13060068-expiredCITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10068 ADRIANA AVE
CONTRACTOR: SHENG'S
PERMIT NO: 13060068
CONSTRUCTION INC
OWNER'S NAME: GAN XIA Yl
10078 SANTA CLARA AVE
DATE ISSUED: 05/14/2014
OWNER'S PHONE: 4155197874
CUPERTINO, CA 95014
PHONE NO: (415) 519-7874
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E]
CONSTRUCT (N) 3700 S.F. SINGLE STORY SFD WITH 517
y� p�
License Class FJ Lic. # D l -1
S.F. ATTACHED GARAGE & 148 S.F. PORCH AREA (DEMO
Contractor �j(1 �py� Date / /
PERMIT REQUIRED FOR (E) 1883 S.F. SFD)
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:
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.
Sq. Ft Floor Area:
Valuation: $700000
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 32620007.00
Occupancy Type:
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
PERMIT EXP S IF W IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DA OF PE IT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM ALLED INSPECTION. i
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Issued by: Date:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
RE -ROOFS:
installed. If is
9.18.
�
S
Signature __ Date /
All roofs shall be inspected prior to any roofing material being a roof
ti ninstalled
without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ O ER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, as owner of the property, or my employees with wages as their sole compensation.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sectio 5, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
ONN ner or authorized agent: Date: X4 1.-
permit is issued.
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, 1
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE:
10068 ADRIANA AVE
DATE: 06/10/2013
REVIEWED BY: MELISSA -
$&ADDRESS:
PN: 366 02 007
BP#: /
VALUATION: $700,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: New Construction
PRIMARY SFD or Duplex
USE: P
2nd Unit? Yes NNo
PENTAMATION 1 R3SFDW
PERMIT TYPE:
WORK
CONSTRUCT N 3700 S.F. SINGLE STORY SFD WITH 517 S.F. ATTACHED GARAGE & 148 S.F.
SCOPE
PORCH AREA (DEMO PERMIT REQUIRED FOR (E) 1883S.F. SFD)
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,III-B,IV,V-B
4,217
$3,065.57
IR3PLNCK
$3,414.98
IR3INSP
Permit Fee:
$3,414.98
Supp/. Insp. FeeQ Reg. 0 OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: IBCONSTAXR
1
# new
units
$ 641.96
Administrative Fee:
0
O
Work Without Permit? 0 Yes (F) No
$0.00
TOTALS:
4,217
$3,065.57
7 i-rtvel Documentation Fees:
$3,414.98
Strong Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments i.e. r/annmg, ruouc rrurns, I tre, -"...'y �.�.•• �• ••- _
,..,I„ nr, octimato_ Cnntact the Dent for addn'l info.
District, etc.. (nese Lees es are auseu urs we reuriW,
FEE ITEMS (Fee Resolution 11-053 Eft: 7/1112)
Nun ( h cr 4,
Plumb; Plan Ched
,Jec. Plan Check
tech. Perrnit Fee:
Plumb. Permit Feer
-t-
I Elec. Permit Fee:
other Alech. Insp.cl—l—
Other Plumb Insp. ET
cher Elec. Insp.
Alech. Insp. 1.,-
lnsp. Fee
ts�u
Permit Fee:
$3,414.98
NOTE: This estimate does not include fees due to other Departments i.e. r/annmg, ruouc rrurns, I tre, -"...'y �.�.•• �• ••- _
,..,I„ nr, octimato_ Cnntact the Dent for addn'l info.
District, etc.. (nese Lees es are auseu urs we reuriW,
FEE ITEMS (Fee Resolution 11-053 Eft: 7/1112)
wa v.nuuv......••».....
FEE
••-•.- »---
QTY/FEE
---__ _._
MISC ITEMS
Plan Check Fee:
$3,065.57
Select a Mise Bldg/Structure
or Element of a Building
Suppl. PC Fee: 0 Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$3,414.98
Supp/. Insp. FeeQ Reg. 0 OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: IBCONSTAXR
1
# new
units
$ 641.96
Administrative Fee:
0
O
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning Fee: IPLLONGR
$548.21
Select a Non -Residential
Building or Structure 0
A
7 i-rtvel Documentation Fees:
Strong Motion Fee: IBSEISMICR
$70.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$28.00
SUBTOTALS:
$7,768.72
$0.00 TOTAL FEE:
$7,768.72
NA
, Revised: 04/29/2013
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingC�cupertino.org
M ❑ ERATION / TI ❑ REVISION /DEFERRED
ORIGINAL PERMIT #
❑ NEW CONSTRUC I IUN ADDITION ALT
PROJECT ADDRESS Q i
APN #
�O o
OWNERNAME PHONE �(� - ,-, E-MAIL
® 7FAX
STREET ADDRESS
CITY, STATE, ZIP
CONTACT NAME
PHON D i E-MAIL
S1,/"_'6 D/
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
ILICENSETYPE
BUS. LIC #
e�
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
n
DESCRIPTION OF WORK
/w
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
OTHER
REMODEL AREA
REMODEL AREA
PORCH AREA
tKEN
DECK ARK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
# DWELLING UNITS:
❑ YES
SECONDSTORY ❑YES
[]NO
ADDITION? []NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED
TOTAL VALU TION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
By my signature below, l certify to each of the following: I am the property owner or authorized agen act on the prope owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and rify it is a . agree to comply with all applicable local
ordinances and state laws relating to b0iRonstruction. I authorize representatives of Cupertino to enter the above -identified roperty for inspection purposes.
�2 2-0
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORKS
_
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEPT
__Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
ElSANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_201 1. doc revised 06/21/11
-l
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, rare, Sanitaryewer tnstrtct, School
Contact the Dent for addn7 info.
//[S[rs, GL[:. Z. l,[yac c - ow _ v..... c. •.-.......•».
FEE ITEMS (Fee Resolution 11-053 E . 7/1113)
ADDRESS: 10068 adriana ave
DATE: 06/12/2014
REVIEWED BY: Mendez
APN:
BP#:
`VALUATION: $0 —1
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
Commercial Building
Suppl. PC Fee: E) Reg. Q OT
PENTAMATION 1 GENCOM
PERMIT TYPE:
USE:
$0.00
PME Plan Check:
$0.00
WORK
deferred #1- truss calcs
Permit Fee:
SCOPE
Suppl. Insp. Fee:Q Reg. Q OT
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, rare, Sanitaryewer tnstrtct, School
Contact the Dent for addn7 info.
//[S[rs, GL[:. Z. l,[yac c - ow _ v..... c. •.-.......•».
FEE ITEMS (Fee Resolution 11-053 E . 7/1113)
FEE
--- -
QTY/FEE
----
MISC ITEMS
Plan Check Fee:
$0.00
= #
$278.00
Deferred Submittal
1DEFSUBM
Suppl. PC Fee: E) Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
('olsfruction I'ax:
'trativ" Fee:
O
Work Without Permit? 0 Yes No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
')(w1wrlu3PIC.ilion Fees
Strong Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
$0.001
$278.00
TOTAL FEE:
$278.00
Revised. 04/01/2014
W" v
CUPERTINO
NEW CONSTRUCTION
N O
(�
CONSTRUCTION PERMIT APPLICATION r O
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION O
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org \`
❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
M1
ADDRESS
APN # r n D
FPROJECr
^ _
,
PHONE
E-MAIL
I
�l!
_
STREET ADDRESSK-9
CITY, STATE, ZIP -
FAX ^%
A091,4,J/c{
i /� S
CONTACT NAME - ,v
PHONE
E-MAIL.l
a o —
l >�N
STREET ADDRESS
JQlIh
CITY STATE, ZI('
/� /t6
cmc �n;�� 3U/
Off/ 2
❑ OWNER ❑ OWNER-BUELDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT XNGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITE NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FA
25--
i35
STREET ADDRESS
/5
CITY, STATE, ZIP
���
PHONE
-4-
/D6 _ d c. CJZu
�iCL
o8 ,o
DESCRIPTION OF WORK a
/
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
�
k
USE
TYPE OCC.
SQTT
VAI 11 FION (S)
Q
e2 -
EX[STG
AREA
NEW FLOOR 1 DEMO
AREA AREA
TOTAL p�
NET AREA /�- - 3
Vn
v�
3700
BATHROOM
OTHER
REMODEL AREA
REMODE AREA
' OD
REMODEL AREA
V
1'
Y
I
PORCH AREA
DECK AREA
TOTAL DECKIPORCH AREA
GARAGE AREA: LJ DETACH
ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? []NO
ADDITION? ONO
PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES R D BYTOTAL VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? []NO ebrd
By my signature below, I certify to each of the following: I am the property owner or autho age ct o the pro rty owner's behalf. I ave read this
application and the information I have provided is correct. I have read the Description of Work rift' it i accurat . I agree to comply with all applicable local
ordinances and state laws relating to buil [ruction. I authorize representatives of Cupertino to enter e a e -identified property for inspection purposes.
Signature of Applicant/Agent: - r Date:_/�
SUPPLEMENTAL INFORMATION REQUIRED
PIAN CHECK TYPE
ROUTING SLIP
❑ OVER-THE-COUNTERBUILDING
PLAN REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
1>1
permit for new building.
❑ EXPRESS
PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
i STANDARD
PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑
submittal of Building Permit application.
MAJOR
SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
BldgApp 2011.doc revised 06/21/11
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10068 ADRIANA AVE
CONTRACTOR: SHENG'S
PERMIT NO: 13060068
CONSTRUCTION INC
OWNER'S NAME: GAN XIA YI
10078 SANTA CLARA AVE
DATE ISSUED: 05/14/2014
OWNER'S PHONE: 4155197874
CUPERTINO, CA 95014
PHONE NO: (415) 519-7874
Qr LICENSED CONTRACTOR'S DECLARATION
r r—r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class 0 Lic. # 14 a i
r
r
MECH RESIDENTIAL COMMERCIAL
Contractor vt � S S# Date f ;+- < <
JOB DESCRIPTION: CONSTRUCT (N) 3700 S.F. SINGLE STORY SFD WITH 517
I hereby affirm the I am licensed under the provisio s of C apter 9
S.F. ATTACHED GARAGE & 148 S.F. PORCH AREA (DEMO
(commencing with Section 7000) of Division 3 of the Business & Professions
PERMIT REQUIRED FOR (E) 1883 S.F. SFD)
Code and that my license is in full force and effect.
REVISION #1- T24 CALCS, CHANGE INSULATION FROM R15-RI9;
I hereby affirm under penalty of perjury one of the following two declarations:
MOVE AIR RETARDER WRAP- ISSD OTC 7/22/2014
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $700000
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
APN Number: 32620007.00
Occupancy Tape:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 0 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAY OM LAST CALLED INSPVCTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
j'
costs, and expenses which may accrue against said City in consequence of the
A
granting of this permit. Additionally, the applicant understands and will comply
Issued by: Date:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
`�
Signa Date l l� �
r ROOFS:
All roofs shall be inspected prior to anyny roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ O R -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, S ibns 25505, 25533, and 25534.
Section 3700 of the Labor Code, for theerformance of the work for which this
p
permit is issued.
t
Owner or authorized ager : i Dater
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
CONSTRUC N LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CONSTRUCTION PERMHT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) I/7-3228 • FAX (408) 777-3333 • buildino(cDcuoertino.orq
77 77 , 5 AF(�T�FFFriR FT�
ORIGINAL PERMIT n
U NEW CONSTRUCTION—
PROJECT ADDRESS
J o
APN
IkLL
OV TERNP.ME PHONE I E-MAIL
CITY, STATE, ZIP FAX /
STREET ADDRESS / Q J�{ I IVZIA
I
F'Q Y J n
CONTACT NAVE PHONE E-MP.IL
eH u cp
�
STREET ADDRESS / `
CITY, STATE, Z1P b / I FAX (�
r O
❑ o%\ITR ❑ OWNER(' -BUDDER ❑ OWNE AGENr ❑ CONrRACrOR ❑ CONTRACTORAGET, ❑ ARCHITECT xENGINEER ❑ DEVELOPER ❑ TENANT
LICENSE NA4BER LICENSE TYPE
BUS. LIC
CO1ANY
E-MAIL x"
FAXSTR-S
CITY, ST Z (Nd L
I PHOT ds
ARCHITECT/EN ER NA�4E 2 LICENSE NUMBER
l
BUS. LIC 4
E-MAIL /
FAX
COMPANY NAME
lj� C C/? c�%ll • Ce
a .
STREET ADDRESS
CITY, STATE, ZIP
�L
PHONE e 16
DESCRIPTION OF WORK
m ( 1
-1 J
R nuc L40 Aw e MIAl �Jr
EXISTING USE I PROPOSED USE CONSTR nrPE R STORIES
USE
TYPE
OCC. I
SQ.FT.
VALUATION (£)
EXISTG
NEW FLOOR
DEMO TOTAL
AREA
AREA
AREA NET AREA
BATHROOM
REMODEL AREA
KITCHEN
REMODEL AREA
OTHER
REMODEL AREA
OR AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
R DV ELLING U 7TS:
IS A SECOND UNIT ❑IES
SECOND STORY LJ YES
BEING ADDED? ❑NO
ADDITION? ❑NO
- -PRE-APPL3C-AVON--Dl'ES ff-�=ES.P"RO]IIDElDP10F
_IS -M ELDG AN M ITS
LL,'RECEII B�' '-
TOTAL VALUATION:
PLANWINGAPPL: ❑NO PLAN-NL'�7G APPROVAL LETTER I
EICHLER HOME? 13 NO
-_
By my signature below, I certify to each of the following: I am the property owner or authori d ag t 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 anjKerify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to b ' _ co7:struction. 1 authorize representatives of Cupertino to enter the above-idproperty for inspection purposes.
Signature of Appl icant/Agent: Date:
SUPPLEMENTAL INFORMATION RE UIRED
QL
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i ROUTLnG BLIP.
New SFD Multifamily d��'ellings: Apply for demolition permit for
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or
existing building(s). Demolition permit is required prior to issuance of building
OVERTHESCOUNT'ER
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s
for new building.
f GPIRE LULj 4�
permit
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_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
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form if anyHazardous Materials are being used as part of this project.
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_ Copy of Planning Approval Letter or Meeting with Planning prior toK
p'0-fATOR
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❑ITSRSE�i£RDISTRICT
submittal of Building Permit application.`
6
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B1dgApp_2011.doc revised 06/21/11
U.,
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10068 ADRIANA AVE
CONTRACTOR: SHENG'S
PERMIT NO: 13060068
CONSTRUCTION INC
OWNER'S NAME: GAN XIA YI
10078 SANTA CLARA AVE
DATE ISSUED: 05/14/2014
OWNER'S PHONE: 4155197874
CUPERTINO, CA 95014
PHONE NO: (415) 519-7874
2K, LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL ❑
CONSTRUCT (N) 3700 S.F. SINGLE STORY SFD WITH 517
License Class_ Lic. # o
S.F. ATTACHED GARAGE & 148 S.F. PORCH AREA (DEMO
PERMIT REQUIRED FOR (E) 1883 S.F. SFD)
,,✓I`
Contractor rG S �o Date
I hereby affirm that I am licensed under the provisions f Ch liter 9
DEFERRED #1- TRUSS CALCS- ISSD 7/17/2014
(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:
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.
Sq. Ft Floor Area:
Valuation: $700000
'I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 32620007.00
Occupancy Type:
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
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 80 D ,OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FR l AST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
City in of the
�'�j �
/!,
costs, and expenses which may accrue against said consequence
(
Issued by: Date: '
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 % � I`
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.
❑ NER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sectio s 25505, 25533, nd 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agen Date: 7 / % kv-
permit is issued.tj
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
CONSTRUCTION LENDING AGENCY
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
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
FREMONT UNION HIGH SCHOOL DISTRICT
589 WEST FREMONT AVENUE
SUNNYVALE, CALIFORNIA 94087
408-522-2200
Developer Impact Fee Compliance
Building permits will not be issued without a completed Certificate of Compliance
The City of
New Residential Development
Name of Owner / Developer
Building Permit Application
has received a request for a Building Permit described as follows:
Residential Addition (501) sq. ft. or more _ Commercial Development
Project Address: � ,%J f' ' ?� =' A'r Lot/Parcel # ' � - '' ' �-
r
Square Footage: Description: 17,1,� 2 5 �3
ja>
Permit / Plan Check # / `
Date: / ' / y By: �..
77— City Building Inspector
Square footage verified by the city prior to issuance of a buildin9Permit-, fees may be adjusted accordingly.
Y.
Feeder Elementary District
4A--,
SCHOOL DISTRICT DEVELOPER IMPACT FEE
CERTIFICATE OF COMPLIANCE
The authorized representative of the Fremont Union High School District has reviewed the
City of
Building Permit Request described above and hereby certifies that the developer or authorized representative has
met the requirements of the District's Developer Impact Fee requirements.
Dated: By:
Certificate not valid without
District Seal, Initial, and Date
Distribution: Facilities Planning —White City — Yellow
Fremont Union High School District
Authorized Representative
Fee $ 243',-I&
Requestor — Pink Accounting — Gold
Dev. Impact Fee Compliance (Rev. 11/22/05) [12/08 — 10001
Cupertino Union School District 10289
10301 Vista Drive, Cupertino, CA 95014
Tel (408) 252-3000 • Fax (408) 865-0326
Developer Impact Fee Compliance
The Cupertino Union School District has adopted Resolution Nos. 1403 and 1404, imposing
developer impact fee pursuant to Government Code 53080.
Building Permit Request
`.
The City of 77 r t& has received a request for a Building Permit described as follows:
Residential Development Project ❑ Commercial/Industrial Development Project
Name of Developer:
Project Address:
Description:
A- V/ SIc- .�)
Square Footage: 3 200 Lot/Parcel #: 2 6 a Zy o 9
Date: -� /—/ y By:
Permit #: / 3 DbI") U 6',-
�/
,,,-City Authorized Representative
Square footage will be verified by the city prior to issuance of a building permit; fees may be adjusted accordingly.
Important Notice:
Cupertino Union School District gives no credit for total demolition of existing square footage area, which makes
way for new construction as mandated in the Government Code Sections 53080, 53080.6 and 65995.
SCHOOL DISTRICT DEVELOPER IMPACT FEE
CERTIFICATE OF COMPLIANCE
The authorized representative of the Cupertino Union School District has reviewed the
I
City of U L420I
Building Permit Request described above and hereby certifies that the developer or authorized representative has
met the requirements of the District's Developer Impact Fee requirements.
Dated: a 1 a, 1:- 7W ! 4 By:
Authorized Representative
Cupertino Union School District
r
Certificate not valid without
District seal, initial, and date.
Fee: S
Check No.:
Facilities Planning - White City - Yellow Requestor - Pink Accounting - Gold
PURPOSE
UTILITY RELEASE REQUEST FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 _
(408) 777-3228 • FAX (408) 777-3333 • buildino(o)cupertino.org
For residential single family or duplex construction, there are cases where gas and electric utilities are
requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the
building inspector, the City of Cupertino is allowing both utilities to be released prior to the final sign -off of
the building.
INSTRUCTIONS -" -
1. Download this form at: httD:H/ v<v<v.cupertino.orLr7index.aspx?paiae=297.
2. Complete the form and obtain signatures from both the owner of the property and the primary contractor.
3. Fax, E -Mail, Mail or hand deliver the original signed form to:
City of Cupertino
Building Division
Attn: Utility Release Request Form 408-777-3228 office
10300 Torre Ave. 408-777-3333 fax -
Cupertino, CA 95014 buildingacupertino.org
4. Schedule a Gas Meter Release inspection (#403) and/or Electric Meter Release inspection (#404). Please
note, a Gas Test inspection (#506) is required prior to or at the same time of the Gas Meter Release
inspection.
BUILDING INFORMATION (Please complete the following information):
APN BLDG PERMIT #:
DATE:
SITE
1 n
ADDRESS: OO ✓EA�O� U -e, '
OWNER'S NAME:
PHONE #:
C
FAX #:
MAILING ADDRESS (if differen from site address):
CONTRACTOR:
PHONE #:
S
FAX #:
CONTACT:
PHONE #:
FAX #:(4ok)L�
I request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of
the building cannot move into the residence until they receive all of the required final sign -offs and the City has issued a certificate of
occupancy for the buil in .
Owner: ................. ..... .�......... Print:......................................................................... Date:..............................
Contractor: ........................................................... Print .... 01,A .....0 .. ................................ Date:..&!,z° (r
UtiliryReleaseForm_2011.doc revised 08/09/11
04
San Jose
Water
Irm Company
110 W. Taylor Street
San Jose, CA 95110-2131
October 8, 2014
XiaYi Gan
10068 Adriana Avenue
Cupertino, CA 95014
Reference: 10068 Adriana Avenue, Cupertino
Dear Ms. Gan: /c/8
San Jose Water ompany
Water Services Administration
1265 S. Bascom Ave., San Jose, CA 95128
Facsimile: 1 408 279-7889
Writer's Direct Dial: 1 408 279-7800, ext. 5805
'�.E�TVED
OCT 0 9 2014
BY
The purpose of this letter is to inform you of the procedures you need to follow to finalize
the installation of a new water service for this project. You will be required to hire a contractor to
perform the service installation work to our standards and under our inspection. It is suggested,
but not required, that you contact one of our general contractors to have this work performed.
They are West Valley Construction at (408) 371-5510, and Lewis & Tibbitts at (408) 925-0220.
In any case, your contractor must possess a valid license to perform this type of work, and must
obtain a permit from the City of Cupertino to perform the work.
Based on the data that was provided on our water service questionnaire, our Engineering
Department has determined that a 2" copper service with a check valve is required for this house.
The piping from the check valve/meter to the house should be 2" in size. By copy of this letter,
we are informing the City of Cupertino of our determination, and I have enclosed our standard
service drawing that details an approved installation. The meter/check valve (service connection)
defines the point at which you receive service, and the point where the owner's piping begins.
The owner of the property is responsible for all piping and equipment past the check valve.
Please note that in addition to the check valve in the meter box, you must also install a
rubber seated single check valve (property of the owner) on the internal plumbing of the house.
The location of the check valve must be where the fire sprinkler piping tees off from the domestic
piping. Also, the water pressure in this area is over 80 PSI. San Jose Water Company
recommends that a pressure regulator be installed on private service lines that will prevent
pressure in excess of 80 PSI from entering the structure. Please contact your plumber regarding
this matter.
w
XiaYi Gan
October 8, 2014
Page Two
If you would like to proceed with the service work, please sign, date, and return this letter
with a construction deposit as discussed below. Also include the address where the monthly
billings should be sent. Monthly billings start when the meter is installed, and a copy of our rate
schedule is enclosed for your information. You must also submit a deposit in the amount of $890
to cover the cost of our reviews and inspection, and the purchase and installation of the new meter
and check valve. Please make your check payable to San Jose Water Company.
At the appropriate time, you will need to provide our Construction Department at least one
week notice for inspection services. Your contact is Daryl Lambert, who can be reached at (408)
279-7830. A San Jose Water Company inspector must witness the actual tap of the water main.
Once the service lateral and meter box have been installed and approved, we can install the meter
and check valve at your request.
If you have any questions, or require further information, please contact me at (408) 279-
7800, extension 5805.
JC:bct
Enclosures
FIN 14-177
cc: Building Department, City of Cupertino
ACKNOWLEDGED AND AGREED
Responsible Party
Signature
Print Name
Date
Sincerely,
Jay Coito
Water Services Representative
MONTHLY BILLINGS TO:
Name
Address
City
Phone Number
CUPERTINO
PURPOSE
UTILITY RELEASE REQUEST FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(Wcupertino.org
For residential single family or duplex construction, there are cases where gas and electric utilities are
requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the
building inspector, the City of Cupertino is allowing both utilities to be released prior to the final sign -off of
the building.
INSTRUCTIONS
1. Download this form at: http://www.cupertino.org/index.aspx?page=297.
2. Complete the form and obtain signatures from both the owner of the property and the primary contractor.
3. Fax, E -Mail, Mail or hand deliver the original signed form to:
City of Cupertino
Building Division
Attn: Utility Release Request Form 408-777-3228 office
10300 Torre Ave. 408-777-3333 fax
Cupertino, CA 95014 building@cupertino.ora
4. Schedule a Gas Meter Release inspection (#403) and/or Electric Meter Release inspection (#404). Please
note, a Gas Test inspection (#506) is required prior to or at the same time of the Gas Meter Release
inspection.
BUILDING INFORMATION (Please complete the following information):
APN 7BLDG
PERMIT #:
-7
DATE:
SITE
ADDRESS:
OWNER'S NAME: j�
PHONE #:
h
FAX #:
/ S ( —
MAILING ADDRESS (if differ nt from site address):
rA
CONTRACTOR:
PHONE #:
p
FAX #:
—
d
CONTACT: V
PHONE #:
FAX #:
S
D d
I request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of
the building cannot rpove into the residence until they receive all of the required final sign -offs and the City has issued a certificate of
occupancy for the bbilding.
Owner: ....... ................. Print: ....... ...(-A .......l ...... �a-�.............. �
Contractor. .... .................. .............:............................ Print:......��........................................................ Date:. �s..0 ....20 �.......
UtilityReleaseForm 2011.doc revised 08/09/11