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B-2017-0984CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0984 10524 LARRY WAY CUPERTINO, CA 95014-2035 (316 02 024) OWNER/BUILDER OWNER'S NAME: Mr & Mrs LO RANDY AND WENDY OWNER'S PHONE: 408-981-3707 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor OWNER/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: 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 performance 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 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. Signatur Date 08/21/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I„ as owner of the property, or my employees with wages as their sole 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: 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. 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 permit is issued. 3. 1 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,,l 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 19.18. Date, 08/21 /2017 DATE ISSUED: 06/26/2017 PHONE NO: BUILDING PERMIT INFO: X BLDG —ELECT —PLUMB _ MECH 3X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: 1 ST FLOOR BATHROOM ADDITION (61 S.F.); BATHROOM REMODEL (24 S.F.); KITCHEN REMODEL (132 S.F.) REV #2 - CHANGE REAR ADDITIONS - HIP ROOF TO GABLE ROOF = ISSUED 8/21/2017 REV #1 - REROOF; TEAR OFF; INSTALL OSB;COMP SHINGLES (30 SQ) ISSUED 8/7/2017 8/17/2017 Sq. Ft Floor Area: I Valuation: $30000.00 APN Number: Occupancy Type: 316 02 024 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Kim Dunbar Date: 06/26/2017 RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without fust obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: 08/21/2017 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 2505, 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, Secti s 25505, 25533, and 25534. Owner or authorized age., ° Date: 08121/2017 CO[ON: 'NDING 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 ARCHITECT'S' DECLARATION I understand my plans shall be used as public records. Licensed CONSTRUCTION •,*RMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUs • CUPERTINO, CA 95014-3255 �/ (408) 777-3228 building@cupertino.or ; PEMIT #B - 00 ( - 98 1 CUPERTINO 46REV # '- DEF # F-1 NRW CONSTRIJCTION n ADDITION F;' <LTFRATIoN I—I T T I—I MF.P I—I RE -ROOF F— SWIMMING POOL/SPA PROJECT ADDRESS p 9 9 a ' APN � OWNERNAMEJ PHO tel® ClYI — 73- 75;bfID T2G-4 OCA. cov -\ STREET ADDRESS Tb CITY, STATE, ZIP ❑ CONTRACTOR NAME OWNER -BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE LL) STREET ADDS,�,R � CITY, TE, ZIP Y �J EMAIL PHONE BUS. LIC # ARCHITECT ❑ OWNER OWNERAGENT ❑ CONTRACTOR AGENT [I ENGINEER ❑ DEVELOPER ❑ TENANT CONTACT NAME E-MAIL cAirn Pz+:� t c7 bQ�_ m I h STREET ADDRESS a 2JS —c)( -vs_ CITY, STATE, ZIPP cA '79 S- G® ONNE dJ /v) DECRIPTON b lb _ I I I ❑SINGLE-FAMILY/DUPLEX ❑ MULTI -FAMILY ❑ INDUSTRIAL ❑ COMMERCIAL USE TYPE OCC SQ.FT. VALUATION ($) EXISTING USE I EXISTING SF NEW FLOORSF PORCH SF DECK SF I DEMO SF STORIES # TOTAL NET SF REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ ATTACHED BATHROOM SF SF SF SF ❑ DETACHED EXISNO ING [I YES . ❑ NO FIRESPRINKLERS EICHLER.. I E:l YES YES SECOND STORY ADDITION El NO DWELLING SECOND DWELLING I❑ YES ❑ ATTACHED❑ DETACHED OTHER UNITS #.. UNIT ADDITON: "1,E] 'NO S F POOLSFIBERGLASS ❑ VINYL -LINED ❑, GUNITE ❑ PREFABRICATED POOL - SF SPA -'SF '. SPA ATTACHED ❑ YES N NO I TOTAL - SF I _ II REC D BY TOTAL VALUATION: ` Commercial or Multi-Fmntl y Buildings with.Puiilic Swimming Pools requires Department of Environmental Heath avprov Iii I RE -ROOF EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES, ❑ WOOD SHINGLES ❑ TILE OTHER (SPECIFY) REMOVE/REPLACE ❑ NO 'IF,NO PLYWOOD ❑'A ❑ 3/8" PLYWOOD TYPE: PITCH: ROOF CLASS []YESI # OFiLAYERS THICKNESS [J5/8" OTHER ❑ OSB ❑ CDX OTHER' 12 A PROPOSED ROOF TYPE: ❑BUIL, -UP ROOF ❑ASPHALT SHINGLES ❑ WOOD SHAKE_ S ❑ WOOD SHINGLES ❑ OTHER *Provide a signed copy of the,Cupertino's Tear -Off Policy SF #of SQUARES 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 apphcAe.local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified, for inspection purposes. I acknowledge and authorize all information cont ined On this application form to be made available for public -record. Signature of Applicant/Agent: Date: m SUPPLEMENTALINFORM?TION REQUIRED *New SFD/Second Dwelling lUnits/Multifamily Dwellings: A Demolition permit is required prior to issuance of a building permit for all new construction. *Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project. *Copy of Planning Approval ILetter.or Meeting with, Planning prior to submittal of Building Permit application. *HOA -Provide a letter of app'r val from the Home' Owner's Association Bld APP_ 2017.doe revised 08101117 S CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0984 10524 LARRY WAY CUPERTINO, CA 95014-2035 (316 02 024) OWNER'S NAME: Mr & Mrs LO RANDY AND WENDY OWNER'S PHONE: 408-981-3707 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor 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. 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. 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 8/7/2017 I hereby affirm that 1 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) z. 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 performance of the work for which this permit is issued. 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. 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 allnQn-poinfsource regujations per the Cupertino Municipal Code, Section 9.18. �(J „ 7 ) 817/2017 ISSUED: 06/26/2017 PHONE NO: BUILDING PERMIT INFO: X BLDG —ELECT -PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: 1 ST FLOOR BATHROOM ADDITION (61 S.F.); BATHROOM REMODEL (24 S.F.); KITCHEN REMODEL (132 S.F.) REV #1 - REROOF; TEAR OFF; INSTALL OSB; COMP SHINGLES (30 SQ) ISSUED 8//2617 Sq. Ft Floor Area: I Valuation: $30000.00 APN Number: Occupancy Type: 316 02 024 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Kim Dunbar Date: 06/26/2017 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 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: Date: 8/7/201 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 ARCHITECT'S DECLARATION I understand my plans shall.be used as public records. Licensed Professional REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228• FAX (408) 777-3333 • building(ftupertino.org n Wj APN,# E-MAIL FAX CONTtC '� pV / / H ',l C'5 7/77 E-MAIL 12 K (IM v /70 I CIT3�', $T IP n I FAX ❑ OWNER 11 OWNERBUILDER 1:1 OWNER AGENT ❑ CONTRACTOR I`ll❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC, 4 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARcurrECT/ENGINEER NAME LICENSE NUMBER BUS. LIC, k COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF V<FD or Duplex ❑ Multi -Family STRUCTURE: ❑ Commercial ROOF AREA: VALUATION: EXISTING ROOF TYPE; ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOODSHINNGLES ❑ OTHER (SPECIFY) REMOVE /REPLACE - YES IF NO, SUPPLEMEiVi' L ITv4FORl4tATIO RE UIRF PLYWOOD ❑ %" ❑ PLYWD '❑ OsBPITCH: CJ BOOP ❑ NO 91—ERS: - ATHICKNESS' Provide Planning approval to verify ifthere any restrictions. 1 ''EVPR s., ' wy 13519- TYPE• 1:1CDX `' ' l.2 CLASS: PROPOSED ROOF TYPE: -❑ BUILT-UP ROOF ElASPHALT SHINGLES ❑ WOOD SHAKES OTHER ❑. WOOD.SHINGLES 11OTHER REPORT , DESCRIPTION OF WORK: By my signature below, I certify to each of a 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 pro Ided is t ct 1 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 b ' in s e ion. thor re tatives of Cupertino to enter the/r d ti%tdproy for inspection purposes. Signature of Applicant/Agent: Date: `" �' SUPPLEMEiVi' L ITv4FORl4tATIO RE UIRF CE Pt ANeH1 CtcT�PE ' - -ROUTING If building is associated ith a Home Owner's Association, provide letter Q ' OVER -THE -CO ©ButlJLhtNC Pt AN REY10 4 of approval fi om HOf . Provide Planning approval to verify ifthere any restrictions. 1 ''EVPR s., ' j; E: © PL%NN1Ni1JP0 Rt VtEu _ Provide copy of Manufacturers Installation Specifications. ❑ , sF�+NDAItn , Cl btRk J}BPT — Provide signedcopy of.Cupertino's Tear -Off Policy. c ,F ❑ Oft .a " :' RerogfApp_201 Woc revixel 03116/11 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-$255 (408) 777-3228 • FAX (408) 777-3333 • building(a cupertino.org PROTECT ADDRESS d AP\ is 0"ER NA>'4IE up STREET ADDRESS (�L/� A, , ��� E-S4ATL C �� CITY, STATE, ZTI _ FAX CO ;RAT W M �--. LIC'. SF, U, LIC .. SETYPE BLS. LIC, H COMI'.ANY 1V 1 �v E- //I/ /J /i /O FAX STR L %pW SS zu_' (jj C Sv,r EvZI/P�6 ��}- t1l. 22 J V I UNDER TDANDAGREE TO THE FOLLOWING: 1. The re -roof project shall comply with all applicable provisions of the 2016 California Codes. 2. An inspection request can be scheduled up to one business -day before. the requested inspection date. To schedule inspections call (40.8) 777=3228 from 7:30 3 3Opm (Mon-Thurs) or :7:30-2:36pm (Friday)'to schedule inspection. For Tear -Off and Nailing Inspections, you must also call on the day of the inspection only after that phase of the work is completed. The building inspector will be•out to the'' job site within one hour. The hours for,this service are: 7:30-10:30ani and 12:30-3:30 (Mon -Thugs), and 7:30-10:30am and 12:30-2:30 (Friday). Final Inspections will be given a two hour window, 3. Tear -Off Inspection is. required. Any, and all dry -rotted wood shall be replaced prior'to this inspection. Unless new plywood roof sheathing is proposed throughout; all the nails/fastefiers' shall, be either completely knocked -down or removed prior to this inspection. 4. If plywood is installed, a plywood hailing Inspection is required: 5. Roofing shall not be applied without first obtaining all prior inspection and written approvals from the building inspector. Any roofing which -is applied without first obtaining an approved inspection will require the removal of all new material !down to the sheathing so a proper inspection can be performed. 6. A Final Inspection and approval shall be obtained from the building inspector when the re -roofing is completed. To receive a final sign-off,!the following items will be verified: a. Flat roofs shall have a minimum of '/" per foot of slope: anddemonstrate there is no ponding. b. Listings from approved testing agencies for all pre -manufactured products used shall be available on-site to review at the time of the inspection. c. Proper spark arrestor installation, vents painted, gutter/downspouts-installed, debris. removed. 7. NOTE: If you call for a tear -off or plywood nailing inspection and the work is not complete, you will be charged a re -inspection fee. The re -inspection fee shall be paid before another inspection can be scheduled. By my signing below, I certify each of the following is true: I am the -property owner or authorized agent to act on the property owner's behalf. I understan and.agree to comply with the re -roof policy stated above. I also understand that smoke detectors and carbon monot e detectors are required to be installed in accordance with Sections R314 :and R315 of the 2016 California Residential C z. Signature of Applicant/Agent: :Date::C ReroojPolfgy. 2014 doc revised 06/01/7 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10524 LARRY WAY CUPERTINO, CA 95014-2035 (316 02 024) CONTRACTOR: OWNER/BUILDER PERMIT NO: B-2017-0984 OWNER'S NAME: Mr & Mrs LO RANDY AND WENDY DATE ISSUED: 06/26/2017 OWNER'S PHONE: 408-981-3707 PHONE NO: LICENSED CONTRACTOR's DECLARATION BUILDING PERMIT INFO: License Class Lie. # Contractor OWNER/BUILDER Date 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: I hereby affirm under penalty of perjury one of the following two declarations: 1 ST FLOOR BATHROOM ADDITION (61 S.F.); BATHROOM REMODEL (24 S.F.); KITCHEN REMODEL (132 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 permit is issued. Sq. Ft Floor Area: 61 Valuation: $30000.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 316 02 024 R-3 (Custom) 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting this permit. Additionally, the applicant understands and will comply with all ll 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 6.26.17 Issued by: SEAN HATCH OWNER-B Iii D R DECLARATION Date: 06/26/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1. I, as owner of the property, or my employees with wages as their sole installed without fust obtaining an inspection, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for inspection. sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature ofApplicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 6.26.17 I hereby affirm under penalty of perjury one of the following three declarations: 1. 1 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. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the �f s. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I exemption, I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections'25505,,25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: ✓� ' APPLICANT CERTIFICATION Date: 6.26.17 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non-point soyrce regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9.18. / 1 understand my plans shall be used as public records. s Signature �n7t Date 6.26.17 Licensed Professional CLIPEfiTINO ❑ NEW CONSTRUCTION CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 85014-3255 (408) 777-3228 - FAX (408) 777-3333 - buildho0cupertino.org -,701- Ntq La D ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINALPERMTT 1 PROJECT ADDRESS�y 1 rA�l NAW- PHOW �" I-0 V eo -8VE c"hot fo&,. STREET ADDRESS �APNy_.qL#W �135{r6N �021OWNER CITY, STATE, ZIP /� ,!1 %01 FAX LATS CONTACT NAME U t PHONE t r— t E-MAIL .l STREETADDRESS %t , ` CITY,STATE. ZIP 7"; t ❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ GONTRACTORAGENT ❑ ARCHITECT Q ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC M COMPANY NAME E-MAM FAX STREET ADDRESS CITY, STATE, ZIP PHONFi !ENGINEER NAW i C + LICENSE NUNMER J BUS, LIC# COMPANY NAMEE E� QSPY'117✓l�t"c�sl� Y)Q�•Lp}'1 FAX 0 (—U c`J r s .r STREFT ADDRESS,. q � L0(—USX CITY, STATS, W w' ' t 'Of � a ,y 9 T2 O T DESCRIPTION OF WORK �'b f4�1'1y-�3®r1 12�--t a 1� �� fC. 1 i �.H-�-r•. t 4 G< EXISTING USE 5', el CiLrc 'PAM PROPOSED USE - ;o0( -7L& FWM CONST?_ TYPE W (34 k STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTO AREA ' (_44 � 1 NEW FLOOR AREA � � DEMO AREA TOTAL t NET AREA (�- O 3 BATHROOM R.EMODEL AREA ''�LY. KITCHEN REMODEL AREA VS 'Z OTHER REMODEL AREA PORCH AREA I DECK AREA TOTALDECK/PORCH AREA GARAGE AREA: '-1 JDF,Tk0I1 foS � �S r�,ry L7^TTACH 6 DWELLING UNITS: IS A SRCOA'D UNIT ❑ YES BEING ADDED? SECDND STORY ❑ ADDITION? N•Idtf l PRF -APPLICATION ❑ YES IP YES, PROVIDE COPY OF PLkI,WWGAPPL6 IS TIM BLDG AN ❑ YES s ItE � D Y �� -� r''a� " � �. TO L VALUATION: []NO PLANNING APPROVAL LETTER EICHLPRnOM-E? ❑NO- By my signature below, I certify to each of the following: I am the property owner or authorized agent to ah on the 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 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 abo/ve-ide tified p operty for inspection purposes. �� Signature of Applicant/Agent: �7�/ / (/ Date: Z��` SUPPLEMENTAL INFORMATION REQUIRED -,-• � g � -�� �- �. _-�.'�,P�!�4'HC.. Ci�7Y�E,�,. �';'_ � _ New SFD or Multifamilydwellings: Apply for demolition permit for g PP Y P a `� }' -OITEItTii> COUI4TER mss* 1] ��urr�nu�crLaxEv>�v�` existing building(s). Demolition permit is required prior to issuance of building r 2� permit for new building. l _�rRssz��IaI\I�m P]{AI�EVIEN ` _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosul'esrAsDAI D �I e trwq gp- form if any Hazardous Materials are being used as part of this project. 14 Q _-FARGE, - s� II2E DEMO- opy of Planning Approval Letter with Planning prior to a. ©MANOR subrn ttal of Rull' dmg Permit applications y,z�y T.ARY�E�i'EttDISTitI T Meeting -s;Y fir.; ®..�•'�d3�IROTT�IvTAL1�4I:TH�'+-_�'� r- �`� rr-wa`s _..�; Bldg4pp_2011.doc revised 06/21111 CUPERTINO SANITARY DISTRICT 20863 Stevens Creek Blvd #100, Cupertino, CA 95014 Tel (408) 253-7071 - Fax (408) 253-5173 a `'axiryvy n. w�'� •r� CUPERTINO SANITARY DISTRICT PERMIT LETTER Cupertino Sanitary District has adopted Resolution No. 1263. Building Permit Request (Over -the -Counter) Single Family Project ❑ Multi -Family Project ❑ Commercial Project Project Address Permit Number: Scope of Work: ?go 12a>E-0 3AT-vAe4xx-s R-'&mc�vEL r—i7-C'L4E-?v t t2owoct2 Owner/Applicant Name: WC--VJi--y l -_U Phone: 062) a? 1-37-0-3 ddress: t652_4 Date:' Z 1-+- Prepared By: Representative /, as property owner or authorized agent, acknowledge that all Cupertino Sanitary District requirements will be metX6)W17 all required fees will be paid prior to �appryal nal inspection for proposed project. Date: `Signature: 92 wrier / Authorized Agent CUPERTINO SANITARY DISTRICT OFFICE USE ONLY ❑ Pre -inspection Required Date Scheduled: Date: (0 - 22 , ( -7 Final Ins p tion Required Conditional Approval By: i Aut orized re entative Cupertino Sanitary District District will notify owner of the required fee within 5 days after Pre -Inspection has been completed and cc City of Cupertino. Inspection Fee Paid Date Paid: Inspe tion Fees: $250/unit - Single Family Residential already connected, but new cleanout is required $150/unit - Single Family Residential already connected with existing cleanout in working order $350 Minimum — Commercial and Retail Actual Amount: $200/each — Disconnect and/or abandon lateral service Connection Permit Fees: $350/unit - Single Family Residential connecting to existing lateral $650/unit — Single Family Residential connecting with new lateral $100/unit — Multi, Hotel, Living Units, etc. Actual Amount: $500/connection - Commercial and Retail Actual Amount: Connection Use Fees (See Attached Calculation Sheet): D Area and Frontage Fees Amount: D Residential Excess Fees over 3.5 unit/acre Amount: O Commercial and Retail Connection Fees Amount: Commercial and Retail Change in Use Fees Amount: Date: — _ Final Approval By: Q')A 4" — Authori ed Representative Cupertil 6 Sanitary District CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingaa cupertino.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 O r T- qpN � / / O ` O , � / (l 1 1vj� Q�+«O f �� OWNER NAME nd� Lo OWNER ADDRESS DESCRIPTION OF WORK: s� 71ta-r d• o y r B 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.) %Lldl—l. 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. I, 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. /_A)d 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. (,�3. 1 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. (L74. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. (�5. 1 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. (L � 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. N17. I 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 safe, unless all work is1. 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. hLq8. I 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. OwnerBuilderForm 2010.doc revised 04114110 �9. 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.csib.ca.gov for more information about licensed contractors. CL110. 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. a11. 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. L_t� 2. 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: 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 t the city may be required to be presented when the permit is issued to verify the property owner's signature. /' Property Owner's Signature: IN Date: ------------------------------------------------------------------------------------------------------------------------------------------- (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: Owne7'BuildelForn1_2010.doc remised 04/14/10 ii y' p� Quality Assurance Services CJ Materials Consulting lug TESTINGENGINEERS INC. Since 1954 Page of Date: 08-17-2017 DSA File#: DSA App.#: Project#: 65553 OSHPD#: Project Name: Permit/SF App.#. '0.'83 Address: 10524 Larry Way Tow Code: f26 City: Cupertino Start Time: 11:00 Requested by: Hours: 4 Reported to: Hector-408-592-7218 - of(Company Name): ❑ EPDXIED DOWELS 125 /1 EPDXIED ANCHORS 126 ❑ EXPANSION ANCHORS 127 ❑Witnessed the drilling of holes of proper diameter and depth. or ®Inspected predrilled holes for proper diameter and depth. Expiration Date of Epoxy: 05/08/19 0 Observed the cleaning of holes and The Injection of: Simpson SET-XP Epoxy or The Insertion of Epoxy Capsules Witnessed the proper insertion of Qty. Bar#/ • Type Length,in. Embed Location Dia,in.! • in. 6 5/8" i All Thread 24" 12" Anchor Bolts to(E)Foundation --4'O.C.Max • Next to New Bathroom Addition AB's per Note Requirement on Sheet S-1 Installation Meets minimum Simpson SET-XP ESR-2508 Requirements. Remarks!: 0 Showup; ❑ Stand-by time; 0 Job Cancelled; 0 Re-inspection;Hours: The work F1 Was❑ Was not inspected in accordance with the ®Building Department❑DSA 0 OSHPD approved documents. The work inspected 1 3 Met 0 Did Not Meet the requirements of the®Building Department 0 DSA 0 OSHPD Approved Documents. ❑Except as noted Above. • Drawings: 10524 Larry Way-Structurals Dated: 06.14.17 ®City 0 County 0 Shop 0 DSA ❑OSHPD f Inspector: Salvador Merino Inspector Sign: Certification# 5258923 Date: 08-17-2017 Received by: Date: q • ; [ Corporate Office—2811 Teagarden Street—San Leandro,California 94577—(510)835-3142—FAX(510)834-3777 11 www.Testing-Enqineers.com • gaol: - TESTING ENGINEERS, INC. 2811 Teagarden St. 510-835-3142" 51Q-834-3777 fax San Leandro,CA 94577 800-660-3142 • . . " San Leandro • ' San Jose • Martinez ' INSPECTION REPORT Week Ending: 8/18/17 PROJECT# j ' TYPE OF INSPECTION: PROJECT: PLACE OF INSPECTION: -9. .- ipa 1'tiiro Permit# -'-'�•8; DATE %17 HOURS INSPECTOR S.Merino Reported to Hector at the jobsite as requested. Inspected predrilled holes for proper diameter and depth. Observed the cleaning of holes and the injection of Simpson Set XP epoxy(g9). Witnessed the proper insertion of six(6)5/8"diameter Allthread anchors,24"in length,embedded 12"into existing foundation next to new bathroom addition. The preceding work was,to the best of my knowledge,in compliance with approved job plans and specifications,including revisions by engineer,and Dra:04-V0/14. Reviewed by: - -. Davi. 'ppero Special Inspection Division Manager RECEIVE t 1cc: Wendy Lo SEP 1 4 2017 City of Cupertino/Bldg.Inspection Dept. The results presented in this report relate only to the item(s)tested/inspected and may be reproduced only in its entirety unless written permission from TEI is obtained. Page 1 of 1