B-2016-3100CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-20.16-310.0
20544 BLOSSOM IN CUPERTINO, CA 95014-4304 (359 18 027)
K & M
DEVELOPMENT INC
CUPERTINO, CA 95014
OWNER'S NAME: SU JERRY C AND KO MENG CHU CATHY
DATE ISSUED: 04/26/2017
OWNER'S PHONE:
PHONE NO: (
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class a Lic. #741814
Contractor KA M DEVELOPMENT INC Date 10/31/2017
X BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MECH X RESIDENTIAL COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
CONSTRUCT 2 STORY HOME (2981 S.F.); ATTACHED GARAGE (457
I hereby affirm under penalty of perjury one of the following two declarations:
S.F.); PORCH (254 S.F.)
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. 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
Sq. Ft Floor Area: 3438
Valuation: $600000.00
V 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 18 027
R-3 (Custom),R-3 (Custom),U (Private Gar /Ag Bldg),U
representatives of this city to enter upon the above mentioned property for
(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.
� Signature Date 04/_26/2017
Issued by: PAUL O'SULLIVAN
Date: 04/26/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
RE -ROOFS:
1. I, as owner of the properly, or my employees with wages as their sole
All roofs shall be inspected prior to any roofmg 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.
2. 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: 04/26/2017
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
shall not employ any person in any manner so as to become subject to the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If, after rriaking 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:
I certify that I have read this application and state that the above information is
Date: 04/26/2017
correct. I agree to comply with all city and county ordinances and state laws
CON TRUCTIO1 ND AGENC
relating to building construction, and hereby authorize representatives of this city
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
consequence of the granting of this permit. Additionally, the applicant understands
Lender's Address
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 04/26/2017
Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3100
20544 BLOSSOM LN CUPERTINO,CA 95014-4304(359 18 027) K&M
DEVELOPMENTINC
CUPERTINO,CA 95014
OWNER'S NAME: SU JERRY C AND KO MENG CHU CATHY DATE ISSUED:04/26/2017
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#741814
Contractor K CM DEVELOPMENT INC Date 10/31/2019 X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
CONSTRUCT 2 STORY HOME(2981 S.F.);ATTACHED GARAGE(457
I hereby affirm under penalty of perjury one of the following two declarations: S.F.);PORCH(254 S.F.)
t. I have and will maintain a certificate of consent to self-insure for Worker's REV#1 -LANDSCAPE CHANGES-ISSUED 8-29-2018
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. Sq.Ft Floor Area:3438 Valuation:$600000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 359 18 027 R-3(Custom),R-3(Custom),U(Private Gar/Ag Bldg),U
representatives of this city to enter upon the above mentioned property for (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.
Signature '" Date 8-29-2018
Issued by:PAUL O'SULLIVAN
OWNER-BUILDER DECLARA Date:04/26/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: RE-ROOFS:
1. I,as owner of the property,or my employees with wages as their sole 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.
2. 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:8-29-2018
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.
z. 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
shall not employ any person in any manner so as to become subject to the Health&Safety Code,Section 25532(a)should I store or handle hazardous
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: �—
I certify that I have read this application and state that the above information is Date:8-29-2018
correct.I agree to comply with all city and county ordinances and state laws N TR TI LE DI
relating to building construction,and hereby authorize representatives of this city 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
consequence of the granting of this permit. Additionally,the applicant understands Lender's Address
and will comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 8-29-2018 Licensed
Professional
NO FEE FOR RECORDING PURSUANT TO
GOVERNMENT CODE SECTION 27383
r
When Recorded Mail To:
City of Cupertino
Community Development Department
10300 Torre Avenue
Cupertino, CA 95014
Regina Aboomendras
Santa Clara County - Clerk -Recorder
12/04/2018 03:30 Air
Titles: I Pages: 3
Fees: 0.00
Taxes: 0
Total: 10.00
NOTICE OF CI'T'Y REQUIREMENT TO MAINTAIN TREES
The undersigned, being the owner(s) of the property shown in the Santa Clara County Assessor's Roll and
identified as A.P.N. 359-18-027 and addressed as 20544 Blossom Lane, Cupertino CA 95014, hereby agree(s) that
the following plantings shall be maintained as privacy and protected trees to screen the views from the second
floor: four (4) Arbutus Marina along the western side property line and three (3) Arbutus Marina along the
eastern property line. In addition the privacy plantings, the following planting shall be maintained as the
required front yard tree in the front yard setback: one (1) Water Gum (Tristania laurina). In the event these
plantings die, the owner(s) shall provide replacement plantings subject to the approval of the City of Cupertino.
This declaration is binding on the successors and assignees of the owners(s).
PROPERTY OWNER(S):
Owner's i ,ature
Print Owner's Ndme
Date
CITY AUTHORIZATION:
rick Serrano, Associate Planner
Co -Owner's Signature
Melia, C� u 6,a4v
Print do -Owner's Name
/11c, 31 zfIt
Date
Date
i�
CALIFORNIAALL-PURPOSE ACKNOWLEDGMENT
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 Santa Clara
On A 26C before me, Kirtl Patel , Notary Public, personally appeared
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s)
it/are subscribed to the within instrument and acknowledged to me that h//sV/they executed the same
in /Ater/their authorized capacity(ies), and that by V/l/r/their signature(s) 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.
i
WITNESS MY HAND AND OFFICIAL SEAL. KIRTI PAT.L
NOTARY PUBLIC -:CALIFORNIA
3 e '
COMMIS'SION # 2179864
AnR'CC,UNTY
MY Comm &p January 27, 202 '
Signature of Notary Public (Notary Seal)
OPTIONAL. 'INFORMATION
The acknowledgment contained within this document is; in accordance with California law. Any cern nate o, f acknowledgement
peforined within the State of California shall use the preceding wording pursuant to Civil Code section 1189. An acknowledg-
ment cannot be affixed to a document sent by mail or otherwise delivered to a notarypublic, including electronic
means, whereby the signer did not personally appear before the notary public, even if the signer is known by the
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and signature cannot be affixed to a document without the correct notarial wording.
DESCRIPTION OF ATTACHED DOCUMENT CAPACITY CLAIMED BY SIGNER
Alo $i'-Gf ��I � �� Individual.
(Ti6e of document) Corporate Officer
Number of Pages �}�� (Including acknowledgment) Partner
Document Date ����3/�f� Attorney-In-Fact
Trustee
fNk-/At �� �('° Other:
OALHFORNRA 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 �� before me, LakA �) to � , 9" ray T ' l
Date Here Insert Name and Title of the Officer
personally appeared+
Name(s) of Signer(s)
who proved to me ,on the basis of satisfactory evidence o be the person(s) whose am (s is/are subscribed
to the within i rument and acknowledged to me that /she/they ;executed the same in' �i her/their
authorize capaci (ies) and by his/her/thei signatur s) on the instrument th ers (s), or the entity
upon behal o which the perso (s) acted, execute e instrument.
a
u ofr LAUREN SAPUDAR
�Pq Nokaryy Pkblic - Calif6rnia Z
Santa Clara County
}Comallssion # 2247155
�itraaaP :�� M®Foto.%X�IPES,Jun 22, 2022
Place Notary Seal and/or Stamp Above
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 /Votary Public
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Completing this information can deter alteration of the document or
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Title or Type of Document:
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Signer(s) Other Than Named. Above:
Ca acit dies) Ciairv'esI b Si nerQs
R Y Y 9
1
Signer's Name: Signer's Name:
❑ Corporate Officer — Title(s): r! Corporate Officer Titles)
ElPartner— ❑ Limited ❑ General ElPartner— 11Limifecl In ,General r
ElIndividual ElAttorney in Fact l individual o:,Attorney'in Fact
11Trustee ❑ Guardian of Conservator El Trustee- ❑ Guardian of Conservator >a
❑ Other: ❑ Other:
Signer is Representing: Signer is Representing:
02017 National Notary Association