D-2017-0019CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: D-2017-0019
20544 BLOSSOM LN CUPERTINO, CA 95014-4304 (359 18 027) K & M
OWNER'S NAME: SU JERRY C AND KO MENG CHU CATHY
OWNER'S PHONE: 408-332-6656
LICENCED CONTRACTOR'S DECLARATION
License Class lj Lic. #741814
Contractor K & M DEVELOPMENT INCDate 10/31/2017
hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
ith Section 7000) of Division 3 of the Business & Professions Code and that my
cense is in full force and effect.
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
DEVELOPMENT INC
CUPERTINO, CA 95014
ISSUED: 04/26/2017
NO: (408) 390-5127
PERMIT INFO:
—BLDG —ELECT —PLUMB
_ MECH X RESIDENTLAL _ COMMERCLAL
JOB DESCRIPTION:
DEMO 1 STORY SFD (840 S.F.); DETACHED GARAGE (400 S.F.)
Compensation, as provided for by Section 3700 of the Labor Code, for the
_ performance of the work for which this permit is issued.
z. I have and will maintain Worker's Compensation Insurance, as provided for by
q' Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. Sq. Ft Floor Area: Valuation: $20000.00
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
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, costs, and expenses which
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
Signature - Date 04/26/2017
hereby affirm that I am exempt from the Contractor's License Law for one of the
illowing two reasons:
r. 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)
2. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
r. 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. 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.
s. 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 waking this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
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 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, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Signature Date 04/26/2017
APN Number: Occupancy Type:
359 18 027
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: PAUL O'SULLIVAN
Date: 04/26/2017
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.
Signature of Applicant:
Date: 04/26/2017
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505 25533, and 25534.
Owner or authorized agent: v
Date: 04/26/2017
N TRUCTI LENDINGie6'�ENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
DEMOLITION PERMIT APPLICATION D�0FI—COR
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 05014-3255 D
(408) 777-3228 - FAX (408) 777-3333 - buildinq@cupertino.org
PROJECT ADDRESS 1050 'PlOsSon) ak7e
APN#
OWNER NAME je
PHONE q 08, 2,?2
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STREET ADDRESS 4)( on e P,
CITY, STATE, ZIP f FAX
CONTACT NAmE A lex Ka n
PHONE � 0
F -MAIL Z/
STREET ADDRESS z P40 s+e C, --e Id. 23
STATE, ZIP
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FAX, )s' 4 2s-
—
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR 13 CONTRACTOR AGENT E3 ARCHITECT E3 ENGINEER Ei DEVELOPER TENANT
NTRACTORN _ ^ d
,J&rLICENSE NUMBER LICENSE TYPE
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BUS. LIC #
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COMPANY NAME,�� E-MAIL
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STREET ADDRESS
&V14
CITY, STATE, ZIP
C1V44r171t411_P. 64- qlbi PHONI 5(
DESCRIPTION OF WORK qyqo P
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RESIDENTIAL
DWELLING a
OFFICE USE ONLY
FLOORAREA
S j
USE
OCC.
TYPE
SQ. Fr.
VALUATION
CONDAERCLNI,
FLOOR AREA
TYPE OF CONSTRUCTION STORIES 2
9tjCd141141 ffl�j& PAM,'/� L
AQMM JOB NUNMER j
RECEIVED BY,
TOTAL VALUATION:
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: VA q—/
SUPPLEMENTAL iNFoRmAu& REQuiuwlhm TO ISSUANCE OF DEMOLITION PERMIT
V'Prpvide
OFFICE USE ONLY
Job Number from Bay Area Air Quality Management District www.baaamd.org @ 415-7494762,
PLAN cHEcK TYPE
EXPRESS
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.
STANDARD
NPlanning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days.
LARGE
Txp�mvide
MAJOR
letter of clearance of all vermin from a licensed pest control contractor.
c
A phant shall call the Public Works Department at 408-777-3104 and schedule a "habitable dwelling" inspection.
Provide signed Debris Bin and Recyclable Materials form.
Commercial Buildings Only: Provide Fire 66pt clearance for fire suppression / alarm system review.
DemoApp-.2016.doc revised 03129116
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FILE
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EDWARD J. HAHAMIAN-CIVIL ENGINEER
10158 RICHWOOD DR.
CUPERTINO 95014
PHONE: 408 257-8298
June 5, 2017
Building Official
City of Cupertino
SUBJECT: 20544 Blossom Ln., Tract No. 420 Lot 13
RE: Pad & Setback Certification
On this date I visited this site made the requirement meaurements and report as follows:
The formwork for the perimeter foundation has been correctly installed in accordance with the
approved plans for this site.
The earth pad ha been correctly graded a per approved plans sheet C-1
Submitted by:
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