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D-2017-0026CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 10240 LEBANON DR CUPERTINO, CA 95014-2648 (342 14 015) CONTRACTOR: PERMIT NO: D-2017-0026 HOMEOWNER BUILDER OWNER'S NAME: HAVALAN LLC I I DATE ISSUED: 05/10/2017 1 OWNER'S PHONE: 408-893-8007 I I PHONE NO: License Class Lic. # Contractor HOMEOWNER BUILDER Date 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: 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 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 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 5/10/2017 III'm L_� 1 I hereby affirm that I am exempt from the Contractor's License Law for one of the following 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) 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: t. 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 t / performance of the work for which this permit is issued. I% z. 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. 3. 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 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. -01 .� Date 5/10/2017 BUILDING PERMIT INFO: —BLDG —ELECT —PLUMB MECH X RESIDENTIAL COMMERCIAL JOB DESCRIPTION: DEMO (E) SFD (1224 S.F.); ATTACHED GARAGE (414 S.F.); DEMO POOL - COMPACT 90% SOIL FOR CONSTRUCTION; REMOVE SEPTIC TANK Sq. Ft Floor Area: I Valuation: $10000.00 "N Number: Occupancy Type: 34214 015 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Abby Avende Date: 05/10/2017 RE -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. Signature of Applicant: Date:/510/2017 ALL ROOF "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. 1 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: Date: 5/110/2012 CONSTRUCTION LENDING AGENCY 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 AR HIT . T'c DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO DEMOLITION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingCGDcupertino.org PROJECT ADDRESS ' � V21/1, ^ Or ­ D r, APN # l Z i I 01 y OWNER NAME ` ' PHONE ((� E-MAIL STREET ADDRESS ^' CITY, STAT ZIP }� F W� 1 CONTACT NAME PHONE E-MAIL +v t h STREET ADDRESS CITY, STATE, ZIP e FAX r Z 1 ❑ OWNER OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR N ' RG / { Y LICENSE NUMBER L 7ICENSE TYPE BUS. LIC # 1/ J � 14- t/S COMPANY NAME Gi , L' E- n FAX STREET ADDRESS CITY, STATE, ZIP P NE 7 f DESCRIPTION OF, WORK ^ RESIDENTIAL # DWELLING OFFICE USE ONLY FLOOR AREA UNITS USE OCC. TYPE SQ. FT. VALUATION COMMERCIAL FLOOR AREA TYPE OF CONSTRUCTION #STORIES AQMD JOB NUMBER RECEIVED BY: TOTAL VALUATION: J #: < ( 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 ding construction. I a rize repre72tatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: ! Date: SUPPLEMENTAL INFORMX5N REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT OFFICE USE ONLY _Provide Job Number from Bay Area Air Quality Management District www.baagmd.org @ 415-749-4762. FLAN CHECK TYPE Provide three copies of a site plan showing protection for any trees 10" in diameter or more at 3' above grade. EXPRESS, / ❑ STANDARD i/ Provide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected. ❑ LARGE Tanning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days. ❑ MAJOR Provide letter of clearance of all vermin from a licensed pest control contractor. tApplicant shallall the Public Works Department at 408-777-3104 and schedule a "habitable dwelling" inspection. t�K e V'j �''1Providsi e ns 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 71 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • build ingCo5cupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS Q� � tom- 1J9WNERAPDRESS, APN 3442-14 - U P aP# _ZO��-Vvzu OWNER AME c DESCRIPTION OF WORK: v We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) C' 1�4'1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. C.1. -2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. C:k , S. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. CP 14. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. (IM_5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. Cd"i'6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. CAH 1 7.1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. (✓ CO. 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuildeYForm 2010.doc revised 04/14/10 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. If 1'4 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. C. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. (�'�12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: �J � : Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. ? _ , / , / Property Owner's Signature: ( .- "� ? 14 - r��'— — �— Date: �4 7 --------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwneYBuilderForm 2010.doc revised 04/14/10 -- 6 lEe o LEBANON DR. ew ti� -6�ew �,00.os.ee aa— y 5 AV 110 GNQG n �ti CONC WW P,CONC GM oll o EM ti� Ex. HOUSE PATID CONS PATIO l DI ouvd INoo Jla]AO oI 6� lnNTVR( d l Poo 1n Nl dl'9.0° o AT O,O THE F ihN v e ❑ dinO3 FENCE �{ oodDAP r. . .o s W,00ss.caFr, vuovav a� DEMOLITION PLAN s 1-lo'—o" NOTE: 1. EX. BLDG & IMPROVEMENT SHALL BE REMOVED. 2. REMOVED EX. SWIMMING POOL AND FILLED UP W/ COMPACTED SOIL (UNDER SOIL ENGR.'S INSTRUCTION) 3. REMOVED EX. SEPTIC TANK (FIELD VERIFY). r �T"f,27 f aff, PRO 1 MR FREE Pflol[GTM STANDARK , ci PC_z(ifk�. E< S111DAft�Pb'1 .& Construction and Demolition Recycling Diversion Requirements and Instructions Covered projects, or all construction, demolition and renovation projects that are 3,000 square„feet or more are requited 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/Environmental Division showing the tons recycled and disposed by material type. Use tonnage infonm ion from weight tags provided by facilities to quantify total estimated waste and percentages for materials. Weight Tugs of all material recycled and disposed must he submitted with the final report in order to receive a Final Building Inspection. Recology is the only debris bin service provider franchised to do business in Cupertino. Debris from a project 3,000 square feet or more in Cupertino can be collected and disposed by using: Ple sp check all that apply: I am not using a Recology debris bin, however, the project is less than 3,040 s.f., e.g, buildings, patios, sidewalks, driveways. . l 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. 13 1 arra not using a Recology debris. bin. 1 will provide the following submittals to the City's Public Works Department, showing that 1 have rccycled at least 60% of all construction demolition material: Ask for the Constr€tctr'otr 8c Demolition Recycling Packet from the Building Department and complete the following: ✓ Sttbrnit a Coustrirctlon.. and Demolition Waste Management Plan with your building perrrrit application. No fee for• this plan. Forms are available at the Building/Public Works counter and online tat www.capertino.org/envir•ownental. Report the tonnage recycled and disposed, by rn.ater•i.al type. Recycling. facilities naaast be selected j porn. the 007's approved list of Recycling Resources. ✓ Submit a Con strraction Recycling Report form. The report is required before the Building 1?epartrnent rtjill schedule afrral irrspecti.orr, 7'lte r•eport•forrrx ii• avrailttble at tit.e Bualrlirag/Pttblic Works Counter and online rywyv.ctrpertirto.or-,zlettvii•ornrterrtal. Signature:Dater Name: (l)rinted) Title: Phone: Project Address:. 1 `tr5�' � • • et. This form to remain in li1B lE"OjL'Cf'S buildiaib anti it ReNsed 3/7/12 I. duuifldiling IlDe ar°tura ent FREVH.�.=..D FDR CODE COWI[JANCE DMEt M/ City of Cupertino Public works Department — - Envirumnentdl Programs Division 10300 j Torre Ave Cupertino, CA 95014 CUPERTINO RiEN Progagramram (408) 777-3354 Construction and Demolition Recycling Diversion Requirements and Instructions Covered projects, or all construction, demolition and renovation projects that are 3,000 square„feet or more are requited 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/Environmental Division showing the tons recycled and disposed by material type. Use tonnage infonm ion from weight tags provided by facilities to quantify total estimated waste and percentages for materials. Weight Tugs of all material recycled and disposed must he submitted with the final report in order to receive a Final Building Inspection. Recology is the only debris bin service provider franchised to do business in Cupertino. Debris from a project 3,000 square feet or more in Cupertino can be collected and disposed by using: Ple sp check all that apply: I am not using a Recology debris bin, however, the project is less than 3,040 s.f., e.g, buildings, patios, sidewalks, driveways. . l 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. 13 1 arra not using a Recology debris. bin. 1 will provide the following submittals to the City's Public Works Department, showing that 1 have rccycled at least 60% of all construction demolition material: Ask for the Constr€tctr'otr 8c Demolition Recycling Packet from the Building Department and complete the following: ✓ Sttbrnit a Coustrirctlon.. and Demolition Waste Management Plan with your building perrrrit application. No fee for• this plan. Forms are available at the Building/Public Works counter and online tat www.capertino.org/envir•ownental. Report the tonnage recycled and disposed, by rn.ater•i.al type. Recycling. facilities naaast be selected j porn. the 007's approved list of Recycling Resources. ✓ Submit a Con strraction Recycling Report form. The report is required before the Building 1?epartrnent rtjill schedule afrral irrspecti.orr, 7'lte r•eport•forrrx ii• avrailttble at tit.e Bualrlirag/Pttblic Works Counter and online rywyv.ctrpertirto.or-,zlettvii•ornrterrtal. Signature:Dater Name: (l)rinted) Title: Phone: Project Address:. 1 `tr5�' � • • et. This form to remain in li1B lE"OjL'Cf'S buildiaib anti it ReNsed 3/7/12 I. duuifldiling IlDe ar°tura ent FREVH.�.=..D FDR CODE COWI[JANCE DMEt M/ CUP'ERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • builftgg 7cupertino,crg Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS (� O ` r- l l.J 7PN jE�} Y �) { BP�E OWNER AME G �U� r�l� LLL NER A DRES ( 0ZZ DESCRIPTION OF WORK: �y 01 E7 We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) I-01. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries, 1 am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. C -,U _2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility, i✓43. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. &14 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. i-5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. G&A `S. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. CAH % 7. 1 understand under California Contractors' State License Law, an Owner-Builderwho builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the nurr uctures does not exceed four within any calendar year, or all of the work ft r or. is performed under contract witha i + ner. � i „ ✓A - 8. 1 understand as an Owner -BL; ell'f i°iif� ii EII iSli (his permit is issued, I may be held liable for any financial or personal injuries sus any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. ViF�(VII: I -D I::OU ODl _ COMII[JANCE OwnerBuilderForria 2010,doc revisecl04/I4/10 DatE�P 05MOM 7 L-1.09. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. I ,10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. -Ir 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. (�_1�'12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information l have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's si natur :'—) Property Owner's Signature: /'�� -�' Date: �4 j ------ --------- - - ---------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that 1 am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, orother verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: CUILEERTINO Date: Buri°iilldiling IlDelpar°turuent VRIEVHI. i...D i°�OR COM C0Mi1[JN`\iCE OwnerBuilderForn7 2010.docrevised04%14/10 DME05M OM 7 Pacific Gais and lolzl Electric Company DATE: 05/10/17 CITY OF CUPERTINO 10300 TORRE AVE CUPERTINO CA 95014 10900 No. Blaney Avenue Cupertino, CA 96014 SUBJECT. REMOVAL OF GAS SERVICES- (CUT@ MAIN IN THE STREET O..N..10240 IIEBANQMAVEOR-P��. SUBJECT: ELECTRIC SERVICES WAS CI POLE ON; 10240 LEBANON AVE ON 04/06/17 If you have any further questions, please contact me at (408) 775-2076 Sincerely, Ma rki(en.nedy Pacific Gas & Electric Company pF DeAnz-a Servi.ce Planning 408./725-2076 Buifldlin IIDepartirrent 1, FREVH.MED FDR CODE COWIt.WNCk, Rev�ewed �3y�Abby Ay&'ide u)atE�P 05M/F FMOMWA�U1 GOM PLIANCE & 3 I ENFORCEMENT BAY ARE ,A 1 ArRCCZAr.rry DIVISION MAN&GCMRN'r ID F S 7 K I C T Randazzo Enterprises, Inc 13550 Blackie Road iCastroville, CA 95012 6113 Regulation If, Rule 2 Acknowledgement of Notification and Payment of Fees A. SAb80 Invoice No' 37,B93 TheIfay Area Air Quality Management D istrict (BAAQMD) acknowledges i=cipt of your payment and your bestos Removal or Demolition Plan described as: Demolition Site address 10240 Lebanon Dr Cupertino, CA 95014 Start Date May i, 2017 Completion Date May 3, 2017 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 immediately copy the District by fax or by mail. REGULATION 11-2 REVISION BAAQMD J## 5A680 REVISION # START DATE 2 / 3 I 1 4 1 1 5 1. COMPLETION DATE 1 I NOTE. This form is not intended as a verification of either the completeness ofyour original notification ol, of its compliance with BAAQMD Regulation 11-2. If you have any questions about this acknowledgment, please call our office at (415) 749-4762. CU1111EIRTINO dui°illdiling Ildnllr artimen't Uilf~VHI.ld ..D U::CU OD-COWI[.W�UCE SOS PEST CONTROL 214 Christich Lane # 103 Campbell, CA 95008 Rodent Inspection Clearance Date: March 22, 2017 Re: Property Address: 10240 Lebanon Dr., Cupertino, CA 95014 To whom it may concern: The property at the above location was inspected today for any infestation of rodents. No active infestation was found. If you have any further questions, please call our office at (408) 866-6609. Thank you, Mike Stadmiller Branch II Field Representative CUIIIIERTINO l uifldlirip Il ell ar°tirrent FREVH.�.WED FDR CODE COWI[JANCE FRANK LEE & ASSOCIATES P I.., GEOTECHNICAL CONSULTANTS 10 KOOTENAI COURT, FREMONT, CA 9453§ (510) 676-5859 VV I.O June 7, 2017 Job No.: 11647 -S2 -L1 Ms. Cindy Hsu 10240 Lebanon Drive Cupertino, California 95014 SUBJECT: INSPECTION OF SWIMMING POOL REMOVED AND BACKFILL Proposed Two -Story Residential Building 10240 Lebanon Drive Cupertino, California Dear Ms. Cindy Hsu: This letter is to confirm that we provided inspection and testing during the swimming pool removal and backfill operation at the subject site. The swimming pool had been removed, cleaned up all debris and backfill with compacted engineered fill. The fill material was placed in lifts not exceeding 8 inches in uncompacted thickness and compacted to a minimum of 90 per cent compaction. The, results of field density testing performed by our firm indicated that a minimum of 90 per cent of relative compaction was achieved on swimming pool backfill. We appreciate the opportunity to work with you on this project. If you have any questions or if we can be of further service, please do not hesitate to call. Thank you. Very truly yours, FRANK LEE & ASSOCIATES FESS/0 �F4nlee*e(9 Professional Engineer CE34975 " NO. 34975 r a Ic I s�grF OFicA�-t��P/