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B-2017-0158 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0158 11801 DOROTHY ANNE WAY UNIT 5 CUPERTINO,CA(366 09 043) OWNER'S NAME: DATE ISSUED: 10/03/2017 OWNER'S PHONE: PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.# Contractor 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: TO CLEAR CODE ENFORCEMENT-UNIT 5(IMPLEMENT HOUSE)- I hereby affirm under penalty of perjury one of the following two declarations: DEMOLISH(458 S.F.)OF GROUND FLOOR LIVING AREAAND �1. I have and will maintain a certificate of consent to self-insure for Worker's SECONDARY ENTRY STAIRS;REMODEL GROUND FLOOR Compensation,as provided for by Section 3700 of the Labor Code,for the BATHROOM(41 S.F.);REMOVE GROUND FLOOR KITCHEN; performance of the work for which this permit is issued. RESTORE GARAGES AT GROUND FLOOR AND INSTALL(2) I have and will maintain Worker's Compensation Insurance,as provided for by GARAGE DOORS;EXTERIOR EAVE AND WALL MODIFICATIONS; ° Section 3700 of the Labor Code,for the performance of the work for which this HISTORIC DOOR(3)AND WINDOW(20)REPLACEMENTS;(N) permit is issued. EXTERIOR ACCESS STAIRS FOR SECOND FLOOR LIVING AREA. APPLICANT CERTIFICATION REV#1 -LEGALIZE PORTION OF DECK AND STAIRS AT SECOND I certify that I have read this application and state that the above STORY(163 SF)WITH MUDROOM AT LOWER LEVEL(163 SF);(N) information is correct.I agree to comply with all city and county ordinances TANK-LESS WATER HEATER;REMOVE(N)STAIRS FROM SCOPE and state laws relating to building construction,and hereby authorize OF WORK-ISSUED 5/30/19 representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the Sq.Ft Floor Area: Valuation:$100000.00 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 APN Number: Occupancy Type: source regulations per the Cupertino Municipal Code,Section 9.18. 366 09 043 Signature '° "- Date 5/30/19 PERMIT EXPIRES IF WORK IS NOT STARTED OWNER-BUILDER DECLARATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR I hereby affirm that I am exempt from the Contractor's License Law for one of the 180 DAYS FROM LAST CALLED INSPECTION. following two reasons: 1. I,as owner of the property,or my employees with wages as their sole Issued by:Abby A ey nde compensation,will do the work,and the structure is not intended or offered for Date: 10/03/2017 sale(Sec.7044,Business&Professions Code) 2. I,as owner of the property,am exclusively contracting with licensed RE-ROOFS: contractors to construct the project(Sec.7044,Business&Professions Code). All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm under penalty of perjury one of the following three declarations: installed without first obtaining an inspection,I agree to remove all new materials for 1. I have and will maintain a Certificate of Consent to self-insure for Worker's inspection. Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Signature of Applicant: 2. I have and will maintain Worker's Compensation Insurance,as provided for by Date:5/30/19 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 3. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the HAZARDOUS MATERIALS DISCLOSURE Worker's Compensation laws of California. If,after making this certificate of I have read the hazardous materials requirements under Chapter 6.95 of the exemption,I become subject to the Worker's Compensation provisions of the California Health&Safety Code,Sections 25505,25533,and 25534. I will Labor Code,I must forthwith comply with such provisions or this permit shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the be deemed revoked. Health&Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous APPLICANT CERTIFICATION air contaminants as defined by the Bay Area Air Quality Management District I I certify that I have read this application and state that the above information is will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and correct.I agree to comply with all city and county ordinances and state laws the Health&Safety Code,Sections 25505,25533,and 25534. 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, Owner or authorized agent: judgments,costs,and expenses which may accrue against said City in Date:5/30/19 consequence of the granting of this permit. Additionally,the applicant understands CONSTRUCTION LENDING AGENCY and will comply with all non-point source regulations per the Cupertino Municipal I hereby affirm that there is a construction lending agency for the performance Code, Section 9.18. of work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name Signature Date 5/30/19 Lender's Address COMMUN; Y :YEL.OPMENT DEPARTMENT * BUILDING DIVISION ts LEI 10 .i1,�T(_)I�T�E AVENUE E(408)777-3228 9 CUPER'TINOf CA 95014-3255 buildin PEMIT#B- �.►D C PERTtNO REV# DEF# �NEW CONSTRUCTION �ADDrrlC)N Ej. ALTERAEON 0 T. O'MEI) ❑RE-Boor ❑SWIMMING POOL/SPA PROIECf ADDRESS ARN# // jai Ofj�or t. OWNER NAME PHONE E-MAIL /.p,o a a 6 L STREET ADDRESS CITY, STATE,ZIP 5 ❑CONTRACTOR NAME OWNER-13VILDER COMPANY NAJMR LICENSE NUMBER LICENSE TYPE STREET ADDRESS CITY,STATE, ZIP E-MAIL PHONE F3tJS.LIC# ❑ARCHI'I'= [:1OWNER OWNTER AGENT ❑CONTRACTOR AGENT ElENGINEER❑DEVELOPER El TFiIyANT [DESCRIPTON ONTACT NAME E-I1�AIL ,. PHONE STREET ADDRESS CITY,STATE,GIP IQ Ir r INGLE-FAMILY/DUPLFIX ❑MULTI--FAMILY []INDUSTRIAL ❑COMMERCIAL EXISTING USE EXISTING SN NEW FLOOR Sr, PORCH SF DECK SF DEMO SFSTORIES# TOTAL NET SF USE TYPE oCC SQ.ItT. VALUATION I L T REMODEL REN40DEL KITCHRN REMODEL OMR GARAGE ❑ATTACHED BATHROOM SF Sr. SF SF ❑DETACHED RXISING ❑YES D YES SECOND STORY ADDITION 0 E DIRE SPRINKLERS El NO EICHLER El NO . DWELLING I SECOND DWELLING ❑YES ❑AVrACHED❑DETACHED OTHER UNITS UNIT ADDI'ION: ❑No S F POOLS1 ❑FIE3F.RGLASS ❑VINYL-LIMED ❑GUMTE [] PREFABRICATED POOL-SF SPA-SIS I SPA Al TACHED❑YES ❑ NO TOTAL-Si-, LE ,D BY: TOTAL VALUATION: Coirltnea cial of Myth Folmilyr I3,uildings with Ptrf;Iie Szvirrjfniijg I'oo)s jMuireS DgMartment ojEnyironnionfal Heath appyovai RE-ROOF EXISTING ROOFTYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES❑WOOD SLAKES WOOD SHINGLES❑TILE OTHER 4(SPCIFY) REmova/REPLACE r7 NO I17 NO PLYWOOD ❑Ve El 3/8' PLYWOOD TYPE: PITCH: ROOF CLASS YES OF LAYERS THICKNESS❑5/g„ OTl-il;R ❑OSB [� CDX OTI-!6R ---�-- PROPOSED ROOF TYPE:1:1 BMT-UP ROOF ElASPHALT SHINGLES ❑WOOD SHAKES❑WOOD SHINGLIaS Q OTHER "Provide a signed Copy of the Cltpe.rtino-s Fear-Off P011Cy Sr #of SQUARES By my signature below I certify to each of the followu1g: I am the property owner or authorized agent to act on the property ownees.behalf. I have read this application and the information I have provided is correct. I have react the Description of Work and verify it is accurate. I agree to colriply 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 contained on this application form to be made available for public record. '..r� - � ent: Date: Signature of Appllc mt f Ag SUPPLEMENTAL INFORMATION REQUIRED *New SFE}/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction. *Comm.ercial 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. 'HDA-Provide a letter of approval frozrt the Horne Owner's Association 1(IgApp_0J 7,roc revised 08101117 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0158 11801 DOROTHY ANNE WAY UNIT 5 CUPERTINO,CA(366 09 043) HOMEOWNER BUILDER • OWNER'S NAME: DATE ISSUED: 10/03/2017 OWNER'S PHONE: PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License'Class Lic.# Contractor HOMEOWNER 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: TO CLEAR CODE ENFORCEMENT: UNIT 5(IMPLEMENT HOUSE)- I hereby affirm under penalty of perjury one of the following two declarations: DEMOLISH(458 S.F.)OF GROUND FLOOR LIVING AREA AND 1. I have and will maintain a certificate of consent to self-insure for Worker's SECONDARY ENTRY STAIRS;REMODEL GROUND FLOOR Compensation,as provided for by Section 3700 of the Labor Code,for the BATHROOM(41 S.F.);REMOVE GROUND FLOOR KITCHEN; performance of the work for which this permit is issued. RESTORE GARAGES AT GROUND FLOOR AND INSTALL(2) 2. .I have and will maintain Worker's Compensation Insurance,as provided for by GARAGE DOORS;EXTERIOR EAVE AND WALL MODIFICATIONS; 'Section 3700 of the Labor Code,for the performance of the work for which this HISTORIC DOOR(3)AND WINDOW(20)REPLACEMENTS;(N) permit is issued. EXTERIOR ACCESS STAIRS FOR SECOND FLOOR LIVING AREA. APPLICANT CERTIFICATION Sq.Ft Floor Area: Valuation:$100000.00 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 APN Number: Occupancy Type: representatives of this city to enter upon the above mentioned property for 366 09 043 inspection purposes. (We)agree to save indemnify and keep harmless the City'of Cupertino against liabilities,judgments,costs,and expenses which mayd accrue againstsaidCity in stands and e of the hg oflthis PERMIT EXPIRES IF WORK IS NOT STARTED Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 10/3/2017 Issued by:Abby Ayende OWNER-BUILDER DECLARATION Date: 10/03/2017 I hereby affirm that I am exempt from,the Contractor's License Law for one of the following two reasons: RE-ROOFS: 1. I,as owner of the property,or my employees with wages as their sole All roofs shall,be inspected prior to any roofing material being installed.If a roof is compensation,will do the work,and the structure is not intended or offered for installed without first obtaining an inspection,I agree to remove all new materials for . sale(Sec.7044,Business&Professions Code) inspection. I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). Signature of Applicant: I hereby affirm under penalty of perjury one of the following three declarations: Date: 10/3/2017 i. 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER z, `i5erformance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by '? HAZARDOUS MATERIALS DISCLOSURE Section 3700 of the Labor Code,for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the permit is issued. • California Health&Safety Code,Sections 25505,25533,and 25534. I will s. I certify that in the performance of the work for which this permit is issued,I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the shall not employ any person in any manner so as to become subject to the Health&Safety Code,Section 25532(a)should I store or handle hazardous Worker's Compensation laws of California. If,after making this certificate of material. Additionally,should I use equipment or devices,which emit hazardous exemption,I become subject to the Worker's Compensation provisions of the air contaminants as defined by the Bay Area Air Quality Management District I Labor Code,I must forthwith comply with such provisions or this permit shall will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and, be deemed revoked. the Health&Safety Code,Sections 25505,25533,and 25534. APPLICANT CERTIFICATION (ipw�ner or authorized agent:. I certify.that I have read this application and state that the above information is Date: 10/3/2017 correct I agree to comply with all city and county ordinances and state laws • CONSTRUCTION LENDING AGENCY relating to building construction,and hereby authorize representatives of this city I hereby affirm that there is a construction lending agency for the performance to enter upon the above mentioned property for inspection purposes. (We)agree of work's for which this permit is issued(Sec.3097,Civ C.) to save,indemnify and keep harmless the City of Cupertino against liabilities, Lender's Name judgments,costs,and expenses which may accrue against said City in • consequence of the granting of this permit. Additionally,the applicant understands Lender's Address and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. ARCHITECT'S DECLARATION •{ I I understand my plans shall be used as public records. jooY'ignature _ -Date 10/3/2017 Licensed AAimM 1m 1623 Wright Avenue - Sunnyvale Ca 94087 Ph# : 408-735-1524 Fax : 408-733-1548 August 22, 2019 City of Cupertino Building Division Attn: Building Inspector Subject: CHANG LONG REALTY DEVELOPMENT LLC ET AL Address:11801 Dorothy Anne Way, Unit #5 Cupertino, CA 95014 Epoxy Hold Down Installation Observation by MHA Consulting Engineers Inc. Dear Sir, Date of Observation: 08-22-19. Time 2.00 pm. On this date, we observed the epoxy installation of Hold Down Anchors for the above project. 5/8" dia rods were installed and embed 18" for HDU5, 12.5" for HDU2 using Set-XP epoxy. All rods were Installed in conformance with manufacturer's specifications and approved plans and specifications. If you have any questions please call. Yours Sincerely, MHA Consulting Engineers Inc.