B-2016-2415CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-2415
20727 RODRIGUES AVE CUPERTINO, CA 95014-2964 (359 10 059)
JEREMY MAO INC
SARATOGA, CA 95070
OWNER'S NAME: LI XIAOCHUN AND ZHANG XIN
DATE ISSUED: 02/02/2017
OWNER'S PHONE:
PHONE NO: (408) 449-9942
LICENSED ONT A TOR' DECLARATION
BUILDING PERMIT INFO:
License Class 5 Lic. #813452
Contractor JEREMY MAO INC Date 10/31/2018
X BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MECH X RESIDENTIAL COMMERCL4,L
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
CONSTRUCT (N) 2 STORY SFD (3,791 S.F.); ATTACHED GARAGE
I hereby affirm under penalty of perjury one of the following two declarations:
(412 S.F.); PORCHES/BALCONIES/DECKS (700 S.F.)
1. 1 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
rformance of the work for which this permit is issued.
/2:/I have and will maintain Worker's Compensation Insurance, as provided for by
/Section 3700 ofthe Labor Code, for the performance ofthe work for which this
Sq. Ft Floor Area: 4203
Valuation: $650000.00
' t 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
Deferred Submittal (R -3),R-3 (Custom),R-3 (Custom),U
representatives of this city to enter upon the above mentioned property for
(Private Gar /Ag Bldg),U (Private Gar /Ag Bldg)
inspection purposes. (We) agree to save indemnify and keep harmless the
City of Cupertino against liabilities, judgments, costs, and expenses which
may accrue against said City in consequence of the granting of this permit.
PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally, the applicant understands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Date 2/2/2617
Issued by: Abby A_ ey nde
OWNER -BUILDER DECLARATION
Date: 02/02/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. I, as owner of the property, or my employees with wages as their sole
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
compensation, will do the work, and the structure is not intended or offered for
installed without first obtaining an inspection, I agree to remove all new materials for
sale (Sec.7044, Business & Professions Code)
inspection.
z. I, as owner of the property, am exclusively contracting with licensed
_ contractors to construct the project (Sec.7044, Business & Professions Code).
Signature of Applicant:
Date: 2/2/2017
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code, for the performance of the work for which this
I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
3. I certify that in the performance of the work for which this permit is issued, I
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Air Quality Management District I
exemption, I become subject to the Worker's Compensation provisions of the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Labor Code, I must forthwith comply with such provisions or this permit shall
the Health & Safety Code, Sections 25505, 25533, and 25534.
be deemed revoked.
�'
APPLICANT CERTIFICATION
Owner or authorized agent:
'bate:
I certify that I have read this application and state that the above information is j
CJ
2/2/2017
LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this city
CONSTRUCTION
I hereby affirm that there is a construction lending agency for the performance
to enter upon the above mentioned property for inspection purposes. (We) agree
of work's for which this permit is issued (Sec. 3097, Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Name
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
ARCHITECT'S DECLARATION
Code, Section 9.18.
I understand my plans shall be used as public records.
Signature Date 2/2/2017
Licensed
Professional
NO FEE FOR RECORDING PUI"SUAT"T TO
GOVERNMENT CODE SECTION 27383
When Recorded Mail To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
23640491.20
Regina Aloomendras
Santa Clara County - Clerk -Recorder
10/24/2018 02:24 PM
`ides: I Pages: 3
Fees:10.00
0.00
Taxes: 0
Total:
mill FIANIn kIXA NUTAI NUTUIRI W 11111
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CALIFORNIA ALL- PURPOSE
CERTIFICATE OF
rE'
A notary public or other officer completing this certificate verifies only the identity
of the individual who signed the document to which this certificate is attached,
and not the truthfulness, accuracy, or validity of that document.
State of California }
County of }
On 6W ?3 i M7 before me, 3 LLLf
(Here Insert name and title oft the officer
personally. appeared t ((
who proved to me on the basis of satisfactory evidence to be the person(s)Whose
name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the prson(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I. certify under.PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph.is true and correct.
NOW
y poblic cilbrnt�
WITNESS my hand_ and official seal.
r S,.
Notary blic Signature (Notary Public Seal) .
®®ITI®NAh OPTIONAL INF®RAMN INSTRUCTIONS FOR COMPLETING THIS FORM
This forth complies with current California statutes regarding notary wording and,
DESCRIPTION OF THE ATTACHED DOCUMENT if needed, should be completed and attached to the document. Acknowledgments
.Z from other states may be completed for documents being sent to that state so long
as the wording does not require the California notary to violate California notary
V� law._
(Title or description of a ached document) o State and County information must be the State and County where the document
r7� a signer(s) personally appeared before the notary public for acknowledgment.
e Date of notarization must be the date that the signer(s) personally appeared which
(Title or description of attached do ument continued) must also be the same date the; acknowledgment is completed.
o The notary public must print his or her name as it appears within his or her
Number of Pages --L Document Date commission followed by a comma and then your title (notary public).
o Print the name(s) of document signer(s) who personally appear at the time of
notarization
CAPACITY CLAIMED BY THE SIGNER
k Individual (s)
❑ Corporate Officer
(Title)
❑ Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
2015 Version .No.taryC[asses.com 800-873-9865
a Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
he/she/# ,wy,- is /4e) orcircling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
o The notary seal -impression must be clear and photographically reproducible.
Impression must not cover teat or lines. If seal impression smudges, re -seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
o Signature of the notary public must match the signature on file with the office of
the county clerk.
Additional. information is not required but could help to ensure this
acknowledgment is not misused or attached to a different document.
Indicate title or type of attached document, number of pages and date.
Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the -title (i.e. CEO, CFO, Secretary).
o Securely attach this document to the signed document with a staple.
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document
to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of Y-
On /��� �-� ! before me,
Daae Here Insert Name and Title o 6 h/e Officer
personally appeared ��� ZHA/QG �C' X7 �� CH 14, V � L
Name(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.
certify under PENALTY OF PERJURY under the
YING FANG laws of the State of California that the foregoing
Commission #k 2108187 z paragraph is true and correct.
a Notary Public - California z
Z "° Santa Clara County n WITNESS my hand and official seal.
My Comm. Expires Apr 23, 2019
Signature
Place Notary Seal and/or Stamp Above Signature of Notary Public
OPTIONAL
Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached ®®caamerat
Title or Type of Document: a'�tC_ E �o aa���;� ddle
Document Date: Z 0& q Number of Pages:
Signers) Other Than Named Above:
Capacity(les) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑ Corporate Officer.— Title(s): ❑ Corporate Officer — Title(s):
❑ Partner— ❑ Limited ❑ General ❑ Partner - ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact ❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian of Conservator ❑ Trustee ❑ Guardian of Conservator
❑ Other: ❑ Other:
Signer is Representing: Signer] s; Representing:
02017 National Notary Association
M1304-09 (09/17)
ZZ
NO FEE FOR RECORDING P SUANT TO
GOVERNMENT CODE SECTION 27383
When Recorded MaH To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
WWI
Regina A b oomendras
Santa Clara County - Clerk -Recorder
10/24/2018 02:24 PM.
Titles: I Pages: .3'
Fees: 0.00
Taxes: 0
Total: 10-00
III PrAll WK) WAIVIVII!' 'iX V, 11111
Gian Paolo Martire, Associate
y .�. u � it (� �✓ _ • � � E•� � mJ � S;� � a� c• [ �uJi � i �, ` � � } a � ��
A notary. public or other officer completing this certificate verifies only the identity
of the individual who signed the document to which this certificate is attached,
and not the truthfulness, accuracy, or validity of that document.
State of California }
County of
On ;7-b I before me,
ere insert name an till o t e officer
personally appeared
who proved to me on the basis of satisfactory evidence to be the person(s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signatures) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph is true and correct.
JULIKKINST
NoBaPy, POW � Bi&oPt�6�
WITNESS my hand and official seal.
COMMI"10.
Notary FUblic Signature (Notary Public Seal)
ADDITIONAL OPTIONAL. INFORMATION INSTRUCTIONS FOR COMPLETING THIS FORM
This form complies with current California statutes regarding notary wording and,
DESCRIPTION OF THE ATTACHED DOCUMENT if needed, should be completed and attached to the document. Acknowledgments
-1 , ®S from other states may be completed for documents being sent to that state so long :
} }� +, as the wording does not require the California notary to violate California notary
AX— law.
(Tide or description of attached docu nt) J o' State and County information must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
Date of notarization must be the date that the signer(s) personally appeared which
(Title or description Uf attached document continued) (ti must also be, the same date the acknowledgment is completed.
o The notary public must print his or her name as it appears within his or her
Number of Pages Document Date commission followed by a comma and then your title (notary public).
o Print the name(s) of document signer(s) who personally appear at the time of
notarization.
CAPACITY CLAIMED BY THE SIGNER o Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
�e/she/they- is /are ) or circling the correct forms. Failure to correctly indicate this .
Individual (s) information may lead to rejection of document recording.
❑ Corporate Officer e The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges, re -seal if a
(Title) sufficient area permits, otherwise complete a different acknowledgment form.
❑ Partner(s) o, Signature of the notary public must match the signature on file with the office of
the county clerk.
❑ Attorney -in -Fact o Additional information is not required but could help to ensure this
❑ Trustee(s) acknowledgment is not misused or attached to a different document.
Other Indicate title or type of attached document, number of pages and date.
E-1 Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i.e. CEO, CFO, Secretary),
2015 Version vwvw.N6taryClasses.com 800-873-9865 a Securely attach this document to the signed document with a staple.
CALEFORNEA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document
to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of
On 1�l �� before me, 1��� l�� /���
Date Here Insert Name and Title of the Offkkr
personally appeared x XIAoName(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.
-- DYING FANG
Commission ## 2108187
ge Notary Public - California z
® Santa Clara County D
My Comm. Expires Apr 23; 2019 .
Place Notary Seal and/or Stamp Above
I certify under PENALTY OF PERJURY under the
laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature
Signature of Notary Public
W9_ U owflIMIAL
Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: NO.icc 0 re M9A is
Document Date: (g La f L=Xo d- Number of Pages:
Signer(s) Other Than Named Above:
Capacity(les) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑ Corporate Officer — Title(s): ❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General ❑ Partner —_ E Limited ❑ General
❑ Individual ❑ Attorney in Fact ❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian of Conservator ❑ Trustee ❑ Guardian of Conservator
❑ Other: ❑ Other:
Signer is Representing: Signer is Representing:
02017 National Notary Association
M1304-09 (09/17)