn 2011 dot- ravhzPd 06121111 PROJECTADDRESS 21543 Terrace Dr, Cupertino, CSA 95014 APN# ' 35620013 OWNER NAME Wa1zhong XU PHONE 408-7718339 E-MAIL willxu@gmail.com STREETADDRESS 21543 Terrace Dr CITY, STATE, ZIP Cupertino, CA 95014 FAX CONTACT NAME WeiZhong Xu PITONE 408-7718339 E-MAIL wilNuCgmail.com STREETADDRESS 21$43 Terrace Dr CITY, STATE, ZIP Cupertino, CA 95014 FFAX © OWNER 11 OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER 13 TENANT CONTRACTOR NAME LICENS UMBER L]CENSE TYPE BUS, LTC # r'1 rail � � i71�'1 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONES'0_213 W f ARCHITECT/ENGINEER NAME Huatang Cut LICENSE NUMBER 078582 BUS. LIC# COMPANYNAME H & H Engineers Group E-MAIL HHEngineersGroup@gMali.com FAX STREET ADDRESS. 4816 Bernal Ave. #A CITY, STATE, ZIP Pleasanton, CA 94566 PHONE 510-5128648 -DESCRIPT{0N{3 WORK- -_`— Addition of 362 sgft, including one bedroom and the master bedroom enlargement. EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES - - Y - I USE TYPE OCC, S(2.FT. VALUATIONEXIST($) L AREA1766 Sf NEW R AREA L00 362 St DEMO AREA 0 TOTAL NETAREA 2128 St �•,� ani/ L,,. BATHROOM KITCHEN OTHER REMODEL AREA - REMODEL AREA REMODELAREA 0 0 a PORCH AREA - DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH - © ATTACH #DWELLING UNITS; ISA SECOND UNIT YES SECONDSTORY FIYES BEINGADDED? ©NO ADDITION? [ONO ` PRE -APPLICATION ©YES IF YES. PROVIDE COPY OF ISTIIEBLDGAN 0YES EIVEABY: TOTAL VALUATION: PLANNINGAPPL# ONO PLANNING APPROVAL LETTER EICIILER HOME? ©NO Ru I *-%Soc)l By my signature below, I certify to each of the following: I am the property owner or authorized agent lo act an tflc property owner's behalf. 1 have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable Iocal ordinances and state laws relating to building construction, I authorize re entatives of Cupertino to enter the above -identified property for inspection purposes. res Signature of Applicant/Agent: Date; — SUPPLEMENTALINFORM 10NREQUIRED PLANCHECKTYPE ROUTING SLIP ❑ OVER-THE-COUNTER ❑ BUILDING PLAN RMEW New SFD or Multifamily dwel. s: Apply for demolition permit for existing building(s), Demolition permit is required prior to issuance of building ,permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project, ll LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWERDISTRICT submittal of Building Permit application. ENVIRQNNIENTAL HEALTH Rldvff nn 2011 dot- ravhzPd 06121111 CAPER ENGINEERING I PO BOX 14198, FREMONT, CA 94539 Tel:(510) 668-1815 Fax: (510) 490-8690 Building Department City of Cupertino 10300 Torre Ave. Cupertino, CA 95014 �l L 16jZj��6 be016 Subject: Remodel and Addition at 21543 Terrace Dr. Cupertino, CA (Permit No. B-2016-2754 SPECIAL INSPECTION SERVICES FINAL AFFIDAVIT FOR DOWELS INSTALLATION WITH EPDXY R Dear Sir: CAPEX ENGINEERING INC', has provided testing and special inspection services at the subject site in accordance with section 1704A of the California Building Code (2013 Edition) as listed below: (1) Inspections of #5 x 6" min. embedment; dowels installation with Simpson Set -XP Epoxy and embedded into existing concrete for connection of new and existing footings at specific locations. (2) All drilled holes for receiving dowels installation were cleaned of dust and: debris and adequate in depth to embed into existing concrete. Personnel under the general supervision of a registered Civil Engineer performed this u inspection. Based on the inspections performed and upon substantiate reports that the inspected work was performed, to the best of our knowledge, in conformance with the approved plans and specifications and the applicable workmanship provisions of the California Building Code. Sincerely, QAPEX ENGINEERING INC., Q�FESS/p ar WS -W, -P - E Principal Site Visit Report #1 Date: December 4, 2016 Project Name: H160702 — Xu Residence Remodel Project Address: 21543 Terrace Dr., Cupertino, CA 9501 Site Visit Date: December 3, 2016 Contractor: Chuen Yang Owner: Weizhong Xu H & H Engineers Group Representative: Huafang Cui, P.E., Purpose of Visit: Observed and inspected the epoxy installai Observation: 1) Observed and inspected two epoxy HDU2 hold dovm installation. The following procedures were observed and inspected during the insta ation: HOLDOWN No. l 2 Blow and Brush x x Check cartridge expiration date: 03/31/17 03/31/17 Fill hole from bottom x x Twist rod into hole x x Depth of embedment (inch) 17.5 15.5 The epoxy installation is in general conformance with m< Sincerely, No. 78582 Eq. 9f3Bf20t7 S, CIVI Huafang Cui, P.E. (C78582) Tel: 510-512-8648 Email: HHen in�group2gmail.com Adress: P.O. BOX 1295, Pleasanton, CA 94566 recommendations.