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14060136 CITY OF CUPEl[ TINO BUILDING PERMIT BUILDING ADDRESS: 21918 LOMITA AVE CONTRACTOR:JUNJIE ZHENG PERMIT NO: 14060136 OWNER'S NAME: JUNJIE ZHENG 161 MUIR AVE DATE ISSUED:06/23/2014 OWNER'S PHONE: 4089167988 SANTA CLARA,CA 95051 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL SFDWL DEMO 752 SQ FT,ATTACKED GARAGE 273 SQ FT License Class Lic.# Contractor Date 1 hereby affirm that 1 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:$500 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:35715002.00 Occupancy Type: 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 WIT 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 IS®DAY FROM T CALLED ES;;WT . indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date 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. OWNER-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 Zeonstruct 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. 1 will 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 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this �� Owner or authorized agent Date: permit is issued. I certify that in the performance of the work for which this permit is issued,I shall of 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,1 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must 1 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 Namc 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 l 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, Signatur Date (y � ®EMOUT0ON PERMIT APPLICATION 12 COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION 10300 TORRE AVENUE .CUPERTINO,CA 95014-3255 CMPER'll"IBI® (408)777-3228 o FAX(408)777-3333^building aacupertino.orq ®� �( PROJECT ADDRESS 9 le APN# OUO,CIU OWNER NAME U f45 v PHONE EMAIL /�1��� STREET ADDRESS ^ CITY, STATE,ZIP f_ FAX 161 Alu CONTACT NAME v ! PHONE ` E-MAIL / ,/S t 1. STREET ADDRESS CITY,STATE, ZIP l �/J/F IAX, �/ ( t d OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT .❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME n 7�® LICENSE NUMBER LICENSE TYPE l BUS 47 COMP NAME 6 E-MAIL FAX 22 -1/C. STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTI OF WORK RESIDENTIAL yy #DWE G " OFFICE USE ONLY FLOOR AREA r� / UNITS USE OCC TYPE SO.PT . ;.VALUATION COMMERCIAL f FLOOR AREA lIIJJY" TYPE OF CONSTRUCTION #STORIES AQMD JOB NUMBER RECEIVED BY: TOT AY J #: 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. c Signature of ApplicanUAgent: Date: — SUPPLEMENTAL INFORMATION REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT "OFFICE USE ONLY. Provide Job Number from Bay Area Air Quality Management District www.baagmd.or;@ 415-749-4762. PLAN CHECK TYPE Provide three copies(Residential)or six copies(Commerical)of a site plan showing protection for any trees 10" EXPRESS in diameter or more at 3'above grade. ❑ STANDARD Provide letter from PG&E(408-725-3325)stating all gas and electric has been disconnected. �; LARGE Provide a letter of inspection,tests,and abatement of any Hazardous Materials.Letter to be initiated by person(s) MAJOR' ` certified in asbestos,mercury and/or hazardous material examination. Planning Dept clearance to verify building is not considered an historical landmark.Allow 10 business days. Provide letter of clearance of all vermin from a licensed pest control contractor. Applicant shall call the Public Works Department at 408-777-3104 and schedule a"habitable dwelling"inspection. Provide signed Debris Bin and Recyclable Materials form. DemoApp_2013.doc revised 02113113 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21918 lomita ave DATE: 0612312014 REVIEWED BY: Mendez APN: BSP#: 3 *VALUATION: $500 'PERMIT TYPE: Demolition Permit I'1.•:.1 ('lll;('ti !)'!'!.'. PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: 1SFDWL-DE M WORKsfdwl demo 752 s ft attached ara a 273 s ft SCOPE FEE ID FLR AREA s.L 1DEMORES 1,025 lilee. flan Check fl:.It. l't'1'ini!l rc !'lrvi2h. Pi'�'nai�1 e�: 1--t', Pei-;?lit lee � iON (i+hrr Pl,e;nh Imp Other LIec Insp, Li --I l•clr ]n',„• 1•,•e.' Iji,oah. h,sp. Ile L-lex. Insp.Fee: NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works, Fire,Sanitary Sewer District,School District,etc. . These fees are based on the prelimina information available and are onl an estimate. Contact the De t or addn'l info. ]FEE ITEMS (Fee Resolution 11-033 UL 711113) ]FEE QTY/FEE Il ISC ITEMS z: iUF�171. PC I't"c' T A Permit Fee: $557.00 Suppl. Insp. Feer Reg. Q OT Q.Q hrs $0.00 'Iz•.+rr G.%,r l;. Floc• 1':•�-.ail !�_. Pcilil. d Strong Motion Fee: IBSEISMlCR $0.50 Select an Administrative Item Bld.;Stds Commission Fee: IBCBSC 1 $1.00 SU BTOTA]LS: $558.50 $0.00 TOTAL FEE: $558.50 Revised: 04/01/2014 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE o CUPERTINO,CA 95014-3255 C9JPERTI N® (408)777-3228^ FAX(408)777-3333 o buildin cu ertino.or 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: —7— SITE ADDRESS 9_0 0 ® ',�� ,/ f APN BP# OWNER NAME CA OWNE JD RESS4401 v DESCRIPTION OF WORK: AVEl�G We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) 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. 2. I understand building permits are not required to be signed by property owners unless they are responsible for e construction and are not hiring a licensed Contractor to assume this responsibility. J�:3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. L4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. A5, 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the lvalue 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. g6. 1 understand if I am considered an "employer"under state and federal law, I must register with the state and ederal 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. � 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family sidLential 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. Jz 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderFonn 2010.doe revised 04114110 9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal evenue 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. 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. -11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. 42. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the in ormation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property,you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers'compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued,this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date:0 —?d -------------------------- ------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: 0wne)Bui1deJF6nn 2010.doc revised 04/14/10 1 padfic Gas and o. X Electric Company* 90900 No.Blaney Avenue Cupertino;CA 95094 DATE: June 11, 2014 CITY OF CUPERTINO 10300 TORRE AVE CUPERTINO CA 95014 SMECT: REMOVAL OF GAS SERVICES QCUT @ MAM IN THE STREETI ON: JUNE 10th ,2014 @ 21918 LOMITA AVE CUPERTINO CA SUBJECT. ELECTM SERVICES WAS CUT AT POLE ON : MAY 16T",2014 @ 1918 LOMITA AVE CUPERTINO CA If you have any question contact us at (408) 725-3325 Sincer y,� John Gambucci Pacific Gas & Electric Company DeAnza Service Planning Dept.