Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
14010002CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7665 PEACH BLOSSOM DR
CONTRACTOR: SCL CONSTRUCTION
PERMIT NO: 14010002
CO.
OWNER'S NAME: WU TONY HSU-YUNG AND LARRISA TSUI M
1664 SAMEDRA ST
DATE ISSUED: 04/14/2014
OWNER'S PHONE: 4082501267
SUNNYVALE, CA 94087
PHONE NO: (408) 497-1556
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
CONSTRUCT A 1390 SQ FT ONE STORY ADDITION;
11,
License Class__ Lie. # 2— Z
INTERIOR REMODEL (836 SQ FT); UPGRADE
Contractor_ L Date_ e-- yo -
ELECTRICALPANEL (200AMPS)
I hereby affirm that I am licensed on r the provisions of Chapter 9
REV #3 - INCREASE AREA OF REMODEL AND INSTALL
(commencing with Section 7000) of Division 3 of the Business & Professions
FIRE SPRINKLERS. ISSUED 8/20/14
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
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
Sq. Ft Floor Area:
Valuation: $170000
performance of the work for which this permit is issued.
1 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
APN Number: 3661 l 147.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION,
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
j
costs, and expenses which may accrue against said City in consequence of the
Issued by: ri/�
��� /_/�� p ��e�
granting of this permit. Additionally, the applicant understands and will comply
��/G�' /�/ Date: G
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
�
RE-ROOFS:
Signature o Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, l agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (See. 7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sce.7044, Business & Professions Code).
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Ifealtb & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
�d
Owner or authorized agent: Date:
permit is issued.
-
1 certify that in the performance of the work for which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. It; after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
l hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address_
I certify, that 1 have read this application and state that the above information is
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 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,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply,
with all non-point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature _ Date
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BF19W #ION7.
10300 TORRE AVENUE • CUPERTINO, CA 950146? �'i _ . D
(408) 777-3228 • FAX (408) 777-3333 • building cuD4d'eii mo. G+
❑ NEW CONSTRUCTION ❑ ADDITION ❑ AL"I FRATIONI / TI I]Q REV1SION / DEFERRED ORIGINTAL PERMIT 4 1,440 -6"")
PROrCrADDRESS /el
APNR
O�✓NER 1 P.14E `? �r p PHO E ©� E-MAIL
STREET ADDRESS 1 CITY, STATE, ZIP FAX
CONTACT NAME � � PHONE
�f
STREET ADDRESS
S""
CITY, STATE, ZIP ' F.• X
h N
❑ OWNER ❑ OR;NER-BU[LDER ❑ OP'NERAGENI' &C67717RACTOR ❑ CON7R.4CTORAGF1,7 ❑ ARCH1yBCT ❑ E:GA'EER ❑ DEVELOPER ❑ TENANT
i n
CONTRACTOR NAM_ '
r
LICENSE NUMBER LICENSE TYPE
BUS. LIC m
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECTIENGINEER MMMT LICENSE NUMBER
BUS. LIC
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIP'T'ION OF WORK
EXISTING USE PROPOSED USE CONSTR TYPE
t STORJ.S
USE
TYPE
OCC. I
SQ.FT.
VALUATION (5)
EXISTG
NEW FLOOR
DEA10
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
RITChEN
OT -TIER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCHAREA
DECK AREA
TOTALDECK/PORCHAREA
GARAGE AREA: DETACH
[]ATTACH
I
mDWELLING UNITS:
ISA SECOND UNIT ❑7'Es SECOND STORY []YES
BEING ADDED? []NO ADDITION? NO
+I
-PRE-A�Lleanov-pYEs—>raEs,�Ro��Ecor�oF _Is.Lx_EstDc.�� S
REOEI _BYE
TOTA VALUATION:
PLAA'N1NG A?PL. ❑NO PL.AN'N`D\1G APPROVAL LETTER EICHLER HOh4E7 ❑f`0WK
By my siatrature 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 cf 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 iin�sp-ection purposes.
SignatureofApp) icant/P.gent: Date: -" '-1 T-
SUPPLENIENTAL INFORMATION REQUIRED
_
r
F.
�OVERTHE COiJhTER ,,,BUIIDIIGPL�1tEiIEVV�
M
' `#
New SFD or Multifamily d.v'ellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
� W
g�
permit for new building.
.
L�1 aPRESS��=� ��
{Tz-,sag""-''i�*x'a�'
1� N! pg
s
_
�IUB
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
s A vrA[iD k
1 zVp�xl.s Y
form if any Hazardous Materials are being used as part of this project.
Approval Letter Meeting Planning to`Y
IRE��*3�r
_ Copy of Planning or with prior
submittal of Building Permit application.
B1d&4pp_M1.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
w
ADDRESS: 7665 Peach Blossom Dr
DATE: 08/20/2014
REVIEWED BY: Sean
APN:
BP#:
"VALUATION: $5,000
YPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY
SFD or Duplex
USE: 7
$0.00
PENTAMATION
1 PERMIT TYPE: 1R3SFDRE
WORK
Revision #3: Increase area of remodel and install firesprinklers.
SCOPE
0.0
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are baser[ on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-05 C/' 7'1 1
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
404 S.
$503.00
Remodel, Other
IREMRESOTH
Suppl. PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -.(2) Reg.
0 OTF0.O
Trs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
0
Work Without Permit? 0 Yes ) No
$0.00
Advanced Planning, Fee:
$0.00
Select a Non -Residential
Building or Structure
E)
Q
Strong Motion Fee:
IBSEISMICR
$0.65
Select an Administrative Item
BI& Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.65
$503.00
TOTAL FEE,.T
$504.65
Revised: 07/10/2014
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7665 PEACH BLOSSOM DR
CONTRACTOR: SCL CONSTRUCTION
PERMIT NO: 14010002
CO.
OWNER'S NAME: WU TONY HSU-YUNG AND LARRISA TSUI M
1664 SAMEDRA ST
DATE ISSUED: 04/14/2014
OWNER'S PHONE: 4082501267
SUNNYVALE, CA 94087
PHONE NO: (408) 497-1556
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL 0
CONSTRUCT A 1390 SQ FT ONE STORY ADDITION;
License Class Lic. #
INTERIOR REMODEL (836 SQ FT); UPGRADE
Contractor `j`P Date w"" �' - %
ELECTRICAL PANEL (200AMPS)
REV # 2 TO REVISE STRUCTURAL SHEARWALL &
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
DECREASE WINDOW SIZE IN FAMILY ROOM AREA -
(commenciog with Section 7000) of Division 3 of the Business & Professions
ISSUED 4/30/14
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
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
Sq. Ft Floor Area:
Valuation: $170000
erformance of the work for which this permit is issued.
I have Ord 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.
APN Number: 3661 1147.00
Occupancy Type:
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF UANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS F INSPECT N.
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. Additionally, the applicant understands and will comply
Yt' Date:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
��-''"- RE -ROOFS:
Signature----Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health Safety ode, echoes 5 5, 25533 and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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 and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
Y
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
` a (4C8) 777-3228 • FAX (408) 777-3333 • buildin cu
CUPERTINQ
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION 1 TI REVISION D
ORIGINAL PERMIT 4
PROJECT ADDRESS
�s
1 ,rL �-
OV✓NER NAME j
PHONEr/� (�I ? G j F� /
E-MAIL
r�'
STREET ADDRESS
CITY, STATE, ZIP FAX
0
�L—
CONTACT NAME �
PHONE ,! „ e � q
`�5�
E-MAIL S L ! /' _h4�L4 �N
[
/
STREET ADDRESS
CITY, STATE, ZI(P
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT L.YCo.NTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICE NUMBER Y
LICENSE TYPE J
BUS. LIC 9
COMPANY NAME
E-MAIL �j� f ����
FAX
l
STREET ADDRESS /rC�
CITY, STATE, ZIP
PHONE 6
/ 7 i
1 7
ARCHITECT/ENGTNEER NAME
LICENSE NUMBER
BUS. LIC d
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK N Z�
61
EXISTING USE
PROPOSED USE CONSTR.
TYPE
1 d STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREATOTAL
DECKJPORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
k DWELLING UNrrS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑YES
BEING ADDED? ❑NO
ADDITION? ❑NG
PRE -APPLICATION ❑l'ES IF YES,PROA'IDE COPY OF
PLATT7NGAPPLB ❑NO PLANNING APPROVAL LET—rER
ISTHE BLDG AN ❑YES
ETCH LER HOME? F-1 NO
RECEI VF�$X%{,��f i'' wa, �,�t�F �;��„��,�'l�,
rayr7
TOTAL VALUATION:
tF�.{
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:
SUPPLEMENTAL INFORMATION REQUIRED
,�t.1r 4aV' �r'✓w�
�,i
�s��i'' <�� �tt',"yr��',°�`�"`
Q� OVER Tf{E CC?Ui� ER'v `�,✓
9'BULLDINGPLA]Y RE IEFV�1 `` �.
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of buildingk
for
y+��tF�/Mrjk;rXirYui���i%� �,f
4 Z'0�. �"V X54 ('r�r`1)il;✓S �� �5�5j,/I%Ed11(11�4i
x"'ltd ,a; ��� ��r/1,���p'�7,i✓��,I�y!,;
�917MtgY%fIf YI.+W �i�� V. �i d� yi',�J 1W; Y,
permit new building.
Bldgs: Provide a completed Hazardous Materials Disclosure❑
�.,. (d F%'. 'NiriR ("✓� d�,"/tt�4�k
„Y:"i $' t„A to m v ��y`
_Commercial
form if any Hazardous Materials are being used as Part of this project.
��xi�l�� hi�ia,'1
�� � � � (�� ,7",r °�� � 7 �
❑r Aa7G��h�> irls���r a� ��i� l �
���.�Pe)✓e'l��rr�,f ������1�„� �, �
`f �» fl"'�,f 1'IR
r �i3;u^t ,,� rt � �drl 9 �
,(`G7
��t, r��1���+�A� �rr
_ Copy of Planning Approval Letter or Meeting with Plahning Prior to
submittal of Building Permit application.
��r�r�„�4{�°(G
"MUS""
g�yd(i�„ar
SUY 4741 �t,/,� ��N� r5 �,�.
Ali '�7,��u'+m 4.�<L,J✓✓ ,,� Yr✓ c,..$,5 'ywrlk'4"�,�
n �^ }' ,%"
f w u 7 px x 1 '.
I.: iTt�� IRONnLEN7 IiEAL71i w l"s "`
BldgApp_201 Ldoc revised 06/21/11
410
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
niclr;ri olr ) Thoco fooc nra hacod an lho nroliminary infnrmalinn nvnilahlo and nro nnly an oclimalo_ rnnlarl lho non/ far nddn'l info_
FEE ITEMS (Fee Resolulion 11-033 Eff 7%L113,�
ADDRESS: 7665 PEACH BLOSSOM DRDATE:
04/30/2014
REVIEWED BY: MELISSA
Plan Check Fee: Hourly Only? 0 Yes Q No
APN: 366 11 047
BP#: 14010002
*VALUATION: $0
*PERMITTYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PME Plan Check:
PENTAMATION 1GENRES
PERMIT TYPE:
WORK
REV # 2 -REVISE STRUCTURAL SHEARWALL TO DECREASE WINDOW SIZE IN FAMILY ROOM
SCOPE
AREA - ISSUED 4/30/14
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
niclr;ri olr ) Thoco fooc nra hacod an lho nroliminary infnrmalinn nvnilahlo and nro nnly an oclimalo_ rnnlarl lho non/ far nddn'l info_
FEE ITEMS (Fee Resolulion 11-033 Eff 7%L113,�
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes Q No
$0.00
1 hours Plan Check, Hourly
$139.00 ISTPLNCx
Suppl. PC Fee: Q Reg. C) OT
0.0
T hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
G
Work Without Permit? 0 Yes Q) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential E)
Building or Structure
i
Strong Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
$0.00
$139.00 TOTAL FEE
$139.00
Revised: 04/01/2014
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7665 PEACH BLOSSOM DR
CONTRACTOR: SCL CONSTRUCTION
PERMIT NO: 14010002
CO.
OWNER'S NAME: WU TONY HSU-YUNG AND LARRISA TSUI M
1664 SAMEDRA ST
DATE ISSUED: 04/14/2014
OWNER'S PHONE: 4082501267
SUNNYVALE, CA 94087
PHONE NO: (408) 497-1556
I LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E]
5 f
CONSTRUCT A 1390 SQ FT ONE STORY ADDITION;
License ClassLic. 4
INTERIOR REMODEL (836 SQ FT); UPGRADE
Gi . y�
ELECTRICAL PANEL (200AMPS)
Contractors Jx SEA t Date
I hereby affirm that I am licensed under the provisions of Chapter 9
REV # 1 - MODIFY FLOOR PLAN IN MASTER BEDROOM
(commencing with Section 7000) of Division 3 of the Business & Professions
TO INCLUDE (N) PATIO DOOR, MODIFY GUEST ROOM TO
Code and that my license is in full force and effect.
MAKE FULL BATH FROM 1/2 BATH & CONVERT & SWAP
1 hereby affirnn under penalty of perjury one of the following two declarations:
HALL CLOSET TO (N) LAUNDRY ROOM - ISSUED 4/15/14
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
Sq. Ft Floor Area:
Valuation: $170000
erformance 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
APN Number: 36611147.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS ALLED INSPECTION.
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. Additionally, the applicant understands and will comply
Date: J
with all non -point source regulations per the Cupertino Municipal Code, Section
9,18
-'R
Signature -- Date_ / "
E -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: _ Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
q►�
Owner or authorized agent: - Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued, 1 shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCTION LENDING .AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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 and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 4
(408) 777-3228 • FAX (408) 777-3333 • building(d),cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI CA REVISION/ DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS
APN H
OWNER NAME
PHONE r
E-MAIL
STREET ADDRESS CITY, STATE, ZIP FAX
`
I 6 14L L
CONTACT NAME`jQe/ / PHONE aO
I%�rlljV 6i1i
c�
STREET ADDRESS STATE, ZI PAX
11OWNER ElOWNER-BUILDER❑ OWNER AGENT ❑ CONTRACTOR 1:1CONTRACTOR AGENT 2r ARCHITECT ❑ ENGB.'EER ❑ DEVELOPER ❑ TENANr
CONTRACTOR NAME { L
(
LICENSE NUMBER /� /� /
`7S
LICENSE TYPE
-r
BUS. LIC 9
COMPANY NAME)
E-MAIL
FAX 0
�� --
STREET ADDRESSCITY
STATE, ZIP L� �q
PHONE
r
/
/
ARCHITECT/ENGTNEERNAME A/ht
LICENSE NUMBER
BUS. LICK
COMPANY NAME
GWd
E-MAILi
FAX
l
li 1 i K Q D%Y1 %6
STREETADDRESS
PHONEArb
O2
X 'r;6).._ K)
DESCRIPTION OF WORK �,✓� ® i
W - " i1
'! /
M
XISTIN USE
P S C N TYPE
4 STORIES
USE TYPE OCC.
SQ.FT.
VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODELAREA
REMODEL AREA
REMODELAREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: LJDETACH
[]ATTACH
k' DWELLING UMTS:
IS A SECOND UNIT [] YES
SECOND STORY ❑ YES
BEING ADDED? ❑NO
ADDITION? []NO
PRE -APPLICATION ❑l'ES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑YES , ;� f �l �F r
TOTAL VALUATION:
PLANNING APPL NO PLANNING APPROVAL LETTER
❑
EICHLER HOME? ❑
By my signature below, I certify to each of the following: I am the property own or authorized agent to acton t roperty 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 i ccurate. 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 purposes.
%for
riinspection
Signature ofApplicant/Agent: Date:
SUPPLEMENTAL rNIFORMATION. REQUIRED
�' "/`%r ✓�FyE �l'rhtr )� Ia"
QVER�TI�E-CO�L�Y4TER�j��o-�yr 5���
�`" �'�l"�ur'��r" +r;°t'i �,r` �3,'-=`
iF ! roi�i�ILDIIyG R;;,V1EV�y,�n,�� � �W�y ,i'r,,
New SFD or Multifamily dwellings: Apply for demolition pen -nit for
existing building(s). Demolition permit is required prior to issuance of building
a��
LAN
permit for new building.
❑ a ESsu x°��i�t",)r�x+
vI°7''G%�� r� r;
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
x�) �s)✓r� �e 1�§ly tifi,��
t a)1 rtn +
��+��itr r, tt� �"
; rrt rg �Jw it r r4,yr.
form if any Hazardous Materials are being used as part of this project.
Pry rttr
1 �Mf�y�9P Vaa �f�pr�m'"ShYfZM
_ Copy of Planning Approval Letter or Meeting with Planning prior to
id �I.1'JyW�,iry'"
7r4P�yId ilr
QPM
a f+ Z��b
submittal of Building Permit application.
;r� x�aR"iy,(iMpz "��t}�4rG>�y"�mt��
IrR�izlr�(,
BldgApp_2011.doc revised 06/21/11
2W
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
2665 PEACH BLOSSOM DR
DATE: 04/14/2014
REVIEWED BY: MELISSA
ImADDRESS:
I APN: 36611147
BP#: 14010002
'VALUATION: Iso
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 GENRES
PERMIT TYPE:
WORK
REV # 1 -MODIFY FLOOR PLAN IN MASTER BEDROOM TO INCLUDE N PATIO DOOR MODIFY
SCOPE
GUEST ROOM TO MAKE FULL BATH FROM 1/2 BATH & CONVERT HALL CLOSET TO (N) 13
NOTE: This estimate does not includefees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Mclrint oln 1 Thoco fooc aro hncod nn tho nroliminnnr infnrmnlinn nvnilnhln and am nnhr an nclimnln Cnntnrt thn Mmf far addn'1 infn_
FEE ITEMS (Fee Resolution I1-053 Fff 7,11/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly
Only? () Yes Q No
$0.00
2 hours Plan Check, Hourly
$278.00 1STPLNCK
Suppl. PC Fee: E) Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg.
Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
0
E)
Work Without Permit? 0 Yes No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
Strong Motion Pee:
$0.00
Select an Administrative Item
Bldg 3tds Commission Fee:
$0.00
SUBTOTALS: 1_$0.001:$278.00
TOTAL FEE:
$278.00
Revised: 04/01/2014
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7665 PEACH BLOSSOM DR
CONTRACTOR: SCL CONSTRUCTION
PERMIT NO: 14010002
CO.
OWNER'S NAME: WU TONY HSU-YUNG AND LARRISA TSUI M
1664 SAMEDRA ST
DATE ISSUED: 04/14/2014
OWNER'S PHONE: 4082501267
SUNNYVALE, CA 94087
PHONE NO: (408) 497-1556
lid LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
CONSTRUCT A 1390 SQ FT ONE STORY ADDITION;
License Class Lic. 8 1 72
INTERIOR REMODEL (836 SQ FT); UPGRADE
r
Contractor x Date r'
ELECTRICAL
PANEL (200AMPS).
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.
I hereby affirm under penalty of perjury one of the following two declarations:
have and will maintain a certificate of consent to self -insure for Worker's
ompensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $170000
erformance 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
APN Number: 3661 1147.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS IT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAY YJt01q I ,BALLED INSPEC ION.
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. Additionally, the applicant understands and will comfit
Date:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
�T
"
RE -ROOFS:
Signature—� Date { T
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(x) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should 1 use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of die work for which this
�[
Owner or authorized agent: o– bate:
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, (
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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 and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
d"Y'rX7 !1T !"'TTTI1rTITTXTA1
OCCUPANCY TYPE:
l.11 l Vl` 1.. 111 L'IN, ill\V
FEE ESTIMATOR - BUILDING DIVISION
FLR AREA
s.f.
PC FEES
ADDRESS: 7665 PEACH BLOSSOM DR DATE: 01102/2014
REVIEWED BY: MELISSA
BP FEE ID
APN: 366 11 147
BP#: ��
`VALUATION: $170,000
$2,657.12
IR3PLNCK
$1,904.00
IR3INSP
PERMIT TYPE: Building Permit
PLAN CHECK TYPE:
Addition
PRIMARY SFD or Duplex
2nd Unit? ; Yes 0 No
PENTAMATION 1R3SFDAD
USE:
Permit Fee:
OTC. O Yes (F)No
PERMIT TYPE:
WORK���90
S.F. & REMODEL E 930 S.F.
SCOPE
$0.00
PME Permit Fee:
OCCUPANCY TYPE:
TYPE OF,
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,III-S,IV,V-B
1,390
$2,657.12
IR3PLNCK
$1,904.00
IR3INSP
$0.00
PME Plan Check:
$0.00
200 amps
$47.00
Electrical
IBELEC200 Services
Permit Fee:
$1,904.00
Suppl. Insp. Fee.e Reg. 0 OT p,p hrs
PME Unit Fee:
$0.00
$0.00
PME Permit Fee:
$47.00
TOTALS:
1,390
$2,657.12
$1,904.00
M GII ,HOURLY ' Q Yes ISa'
1'"LUMl3 Hou �; Yes' Q N
ELEC, H©URLY ; Y +�
atG /I, l lfw, ''r�, I
['�r�t;��z, �h4�� E: t,,�_ h
Elec. Plan Check0.0 I hrs $0.00
I"'f ,n
$2,657.12
Elec. Permit Fee: IEPERMIT
�rhr r t lrrr.vr. lrzs �.
--------------
( (hcr Plu, ,"b Ir,,;,
Other Elec. Insp. 0.0 hrs $47.00
0.0
hrs
$0.00
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the nreliminary information available and are only an estimate Contact the Dent for addn Y info.
FEE ITEMS (Fee Resolution 11-053 Ef 711113)
FEE
QTY/ EE
MISC ITEMS
Plan Check Fee:
$2,657.12
930 s.f.
$628.00
Remodel, Other
IREMRESOTN
Suppl. PC Fee: 0 Reg. © OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
200 amps
$47.00
Electrical
IBELEC200 Services
Permit Fee:
$1,904.00
Suppl. Insp. Fee.e Reg. 0 OT p,p hrs
PME Unit Fee:
$0.00
$0.00
PME Permit Fee:
$47.00
Dj llll il0'i' Yat r v!'Q_`.'
Q
E)
Work Without Permit? © Yes (F) No
$0.00
Advanced Planning Fee.
IPLLONGR
$194.60
Select a Non -Residential
Building or Structure
0
0
i
Travel Documentation Fee: ITRAVDOC
$47.00
Strong Motion Fee:
IBSEISMICR
$17.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$7.00
SiIBTUTAUS:
$4,873.72
$675.00
TOTA1G FES.'
$5,548.72
Revised: 10101/2013
C—
rIUPERTINO
I NEW CONSTRUCTION
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingacupertino.org
ADDITION I-1 ALTERATION / Ti n REVISION / DEFERRED ORIGINAL PERMTT #
PROJECT ADDRESS 966 ' ?eae4 V+!fes •
APN # � /V � / I � q 7
/
�r���/�VJI
OWNERNAME 1
P O O ^�
EMAIL
STREET ADDRESS //
CITY, STATE, ZIP /a
FAX
D L '
CONTACT NAME Tao
(.j
PHONE_ !�`ppj
E-MAIL �` 1
STREET ADDRESS PO "L�oy
CITY, STATE, ZIP ?% /6 r p C
/TO/RvAGENT/7U /ARRCHITEJ
FAX
B. CT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
❑ OWNER ❑ OWNER -BUILDER 1:1 OWNER AGENT ❑ CONTRACTOR 11CONTRAC
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
EMAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
1
ARQ D? T/ENGWEERNAME / A'C1 n `r40
[I �N 15
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL 11 // LL
FAX
STREET ADDRESS �i1 '� `,� O��
1•,(5i 0
CITY, STATE, ZIP F.1 /Q Ii LC /y,� C//
/Gt/ l' /`j
L/�AI
PHONE AM 06. %��
Irr/v ,G�
DESCRIPTION OF WORK
`C O J 71' CA% Q1S7�7 �W N Ih.0 O�Y►C
uac wkraut C-1 391) �e_*4ojej 4t 1 k0CA&A 6AVVI f
. exidi Wd,,-4 ; .
4�t ex�r.3 nwOei,6kroam fo kvil"%5 "owl "J u Ievj cow, VP oWt 2le Mme'to J)oo,4{n
EXISTING USE
t
PROPOSED USE CONSTR.
TYPE
# STORIES
USE TYPE
OCC.
SQ.FT.
VALUATION (S)
EEXISSTTGG•
/ j
b �3
NEW FLOOR
AREAt 3 9 o
DEM
AREA
TOT
NET AREA
/�,
�/ O
l (,
BATHROOM
REMODEL AREA
KITCHEN
REMODEL AREA o
OTHER
REW9L Ait .7 63
PORCH AREA
DECK AREA
l](
TOTAL DECK7PORCH AREA
GARAGE DETACH
[ �J u ATTACH
# DWELLING UMTS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
'
BEING ADDED? 1't NO
T�
ADDITION? 04NO
PRE -APPLICATION YES IF YES, PROVIDE COPY OF
❑
LETTER
IS THE BLDG AN YES
EICHLER HOME. NO
- V. TOTAL VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL
('IO 00V.
By my signature below, I certify to each of the following: I am the propertyowner or authorized agent to ac on th perty 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 con e tives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: I
SUPPLEMENTAL INFORMATION REQUIRED/'r
,y i fu r
%
.,
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
i
permit for new building.
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
I
form if any Hazardous Materials are being used as part of this project
_ Copy of Planning Approval Letter or Meeting with,Planning prior to
r,
submittal of Building Permit application.�I
BldgApp_2011.doc revised 06/21/11
CUPERTINt
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: S'
PERMIT # `ab
OWNER'S NAME: 1
PHONE # 47 4Pf (f- ZI-
GENERAL CONTRACTOR: +/
BUSINESS LICENSE #
ADDRESS:
CITY/ZIPCODE: Z4 7 Z -i
*Our municipal code requires all businesses working in the city to have a City of Cupertino"business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
Date
Owner / Contractor Signature Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature Date
CUPERTINO
STATEMENT OF SPECIAL INSPECTIONS, 2010 CBC
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org
SITE
ADDRESS
x1665 Peack I�IOSSt7iVl T}-
APN 396-11-/47
Registered Design Professio al in Charge
BP# I401000�
Lic.#....................................... Date:.........................
Owner...............QY.1Sy$.a.................
........................................................
Contractor..........................................................
Owner's Authorization
Si gnatu7e ::,... �- '�. .......
Address...........................................................................................................
Inspection Agency / Inspector Name:
Address...........................................................................................................
City/St.............................................
Zip ........................... Phone.....................
City/St.................................................
Zip ................... Phone ........................
Applicant.........................................................................................................
Signalure ..............
Engineer/ chi ct..............!t.Ae.1
-6cto
.........................................................
Address...........................................................................................................
Address...........�..8a
................. .2......................../.f......./........ .
City/St.............................................
Zip ........................... Phone.....................
City/St... P40...41 fp.................
1..11
Zily= aZ.... Phone
PROJECT DESCRIPTION:
SFD, 0&14- 130 ss. W<d le-woW 93o s,+•
This "STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This
form is structured after and used by permission from the Structural Engineer Association of Northern California's (SEAONC) mode
statement of Special Inspections. Also, included with this form is the following:
❑ "LIST OF SPECIAL INSPECTION AGENCIES (page 2). A list of testing agencies and other special inspectors that will be
retained to conduct the tests and inspections for this project^
❑ "SCHEDULE OF SPECIAL IS ECTION" (page 3 - 6). The Schedule of Spe, ,al Inspections summarizes the Special
Inspections and tests re44in d.eCial Inspectors beef ed> ns and specifications for detailed special
inspection requirements. Arty dtional tests and ir� cti` s uipproved plans and specifications shall also
be performed.
Special Inspections and Testing will be performed in accordance with the approved plan nd specifications, this statement and CBC
Sections 1704, 1705, 1706, 1707, and 1708. Interim reports will be submitted to the Building Official and the Registered Design
Professional in Responsible Charge in accordance with CBC Section 1704.1.2.
A Final Report of Special Inspections documenting required Special Inspections, testing and correction of any discrepancies noted in
the inspections shall be submitted prior to issuance of a Certificate of Use and Occupancy (Sectio ). The Final Report will
document:
• Required special inspections.
• Correction of discrepancies noted in inspections. 01�
The Owner recognizes his or her obligation to ensure that the construction complie wlth��Rproved per l disc t �� to
implement this program of special inspections. In partial fulfillment of these obligati ns, the O er will reta��r a� .dAi bappa) l'fpyi-jh,0
Special Inspections as required in CBC Section 1704.1. p
Y`
This plan has been developed with the understanding that the Building Official will. 4,4'rfl
• Review and approve the qualifications of the Special Inspectors who will rform the inspections.�4
PP q P P P�.
• Monitor special inspection activities on the lob site to assure that the �pe�iFinpectdtaVigital)f.c[t r r heir
duties as called for in this Statement of Special Inspection.
• Review submitted inspection reports. r3>'
• Perform inspections as required by the local building code.
1 have read and agree to comply with the terms and conditions of this statement
Prepared By:
Project LJ Engineer Architect
Registered Design Professio al in Charge
Signature ............... ..... .........................................
Lic.#....................................... Date:.........................
Owner Name:
Owner's Authorization
Si gnatu7e ::,... �- '�. .......
...................................................... Date:..��.Y...
Inspection Agency / Inspector Name:
Si nature ............... ......
Lic.#..G...��7. ....... Date:....ial
or desig ee:
n
Signalure ..............
...................................... Date:....
D " --
SpecialnspeclionForm - revised 02/13/13
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: PERMIT # l &rut uv v v
OWNER'S NAME: y C PHONE # LLQ z ' �
GENERAL CONTRACTOR: . PY.�' -�/ BUSINESS LICENSE #
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: t�WW
Signature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
`f •/V -/S
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
`f •/V -/S
Date
