B-2017-1560 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1560
11164 LA PALOMA DR CUPERTINO,CA 95014-4773(356 16 040) A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS,TN 38120
OWNER'S NAME: LYU MENG HSIUNG AND SHU CHEN TRUSTEE DATE ISSUED:09/12/2017
OWNER'S PHONE: PHONE NO:(901)271-9700
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36:C-42:A Lic.#765155
Contractor A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X BLDG _ELECT X PLUMB
Date 07/31/2018 _MECH X RESIDENTIAL_COMMERCIAL
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 JOB DESCRIPTION:
license is in full force and effect. PROPERTY LINE CLEAN OUT
• REV#1-SEWER LINE REPAIR-PIPE BURST METHOD(40 S.F.)
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
/ ..kr+drformance 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 Sq.Ft Floor Area: Valuation:$4973.00
permit is issued.
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 356 16 040
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 PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgments,costs,and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against.said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION.
source regulations per the Cupertino Municipal Code,Section 9.18.
.Ci^
<," Issued by:,ABBY AYENDE
,:
•
``* l
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
,1I9� (408)777-3228 • building@cupertino.org PEMIT#B-�l - �r7
Jl
CUPERTINc" REV# I DEF#
❑ NEW CONSTRUCTION 1=1 ADDITION ❑ALTERATION ❑T.I. MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS' 16 r S Lex.. PGS Lovv � 55 /D APN# —t'/040
OWNER NAME ", HONE E-MAIL
-\c,‘ivxo.i A.L4
STREET ADDRESS' CITY,STATE,ZIP
4 k 1 (o'Lt 1.c• Vat-s 0-r n C` - �-� , C Ft- 95-0 `I
4 CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME A.-cS LICENSE UMBER LICENSE TYPE
STREET ADDRESS
I
CITY,STATE,ZIP
' 227v�_ Qc„C-C C)r S a o sc , Cit s 1
E-MAIL PHONE' I BUS.LIC#
' : \JCCo'':30,1,C'S- C 4056''G. --C3L4.0S -1 USS'Zc
• ' 0 ARCHiTECT ❑OWNER❑OWNER AGENT,[C CONTRACTOR AGENT ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME ' ' E-MAIL
alLC\ _ \JCa ) pot cc --\
STREET ADDRESS CITY,STATE,ZIP PHONE
1 „ 01- Qln..cencw\ 0✓ ;� CA- CI S-11 4M-9 2-O-10�
DECRIPTON .'
c..1
❑SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL I
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
' REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF ❑DETACHED i '
6XISING I' ❑YES EICHLER ❑YES ' SECOND STORY ADDITION ❑ -
FIRE SPRINKLERS❑NO ElNO ❑NO
DWELLING; SECOND,DWELLING ,DYES',❑ATTACHED❑DETACHED OTHER
UNITS#„' UNITIADDITON: 0N I SF
II I
POOLSI ,❑FIBERGLASS ❑VINYL-LINED r❑GUNITE ❑PREFABRICATED - ”
Commercial or M lti Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval RE V D BY: ,w� D
POOL SF I SPA-SF SPA ATTACHED❑YES ❑NO TOTAL-SF Na'l-
ii:'. I 1• . _ I , r"ti / VALUATION:
TOTAL
RE=ROOFI'EXISTING ROOF TYPE:,in BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHIN LES❑TILE OTHER(SPECIFY)
.I:'°,I 'I 1 I.
REMOVE/REPIACE NO IIFNO,� ' . PLYWOOD CI'A" CI 3/8" PLYWOOD TYPE: - PITCH: ROOF CLASS.
ItOFLAYERS , THICKNESS 5/8" OTHER El OSB ❑CDX OTHER 1,2 A
;1;1- OYES ❑
PROPOSED ROOF TYPE:'GBUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER
*Providea�silgned copy of the CCupertino's Tear-Off Policy SF not SQUARES
By'myfsignaiture 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 itis accurate. I agree
to comply with all applicable local ordinances and state laws relating to,building construction.. I authorize representatives of Cupertino to
enter:theabove-identified property for inspection rposes. I acknowlede and authorize all information contained on this application form
to be made a
g vi ilable for public recor '
Signature,ofiApplicarit/Agente 9i/,
Date: ll
SUPPLEMENTAL INFORMATION'REQUIRED '
1 ; 'r I „ , ,
'New SFD/SecoiidDwelling Units/Mi ltifamily 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 Letter or Meeting with Planning prior to'submittal of Building Permit application.
*HOA-Propide a,lett'er of approval'from the Home Owner's Association' ,
' I , Bldpp 2017.doc revised 08/01/17 ,
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1560
11164 LA PALOMA DR CUPERTINO,CA 95014-4773(356 16 040) A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS,TN 38120
OWNER'S NAME: LYU MENG HSIUNG AND SHU CHEN TRUSTEE DATE ISSUED:09/12/2017
OWNER'S PHONE:408-666-7349 PHONE NO:(901)271-9700
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 C42 A Lic.#765155
Contractor A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X BLDG _ELECT X PLUMB
Date 07/31/2018 _MECH X RESIDENTIAL_COMMERCIAL
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 JOB DESCRIPTION:
license is in full force and effect. PROPERTY LINE CLEAN OUT
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.
s I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the'perfortnance of the work for which this Sq.Ft Floor Area: Valuation:$4973.00
permit is issued.
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 356 16 040
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 PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgments,costs,and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands'and will comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION.
source r gulations per the Cupertino Municipal Code,Section 9.18.
Issued by:Kim Dunbar
Signet Date 09-12-2017 Date:09/12/2017
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that l,am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1. I,as owner of the property,or my employees with wages as their sole - inspection.
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professions Code) Signature of Applicant:
2. I,as owner of the property,am exclusively contracting with licensed Date:09-12-2017
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty' of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 1 have and will main'taina Certificate of Consent to self-insure for Worker's
Compensation,asprovided for by Section 3700 of the Labor Code,for the HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
3. I certify that in the,performance of the work for which this permit is issued,I material. Additionally,should fuse equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the
will maintain compliance with the Cupertino Municipal Code;Chapter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety U ode,Sections 25505,25533,and 25534.
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 Owner or authorized a
01.
be deemed revoked. 9,
Date:09-12-2017 •
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C:) '
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
3:,!-- GENERAL PERMIT APPLICATION M P
.:. COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
g'x t�9
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISC •
GURER'#'IPfO {408)777-3228•FAX(408)777-3333•buildingacupertino.orq
®PLUMBING -. ❑MECHANICAL , ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS APN# //
11164 LA PALO ADR �P ' l0 '.OYO
•OWNER NAME MICHAEL LUY PHONE 408-666-7349 E-MAIL
STREET ADDRESS 11164 LA PALOMA DR CITY, STATE,ZIP CUPERTINO, CA 95014 FAX
CONTACT NAME PHONE E-MAIL '
STREET ADDRESS CITY,STATE,ZIP FAX •
❑.OWNER ❑ OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER , ❑ DEVELOPER 0 TENANT: '
CONTRACTOR NAME LICENSE NUMBER LICENSE 36 C42 A - /
RESCUE ROOTER 765155 "601-3-52 ,711'1,61
COMPANY NAME E-MAIL FAX
ARS RESCUE ROOTER VCAO@ARS.COM
STREET ADDRESS ' CITY,STATE,ZIP PHONE,;
2305 PARAGON DR SAN JOSE, CA 95131 ,;408-982-0405
ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS.LICE# •
i'
COMPANY NAME E-MAIL FAX '
I.
STREET ADDRESS - CITY,STATE,ZIP PHONE I a i
I I'
USE OF SFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILDLAND 0 YES PROJECT IN ❑YES . IS THE BLDG;AN , , ❑,YES: .
I,
BUILDING: El COMMERCIAL URBAN INTERFACE AREA El NO FLOOD ZONE 0 NO EiCHLERi HOME?
1:1 NO
DESCRIPTION OF WORK PROPERTY LINE CLEAN OUT
.
•
.
TOTAL VALUATION: 4,973 RECEI •,!.•)(_:,---e.'• s. , d r N ,L.
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 witli all applicable local '
ordinances and,state laws relating,to building construe n..I authorize representatives of Cupertino to enter the oye-iden i ied property for Inspection purposes. ,
1
Signature of Applicant/Agent: ..: - . Date: 1[/1 7 1',!
SUPPLEMENTAL INFORMATION REQUIRED T oFk its ,oiSLY�I;�' a , a
i9=W OYER THE- .9.0 1R '°_{;.',`ie,.
'r D'EXPRESS r V ai a
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a.x•re O.,06.R•=, t,x. ,n' '
MEPMiscApp 2011.doc revised 06/21/11 •
@�\`�o SANITg4,,,d,,r \\ e
CUPERTINO SANITARY DISTRICT S 24 „.40,/,,,,,,
\
20863 Stevens Creek Blvd#100, Cupertino, CA 95014 /4-
Tel(408)253-7071 • Fax(408)253-5173 4'`47et/aNEO," cmPERTINO
SANITARY DISTRICT PERMIT LETTER
Cupertino Sanitary District has adopted Resolution No. 1263.
Building Permit Request
(Over-the-Counter)
Single Family Project n Multi-Family Project n Commercial Project
roject Address: //ICO'•-/ c /C�!/1'7 7� -
Permit Number: a ?Z r - LS-Co D
Scope of Work: I-14. -ham.I (e in. /it_.."(A3 ?(L 4
Owner/Applicant Name:Z-t?56- e 'Z&7)4-e-- Phone: 41O q6-2_-0(-7105
Address:
Date: 9-12.--- I 7-Prepared By: ,
City Authorized Representative
I, as property owner orauthorized agent, acknowledge that all Cupertino Sanitary District requirements
will be met and all required fees will be paid prior to the approval of final inspection for proposed project.
Date: Signature:
Owner/Authorized Agent
CUPERTINO SANITARY DISTRICT OFFICE USE ONLY
n Pre-inspection Required Final Inspection Required
Date Scheduled:
Date: Conditional Approval By:
Authorized Representative
Cupertino Sanitary District
District will notify owner of the required fee within 5 days after Pre-Inspection has been completed and cc
City of Cr .
Inspection Fee Paid Date Paid: 9/i/(1
Inspection Fees:
I $250/unit-Single Family Residential already connected, but new cleanout is required
A l $150/unit-Single Family Residential already connected with existing cleanout in working order
0 $350 Minimum—Commercial and Retail Actual Amount:
0 $200/each—Disconnect and/or abandon lateral service
Connection Permit Fees:
0 $350/unit-Single Family Residential connecting to existing lateral
fl $650/unit—Single Family Residential connecting with new lateral
D $100/unit—Multi, Hotel, Living Units, etc. Actual Amount:
0 $500/connection -Commercial and Retail Actual Amount:
Connection Use Fees (See Attached Calculation Sheet):
In Area and Frontage Fees Amount:
L Residential Excess Fees over 3.5 unit/acre Amount:
n Commercial and Retail Connection Fees Amount:
0 Commercial and Retail Change in Use Fees Amount:
Date: q/1 ! 1 -7 Final Approval By: / - (
mir Authori -. 'epresentative
Cupertino Sanitary District
SMOKE / CARBON MONOXIDE ALARMS
if) OWNER CERTIFICATE OF COMPLIANCE
g,«s COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinq a(�cupertino.orq
PERMIT CANNOT BE FINALED UNTIL THIS CERTIFICATE HAS BEEN
COMPLETED,SIGNED'"AND RETURNED TO THE BUILDING DTVISION
J.�..rkrt
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance-with 2016 CRC Section R314, R315,2016 CBC Sections 420.6 and 907.2.11.2 where no interior access
for inspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314, R315, and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or
Carbon Monoxide Alarms be installed in the following locations:
AREA SMOKE ALARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the X X
bedroom(s)-(Smoke alarms shall not be located within 3 feet of bathroom door)
On every level of a:dwelling unit including basements and habitable attics X X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage. .Carbon monoxide alarms combinedWith smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply:In dwelling units with no commercial power supply, alarm(s)may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the'removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl
space.'''Refer to:CRC Section R314 and CBC Sections 907/2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above-referenced property, I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms specified below have been tested d are operational, as of the
date signed below.
t
gAddress: ibLa 'T0.[oaa
Permit No. (3 24 1'7 . I�6
• Specify Number of Alarms: #Smoke Alarms: #Carbon Monoxide Detectors:
I have read and agree to comp) kith the terms and conditions of this statement
Owner(or Owner)4ent's)Name:
cw`OL ;LN(Li
Si.nature���� �� .Date: '
Contractor Name:
Signature Lic.# Date.
Smoke and CO form.doc revised 01/10/2017 .�
•
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