D-2016-0423CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS:
CONTRACTOR:
PERMIT NO: D-2016-0423
20727 RODRIGUES AVE CUPERTINO, CA 95014-2964 (359 10 059)
M S CONSTRUCTION
SAN JOSE, CA 95129
OWNER'S NAME: LI XIAOCHUN AND ZHANG JGN
DATE ISSUED: 12/07/2016
OWNER'S PHONE: 408-306-5656
PHONE NO: (408) 230-5080
LICENSED CONTRACTOR'S ARATION
BUILDING PERMIT INFO:
License Class $ Lic. #884933
Contractor M S CONSTRUCTION Date 09/30/2018
— BLDG —ELECT _PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
_ _
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
DEMO SFD (2006 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
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.
2. Cl I have and will maintain Worker's Compensation Insurance, as provided for by
JL�f Section 3700 of the Labor Code; for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $15000.00
permit is issued.
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
359 10 059
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 Date 12/07/2016
Issued b
`'
O R -B 1lL D R DECLARATION
Date: 12/07/2016
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed If a roof is
following two reasons:
1. I, 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 ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 12/07/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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.
HAZARDOUS MATERIALS DISCLOSURE
z. 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
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
a. 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 snaking 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: 12/07/2016
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
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 C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 12/07/2016
Professional
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION Li
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building G�ertino.or
CUPERTINO �r � — ; of
l li
PROJECT ADDRESS 3 _
OWNER NAME PHONE E
STREET ADDRESS y� J CITY, STATE, ZIP
Im #/4 4 t4 C�_�vYs�} , FAX
CONTACT NAME �- �/�l i PHONE EMAIL��Z%lZ'-� s�'rl/"' COM
STREET ADDRESS CITY, STATE, ZIP FAX
❑ OWNER ❑. OWNER -BUILDER !!J OWNERAGENT ❑ CONTRAcrop, ❑ coNTRACTORAGENT ❑ ARCHITECT ❑- ENGINEER ❑ DEVELOPER ❑ TENANT
COATR.4GTORN ^1V LICENSE is LICENSE E BUS. LIC#
0 I
COMMPANYN A!r�
E MAII, ri %(iG� i�J� • ��j FAX
STREET ADORES CITY, STATE, ZIP CPi1 8 61
v^2_2
DESCRIPTION OF WORK q
RESIDENTIAL #DWEUING. O [G uSEONLi
'rLOCIRAREA UNITS
COMMERCIAL r s £ z E
FLOOR AREA
TYPE,OF CONSTRUCTION # STORIES.
AQMD JOB NUMBER 1 TOTAL VALUATION:
.µµ 7 'v
By my signature below, I certify to each of the following: I am the -property owner or authorized agent to act on the property owner's behalf. I 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 local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: yp/
SUPPLEMENTAL INFORMATION REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT oFFa[cI USE oxr Y: '
Provide Job Number from Bay Area Air Quality Management District www.baggmd.org @ 415-749-47612.
_ Provide three copies of a site plan showing protection for any trees 10" in diameter or more at 3' above grade.
Provide letter from PG&E (408 -725 -3325) -stating all gas and electric has been disconnected.
�❑ Lr�GE � �
Planning Dept clearance to verify building is not considered an historical landmark. Allow 10 business flays, ` F ,
Provide letter of clea'r'ance of all vermin from a licensed pest control contractor. -
,,,�Vplicv tall t
( call the Public Works Department at 408-777-3104 and schedule a "habitable dwelling" inspection.
x
Provide si esd Deliria Bin and Recyclable Materials form.
Commercial Buildings Only: Provide Fire Dept clearance for fire suppression / alarm system review.
DemoApp 2016.doc revised 03/29/16
Pacific Gas and
Electric Company,.
WE DELIVER ENERGY."
October 24, 2016, 2016
XIN ZHANG
20727 ROMIGUES AVE.
CUPERTINO, CA 95014
RE: 20727 ROMIGUES AVE. CUPERTINO CA. 95014
Order Number: 111721534
To whom it may concern,
The gas meter at the above referenced address has been removed and the gas service
was cut off at main on (08122116).
The electric service & meter at the above referenced address has been disconnected and
removed on (09127116),
Sincerely,
, /f, V� P
Justin Pigg
Project Coordinator l Pacific Gas & Electric Co
DeAnza Divisions 10900 N Blaney Ave. Cupertino, CA 95014
2PY@pc e.com 10ffice: 408.725.2165
M -F 7:OOAM -- 3:30PM
"AVAILABLE BY APPOINTMENT ONLY"
"Safety is a full time job; don't make it apart time practice"
II1I°)E 1 1`1140
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fWIME''D FOR CODE CONA['sI[JANCE
Rena wed l y:! Melhssa Ilw^J&m e
Data: E?/07M
M & G Hauling, Inc.
P. O. Box 1123
San Martin, CA 95046
Regulation 11, Rule 2
Acknowledgement of
Notification and
Payment of Fees
11/2.1/2016
Job No: 4Y233
Invoice No: 3X '14
The Bay Area Air Quality Management District (BAAQMD) acknowledges receipt of your payment and
your Asbestos Removal or Demolition flan described as: Demolition
Site address 20727 Rodrigues Ave.
Ctlpertino, CA 95014
Start Date December 2, 2016
Completion Date December 7, 2016
Removal amounts of friable ACM 0 linear feet 0 square feet 0 cubic feet
Should it become necessary to revise this plan, please do so in the spaces provided below and inunediately
copy the District by fax or by mail.
REGULATION 11-2 REVISION BAAQMD J# 4Y233
REVISION # START DATE COMPLETION DATE
I I I I I
2 I I 1 1
3 I I Il
4 I I I 1
5 I I 1 I
NOTE: Thisfornz is not intended as a verification of either the completeness of'your original notification
or of its compliance with Bt1AQMD .Regulation 11-2. If you have any questions about this
acknowledgment, please call our office at (415) 749-4762.
IIII°°')SII 11140
1I°1e°iilId°iiat2 I1)eiiari ineut1
ttVUUI:�°: UE:) FCU3 CO[A-C&\A:'I[JNU �E
UtevUe ed By:! Melhssa `,James
Date:
COMPLIANCE &
ENFORCEMENT
BAY AREA
.Ai P, QUALITY .
DIVISION
D i s "r is i c r
M & G Hauling, Inc.
P. O. Box 1123
San Martin, CA 95046
Regulation 11, Rule 2
Acknowledgement of
Notification and
Payment of Fees
11/2.1/2016
Job No: 4Y233
Invoice No: 3X '14
The Bay Area Air Quality Management District (BAAQMD) acknowledges receipt of your payment and
your Asbestos Removal or Demolition flan described as: Demolition
Site address 20727 Rodrigues Ave.
Ctlpertino, CA 95014
Start Date December 2, 2016
Completion Date December 7, 2016
Removal amounts of friable ACM 0 linear feet 0 square feet 0 cubic feet
Should it become necessary to revise this plan, please do so in the spaces provided below and inunediately
copy the District by fax or by mail.
REGULATION 11-2 REVISION BAAQMD J# 4Y233
REVISION # START DATE COMPLETION DATE
I I I I I
2 I I 1 1
3 I I Il
4 I I I 1
5 I I 1 I
NOTE: Thisfornz is not intended as a verification of either the completeness of'your original notification
or of its compliance with Bt1AQMD .Regulation 11-2. If you have any questions about this
acknowledgment, please call our office at (415) 749-4762.
IIII°°')SII 11140
1I°1e°iilId°iiat2 I1)eiiari ineut1
ttVUUI:�°: UE:) FCU3 CO[A-C&\A:'I[JNU �E
UtevUe ed By:! Melhssa `,James
Date:
P H T' i
City of Cupertino
Public works Department
tom:
Environmental Programs Division
10300 Torre Ave
Cupertino, CA 95014
E:11Yr: MM6GREEN
Fragraen
(408) 777-3354
Construction and Demolition Recycling Diversion
Requirements and Instructions
Covered proiects, or all construction, demolition and renovation projects that are 3,000 square feet or more
are required to complete a Waste Management Plan for the City of Cupertino demonstrating that 60% of the
material generated is recycled, in compliance with ordinance CMC 16.72.050. At the conclusion of the project
a Construction Recycling Report must be filed with the Public Works Department/Envuarunental Division
showing the tons recycled and disposed by material type, Use tonnage information fionn weight tags provided
by facilities to quantify total estimated waste And percentages for materials. Weight Tags of all material
recycled and disposed must be submitted with the final report in order to receive a Final Building
Inspection.
xovirier
Debris from a project 3,000 square feet or more in Cupertino can be collected and
disposed by using:
Please check all that apply:
am not using a Recology debris bin, however, the project is less than 3,000 sS., e.g, buildings, patios,
sidewalks, driveways.
Cl 1. will use a Recology debris bin.. By Agreement with the City, Recology will prepare my required.
Waste Management Plan & Recycling Report. Contact Recology: (408) 725-4020,
0.. 1 am not using a Recology debris bier. I will provide the following submittals to the City's Public
Works Department, showing that I have recycled at least 60% of all construction demolition material:
Ask for the Construction & Demolition Recycling Packet from the Building Department and
complete the following:
✓ Submit a Construction and Demolition. Waste Management Plan with your briilding perinit
application. No fee for• this plan. Forms are available at the Building/Ptiblic Works counter and onlzire
at ivyvirtctipertbio.org/eiivii•oiiiiteii.tal. Report the tonnage recycled and disposed, by material type.
Recycling facilities inust be selected fi-oni the City's approved list of Req)Ycling Resources.
+� Stibi7iit a Constrtrctioii I?ecycliirg l?elror•t form. J he r'epor't is regtiii-ed before the Building
Department will schedule a fr.nal inspection. The report forin is available cit the Building/Public
ff"orks Counter and airline iyiyiy.cuperfino.orl-LA12 VironnientaL
Signature: _ 1� Date: 1 -l-'Z f 6
Naive: (printed)
Title:
Phone:
Project Addres
This form to remain in the project's ttrr r th
Revised 3/7/12 or:
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tILWIME'D FOR CODE CONA[IEJANCE
Revue ed By:! \46ssa w^ J&i,° e
Date: E?/07M
0ATTLLAE
PESO` CONTROL SERA71CE Sy INC.
Branch 2 Notice to Owner/Tenant for Pesticide Application
Dear Valued Customer:
Front Line,Pest Control Services, Inc. provides pest control management using proven efficient
methods to eliminate, your pest.. problems, quickly.-,We,afe a company that believes in combining
old technology, with new. By keeping.our number of clients Iffilitedi we aro able to offer you
more personalizes( service than our competitors. We challenge you'to find this type of service
elsewhere: Please read.,the following: informationjor your safety:
(3) "State law requires that you be given the following information: CAUTION —
PESTICIDES ARE TOXIC CHEMICALS. Structural Pest Control companies are registered and
regulated by the Structural Pest Control Board, and apply pesticides which are registered and
approved for use::by the California Department of Pesticide Regulation and the Unites States
Environmental Protection. Agency. Registration is granted when the state finds that, based on
existing scientific evidence, Lire are no appreciable risks if proper use conditions are followed
or that the risks are outweighed by the benefits, The degree of risk depends upon the degree of
exposure, so exposure should be minimized."
"lfwAin 24 hours following application you experience symptoms similar to common seasonal
illness comparable to the flu., contact your physician or poison control."
"If within 24 hours following application, you experience headaches, dizziness, nausea; tearing,
coughing, nose or threat irritation or develop shortness of breath, double vision, unusual
drowsiness and weakness or tremors, contact your physician Or poison control operator
immediately."
For further information, contact any of the following.
Front Line Pest Control Services, Inc. (408) 972-2844
Poison Control Center (800) 222-1222
County Health Department (408) 792-5040
County Agricultural Commissioner (408) 918-4600
Structural Pest Control Board (800) 737-8188
95825-3280
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796 unset Glen Dr a� gLY, /CA 95123 �
408-972.-BUGG (284)
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FREWEMED FDR CODE COWI[JANCE
Date: 12/07PH3
CUPERTI:NO
PURPOSE
PROCEDURE GHECKLIST FOR DEMOLITION PERMI`T`S.
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
14300 TORRE AVENUE - CUPERTINO, CA 95314-3255
(408) 777-3228 a FAX (4W) 777-3333 . buildin cuu ertino.ora
The demolition application should be applied for before or at the same time as the new construction
permit application (these are separate permit applications and fees). Plan check fees are due at the
time of the application/plan submittal. The new construction permit will not be issued until the
demolition permit is issued or a letter is provided acknowledging the demolition of any existing
building will not take place prior to the issuance of a demolition permit.
REQUIREMENTS
To obtain a demolition permit in the City of Cupertino, please complete a Demolition permit
a1212lication along with each of the following requirements as it applies to your specific project.
E6. 1. Three (3) copies for (residential) and six (6) copies (commercial) of a Site
(Demolition) plan will be required showing any trees 10 inches in diameter at 3
feel: above grade on the subject property, and what means will be taken to protect
these trees, �.
2. One 1 scaled copy of the Site Demolition Ian to fit on a 8-1/2"x 11" sheet.
3. PG&E must be contacted AS EARLY AS POSSIBLE prior to demolition to
schedule the abandonment. Contact PG&E at (4.08) 725-3325. A letter from
PG&E shall be provided to the City, stating that all gas and electric has been
disconnected. (This step can be time consuming, so it is important to begin the
process immediately)
4. Provide job Number. from Bay Area Air Quality Management District
www.baaQmd.gov @ 415-749-4762.
�✓" 5. Check to see if the building is considered an historical landmark. Obtain clearance
from the Community Development PIanning Department, Allow 10 working
days._
6. Provide a letter of clearance of all vermin from a licensed pest control contractor,
7. Important: Prior to the issuance of the demolition permit, the applicant must call
the Public Works Department at (408) 777-3104 and arrange a "habitable dwelling"
inspection.
f% ^L 8. Debris bin and Recycling sheet: read, sign and date. The sheet will remain in the
project's building permit file for the duration of the project.
!. 9. Prior to issuance of the demolition permit (commercial only), the Fire Department
must review the plans for fire suppression/ alarm systems that shall remain in
service or be modified during Demolition or that shall be replaced with the new
construction.
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DemoProcedure.doc revised 11/1085
Revuewed a yd\46llissa ',James
DatE:P E?WM
TYPICAL SARK MTECTTON
NOT TO scAB
a+oar HMH FNMA
TYPICAL TREE PROTECTION PENCiNG
NOT TO SCALE ..�.w
1. Prior to any construction operations contractor shall construct and maintain, for each prota<rteci tree on a construction site, a protective fencing
which encircles the outer limits of the critical root zone(CRZ) of the tree to protect it droit construction activity. The CRZ is calculated 1.25 feet
times the -diameter of the trunk in.easurM in inches 4.5 feet above the natural grade).
2. All protective fencing shall be in place prior to commencemant of any site work and remain in place rmdl all exterior construction activity at the
site has been completed,
3. Protective fnrrcing shrill be at least six (6) feet high, clearly visible, and shall have a tree protection sign affixed to the fence every twenty (20)
feet in such a manner to be clearly visible and legible to workers on the site at a distance of twenty-five (25) feet. The sign(g) shall read "Tree
Protection Zone Keep our,
4, The owner shall cause the required feacinq and slgnage to be installed and maintained for the duration of the construction.
5. in situations where a protected tree remains is tlro fnsmcdiate area of intended construction and the tree may be in danger of being darnaged by
construction equipment or other activity, the eontractor or subcontractor shall protect the tree with 2'xV lumber encircled Hzth wire or other
means that do not damage the tree. The intent is to protect the trnrk of the free against incidental contact by large construed On equipment.
6. Material Storage: No storage or placcruent of materials intended for use in construction or waste materials accumulated due to cxeavad m or
demoHtion shall be placed within the limits of the critical root zone of any protected tree.
7. Equipment Cleaningll iquid Disposal: No equipment shall be cleaned or other liquids, luolu&ag, without lfruita6on, paint, oil, solvents, asphalt,
concrete; mortar or similnr materials deposited or allowed to flow into the eridoal root zone of a protected taco.
8, nee Attachments: leo signs, wires or other attachments, outer than those of a protective nature, shall be attached to any protected tree,
9. Vehicular Traffic: Mo vehicular andlor construction equipment traffic or parking shall take place within the critical root zone of any protected
tree ollrer thmr on existing Areet pavement.
10. No heavy equipment, fucluding but not limited to trucks, tractors, trailers, bulldozers, excm ators, skid steer tractors, trenchers, compressors,
and hoists, shall be allowed inside the drip -Eine of any protnted tree on any construction site.
11. Grade Changes: No grade changes shall be. allowed within the Iimits of the oritiml root zone of any protected tree unless adequate protective
construction methods are approved in advance in writing by the city,
12.1mpervious PaNing: No paving with aspbatt, woemic or otber impervious materials shall be placed within the Iimits of the critical root zoned
a protected tree, unless expressly pennitted by the public works Dept
13. Root Pruning: All roots two inches or larger in diameter which are exposed as a result of trenching or other excavation shall be cut off square
with a sharp medium tooth save and wverr✓d with natural fiber burlap within two hours of initial exposure.
14, All public sidewalks shall remain open, free and cl esu for public access, unless closure is permitted by the Public Works Depar"ent,
TREE PROTECTION TANQMS
REVISED 5113
CITY OF CUPERTIN
APPRO ui. i u , ur eat DATE: i 6-4
STANDARD DETAILS r'., , ,� —
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