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14120001 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19042 TILSON AVE CONTRACTOR:HSU TRACY TRUSTEE PERMIT NO: 14120001 OWNER'S NAME: HSU TRACY TRUSTEE 22330 SANTA PAULA AVE DATE ISSUED: 12/01/2014 OWNER'S PHONE: 4084645030 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑ DEMO(E) 1,544 S.F. SFD License Class Lic.# Contractor Date 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:$10000 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:375 09 006 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 WITHIN 180 D 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 D OM CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the -- //h granting of this permit. Additionally,the applicant understands and will rr�pty"-- ssued b - 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) 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,Sections 2 05,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized agent: Date: u1 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 CONSTRUCTION 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 �� I DEMOLITION PERMIT APPLICATION QO Is COMMUNITY DEVELOPMENT DEPARTMENT r BUILDING DIVISION 10300 TORRE AVENUE r CUPERTINO, CA 95014-3255 CUPERTIN© (408)777-3228 r FAX (408)777-3333 r buildinq(57cupertino.org PROJECT ADDRESS �-/ APN 4 3 ? � �� OWNER NAME � PHONE E-MAIL�t-Dff-46+G-o36 -tea c:X _ ksu STREET ADDRESS O S vd,, CITY, STATE,Z ��N ' /� FAX^ 6 Z "_„ti ���J�l �t�v CON'T'ACT NAME rQ- '� K PHONE w D Q ,� / E-MAIL _ STREET ADDRESS Z 2 3+ IQ CITY,STATfE,-FZ�aP !�-(,\ S(� / FAX S � r ❑OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS LIC4 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK q 0 0 RESIDENTIAL 4 DWELLING OFFICE LSE ONLY FLOOR AREA UNITS USE OCC. TYPE SO.FT, VALUATION COMMERCIAL FLOOR AREA TYPE OF CONSTRUCTION 4 STORIES yqL�1 AQMD JOB NUMBER J k 3� s VALUATION \ TOI By my signature below,I certify to each of the following: I am the property owner or au agen c e 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 It is accurate. 1 agree to comply with all applicable local ordinances and state laws relating to buildin construction. 1,eugiorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: /i l SUPPLEMENTAL INF RMATIO QUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT OFFICE USE ONLY Provide Job Number from Bay Area Air Quality Management District wkvvv.haacl1-nd.ore n 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 02/13/13 CITY OF CUPERTINO D FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 19042 TILSON AVE DATE: 12/01/20147] REVIEWED BY: MELISSA Fj APN: 375 09 006 BP#: 14110036 "VALUATION: 1$10,000 PERMIT TYPE: Demolition Permit PRIMARY SFD or Duplex PENTAMATION 1SFDWL-DEM USE: PERMIT TYPE: WORK DEMO E 1,544 S.F. SCOPE FEE ID FLR AREA s.f. 1 DEMORES 1,544 NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff 7%1 X13) FEE QTY/FEE MISC ITEMS Permit Fee: $574.00 Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00 i Strom Motion Fee: IBSEISMICR $1.30 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $576.30 $0.00 TOTAL FEE: $576.30 Revised: 10/01/2014 Building Department City Of C upertino 1 ` 10300 Torn!Avenue Cupertino,CA 95( 14-3255 Telephone: 408 77-3228 CUPERTINO Fax: 408 77-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: kCA p Z 14 M PW Q PERMIT# ( 17, 00 C) OWNER'S NAME: PHONE# l-17 — t(40' GENERAL CONTRACTOR: fit' irl BUSINESS LICENSE# Z 3 g tF ADDRESS: 5�� V& Z I CITY/ZIPCODE: 0 Z *Our municipal code requires all businesses orking in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL CUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AN LL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subco actors: i rer �� Date Please check plicable subcontractors and complete the following informati (Y 1 V SU CONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum/Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/eontraceor Signature Date OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• building(c)cupertino.org 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 APN BP# OWNER NA OWNER ADDRESS - Lil ZZ 3 0 7 Cary i ►� �j�71� DESCRIPTION OF WORK: 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.) W1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner- ilder"der"er" 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. -A—, 2. 1 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. 3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may pr tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. IrV 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. i4-5. I 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 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. �7. 1 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. 7 8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for a y financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 1 9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal R venue 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.csib.ca.gov for more information about licensed � contractors. `1 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. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the inf rmation 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 drivel'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 owners signature. Property Owner's Signature: Date: -------------------------------------------------------------------------------------------------------------------------------------------- (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: OwnerBuilderForm 2010.doc revised 04/14/10 f PROCEDURE CHECKLIST FOR DEMOLITION PERMITS COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ALBERT SALVADOR,P.E.,C.B.O.,BUILDING OFFICIAL CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 950143255 (408)777-3228•FAX(408)777-3333•building acuoertinc.cra PURPOSE U Z4-2- The ZThe demolition application should be applied for before or at the same time as the new construction permit application(these are separate permit applications and fees). Pen-nit fees are due at the time of the application/plan submittal. The nein construction permit will not be issued until the demolition permit is issued,unless a letter obtained from the Building Department is submitted stating that "The existing house will not be demolished until the new construction permit is issued".The letter needs to be signed by both the property owner and general contractor, REQUIREMENTS To obtain a demolition permit in the City of Cupertino, please complete a Demolition permit application along with each of the following requirements as it applies to..your specific project. 1. Three(3)copies of a Site(Demolition)plan for Residential or six(6) copies for Commercial will be required sho-cirig any trees 10 inches in diameter at 3 feet above grade on the subject property, and what means will be taken to protect these trees. 2. PG&E must be contacted AS EARLY AS POSSIBLE prior to demolition to schedule the abandonment. Contact PG&E at(408) 72.5-3325. A Ietter from PG&E shall be provided to the City,stating that all gas and electric has been di - iected. (This step can be time consuming,so it is important to begin the process immediately) 3. Provide Job Dumber from Bay Area Air Qualih-Management District www.baagmd.gov 415-749-4762. t Zo 4. Check to see if the building is considered an historical landmark. Obtain clearance f the Cornmunih- Development Planning Department. Allow 10 workin& days. r�- Providle a letter c:i cli ar?ance of all vormin from a licensed pest control contractor. 6. Important: Prior to the issuance of the demolition permit,the applicant must call the Public Works Department at(408)777-3104 and arrange a"habitable dwelling" inspection. Debris bin and Recycling sheet: read,sign and date. The sheet will remain in the project's building permit file for the duration of the project. 8. Commercial only-prior to issuance of the demolition permit, the Fire Department must review the plans for fire suppression/alarm systems that shall remain in serf ice rr be modifiNd during Demolition or that shall be replaced tiff ith the new construction. '13 13 Pacific Gas a,i P Electric Company 10900 No. Blaney Avenue " - Cupertino, CA 95014 DATE: November 19, 2014 CITY OF CUPERTINO 10300 TORRE AVE CUPERTINO CA 95014 SUBJECT: REMOVAL OF GAS SERVICES (CUT @ MAIN IN THE STREET) ON: November 18 2014 CO) 19042 Tilson, Cupertino SUBJECT: ELECTRIC SERVICES WAS CUT AT POLE ON October 31 , 2014 @ 19042 Tilson, Cupertino If you have any question contact us at (408) 725-2153 Sincerely, John Gambucci Pacific Gas & Electric Company DeAnza Service Planning Dept. m-- _ Regulation 11, Rule 2 COMPLIANCE & ENFORCEMENT Acknowledgement of BAY A R- F A Notification and AiR,QUAUTY DIVISION Payment Of Fees MANAGEMt N"F D 1 S T A t C T 11/24/2014 Randazzo Enterprises,Inc Job No:4K354 13550 Blackie Road Invoice No:3LY39 Castroville,CA 95012 The Bay Area Air Quality Management District(BAAQMD) acknowledges receipt of your payment and your Asbestos Removal or Demolition Plan described as:Demolition Site address 19042 Tilson Avenue Cupertino, CA 95014 Start Date December 8, 2014 Completion Date December 10,2014 Removal amounts of liable ACM 0 linear feet 0 square feet 0 cubic feet Should it become necessary to revise this plan, please do so in the spaces provided below and immediately copy the District by fax or by mail. REGULATION 11-2 REVISION BAAQNID J#4K354 REVISION# START DATE COMPLETION DATE 1 2 3 5 --------- NOTE: This form is not intended as a verification of either the completeness of your original notification or of its compliance with BAAQMD Regulation 11-2. If you have any questions about this acknowledgment,please call our office at(415) 749-4762.