B-2017-1565 CITY OF CUPERTINO BUILDING PERMIT
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BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1565
19358 GREENWOOD DR CUPERTINO,CA 95014-3454(375 43 033)119342 OWNER/BUILDER
GREENWOOD DR CUPERTINO,CA 95014-3454(375 43 033)
OWNER'S NAME: HSU JUI-CHUN AND HWANG HENRY YAO-TEH ET AL DATE ISSUED:09/13/2017
OWNER'S PHONE:408-802-5443 PHONE NO: ,
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Date X BLDG _ELECT _PLUMB
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
license is in full force and effect. JOB DESCRIPTION:
RE-ROOF;TEAR-OFF;INSTALL OSB;COMP SHINGLES(5000 SF)
I hereby affirm under penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the ,
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$20000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 375 43 033
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 of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will'comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 09-13-2017 Issued by:Kiri Dunbar
Date:09/13/2017
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
followi. two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
- 0I,as owner of the property,or my employees with wages as their sole installed without first 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'of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:09-13-2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. ; 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
a. 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 ateriaAddit•
ionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the .'the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall ii EE'
bebe deemed revoked. Owner or authorized agent Y., ` �
APPLICANT CERTIFICATION Date:09-13-2017 '
I certify that I have read this application and state that the above information is I►.T,I 1 CTION 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 source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signat' a Date 09-13-2017 Professional
CONSTRUCTION PERMIT APPLICATION
\ 'k� COMMUNITY DEVELOPMENT DEPARTMENT •• BUILDING DIVISIONg .
/v 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 _
s (408) 777-3228 • building@cupertino.org PEMIT#B-ZOI 1 S 5
CUPERTINO REV# DEF#
1=I NEW CONSTRUCTION ❑ADDITION ❑ALTERATION 111T.I. 111 MEP 1 RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS APN I `J'
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OWNER NAME / PHONE E-MAIL
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STREET DRESS CITY, STATE,ZIP
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ONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
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0 ARCHITECT 0 OWNER ❑OWNER AGENT 0 CONTRACTOR AGENT ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
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STREET ADDRESS CITY,STATE,ZIP PHONE
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SINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY ElINDUSTRIAL ElCOMMERCIAL I
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK 5F DEMO SF STORIES I TOTAL NET SF• USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
YES
FIRETS SPRINKLERS 0 NO :EICHLER,❑❑ NO SECOND STORY ADDITION OS
NO
DWELLING ,SECOND DWELLING ❑YES 0 ATTACHED 0 DETACHED OTHER
UNITS I UNIT ADDITON: ❑NO' S F
POOLS' ❑FIBERGLASS D.VINYL-LINED ❑GUNITE ❑PREFABRICATED
POOL-SF SPA-SF J I 'SPA ATTACHED❑YES 0 NO I TOTAL-SF
I i RE VED Y: n TOT,L VALUATIO
Commercial or Multi-Family Buildings with Public Swimming Pools requires Department pf Environmental Heath approval ` ',r,--I e✓ i��
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RE-ROOFI EXISTING ROOF TYPE: E BUILT-UP ROOF E ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGL S❑TI I E OTHER(SPECIFY)
REMOVE/REPLACEE NO IF NO PLYWOOD '' ❑3/8" PLYWOOD TYPE: PITCH1:'`^i ROOF,CLASS
C,EYES ElLY
I OF LAYERS 0 THICKNESS 5/8" OTHER x BB ❑CDX OTHER '12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES❑WOOD SHINGLES 0 OTHER '
*Provide a signed copy of the Cupertino's Tear-Off Policy S40'�y'�;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 applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection purposes. I.acknowledge and authorize all information contain d on this application form
to be made available for public record.
Signature of Applicant/Agent: Date: - ? f �. ( 7
SUPPLEMENTAL INFORMATION,REQUIRED
*New SED/Second Dwelling Units/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 Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
B1dgApp_2017.doc revised 08/01/17
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REROOF TEAR-OFF POLICY
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COMMUNITY DEVELOPMENT DEPARTMENT 4 BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O.,BUILDING OFFiCIAL
10300 TORRE AVENUE•CUPERTINO,CA 95014-3265
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(408) 777-3228•FAX(408)777-3333 0 building@cuerlino:org
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UNDERSTAND AND AGREE TO,THE FOLLOWING:
1. The re-roof project shall comply with all applicable provisions of the 2016 California Codes.
2. An inspection repest can be scheduled up to one business.dav before the requested inspection date.
To schedule inspections call (408) 777-3228 from 7:504..„3Qpi-Oifon4hurs) Or 7:30-2:30pm(Friday) to
schedule inspection. For Tear-Off and Nailing InspeetionSnott 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: 730-10:30a.m and 12:30-3:30 (Mon-Thurs)
and 7:30-10:30am and 1.2:30-2:30 (Friday). Final Inspection S 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/fasteners shall be either
completely knocked-down or removed prior to this inspection.
4. If plywood is installed, a plywood Nailing Inspection is required.
5. Roofing shall not be applied without first obtaining all.prior inspection and written approvals froninthe
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 perfonned.
6. A Final Inspection and anproval shall be obtainettfroMthebuilding inspector when the re-roofing.is
completed. To receive a final signoff,the following heMs.will be-verified:
a. Flat roofs shall have a minimum of 1/4" per foot ofSlopp arid-demonstrate there is no ponding.
b. Listings from approved testing agencies for all premarmfactured 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 shaltbe aid before another ins ection can be
scheduled.
By my signing below,I certify each of the following is true: I ani the property owner or authorized agent to act on the
property owner's behalf. I understand and agree to comply with the re-roof policy stated above. I also understand that
smoke detectors and catbon monoxide detectors are required to be installed in accordance with Sections R314 and R.3'15 of
the 2016 California Residential Code.
. .
7 3-
SIgnature olApplicant/Aaent: Dap.: "
Reroeolicy 2014.doe revised 06/01-7
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1 "1 OWNER-BUILDER DISCLOSURE FORM
: COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
,y-E:1 -, 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 -
CUPERTINO (408)777-3228 • FAX(408)777-3333• buildina(a cupertino.orq
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 , BP#
/9312 R 193- 1-4. �Poweact, 0/,. & aim
OWNER NAME OWNER ADDRESS
' Nwgg, cfej4n'y /(1.6o, 14'4,-14 C40 _.9e
DESCRIPTION OF WORK: Rem ,eX/r1/4 I 'O f , ,,„.s'tj' '01'2 -(744-71:4/9 fpr
WA) ./dikt 0-.04‘0,,4i0o ,94t 9
v
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless '_
you,the'property,owner;obtain the prior approval of the permitting authority. ”
OWNER'SACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS;Please read and initial each statement below to signify you understand or verify this information.)
GK 1. 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.
G6'f 2. I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and'are not hiring a licensed Contractor to assume this responsibility.
dii 3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her _
name in'Stead of my own.
C 4. I'und'erstand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on,permits and contracts.
01 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.
6/1 6. I 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.
C 171 7. 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 sale, unless all work is performed by-
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work :
is performed under contract with a licensed general building Contractor.
Ci-7 8,. I understand1as an Owner-Builder if I sell the property for which.this permit is issued, I may be held liable for
any financial'1or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderFornz 2010.doc revised 04/14/10
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.cslb.ca.gov for more information about licensed
contractors.
a/ 10. I 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.
re 11. I 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.
C/1 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract,with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important fog you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying whether or not
those Contractors are properly':licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY.
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: CJ J c Date: 1?/2/2-'717
(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).
' I
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. /� /rJ
Scope of Construction Project(or Description of Work): /c 'n3°
Project Location or Address: 193N2 a/leew^f'ccr u"\-- e-yao 2-zo ,
Name of Authorized Agent: Are Tel Tel No/J
Address of Authorized Agent: 4o'72s LvtG�y ��/y'q�e ��"7 ' �� ?f`�3?
I declare under penalty of perjury that I am the propertyroowner 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.
-6
Property Owner's Signature: G Date:
yt/Zerf 7
O1+'nerBuilderForm 2010.doc revised 04/14/10
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SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinq@cupertino.org
PERMIT CANNOT BE FINALED UNTIL THIS CERTIFICATE HAS BEEN
COMPLETED,SIGNED'AND"RETURNED TO`THE BUILDING DI ISION
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 combined with 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 and are operational, as of the
date signed below. �/
Address: /93S ff' a4QeJLv'6v` O'• 74-6. (4 Permit No. 6-26(7" 7' (S
Specify Number of Alarms: #Smoke Alarms: I S I #Carbon Monoxide Detectors: I .
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Na e:
l ' //�7
�• / Signature Date: ( 9
Contractor Name: 444 9�'q p
' Signature Lic.# 12 o f Date: 66../91(1
Smoke and CO form,doc revised 01/10/2017