D-2017-0067 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:D-2017-0067
10177 BRET AVE CUPERTINO,CA 95014-3557(375 11 029) HORIZON CUSTOM
HOME
NEWARK,CA 94560
OWNER'S NAME: CHUANG SAN-TSAI AND TWE FUN TRUSTEE DATE ISSUED:12/07/2017
OWNER'S PHONE:408-515-2571PHONE NO:(510)673-4769
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#1027159
Contractor HORIZON CUSTOM HOJv1E Date 05/31/2019 _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:
DEMO EXISTING SFD(1672 SF)AND DETACHED GARAGE(600 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
iL- Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$10000.00,
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 11 029
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 1 ;
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature /La Date 12-07-2017 Issued by:Kim Dunbar
�.....,---- Date: 12/07/2017 '
OWNER-BUILDER DECLARATION ' '
I hereby affirm that I am exempt from the Contractor's License Lawfor one of the RE-ROOFS: ,i ,
following two reasons: All roofs shall be inspected prior to any roofing material being,installed.If a roof is
1. I,as owner of the property,ormy 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. I '
sale(Sec.7044,Business&Professions Code) ;I
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: I '
. contractors'to construct the project(Sec.7044,Business&Professions Code). Date:12-07-2017
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. 1 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 theLaborCode,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
Health&Safety Code,Section 25532(a)should I store,`or handle hazardous
3. I certify that in theperformance 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 material. Additionally,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 _. - -
be,deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:12-07-2017 !'
I certify that I have readthis application and state that the above information is CONSTRUCTION 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,CivIC.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name i ii
to save indemnify and keep harmlesa the City of Cupertino against liabilities, I
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. 1-understand my plans shall be used as public records.
Licensed
Signature Date 12-07-2017 Professional
DEMOLITION PERMIT APPLICATION -
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION — .7 D.
.-.F.,..:.:,136 :
' 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
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GUPERTINO (408)'777-3228• FAX(408)777-3333•building a,cupertino.orq
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PROJECT ADDRESS/0 ^17 h n ti K0 , qs�1 4_ APN# 3-7! au i a.1 q
OWNER NAME PHONE E-MAIL
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STREET ADDRESS CITY, STATE,ZIP FAX
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CONTACT NAME PHONE E-MAIL
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STREET ADDRESS CITY,STATE,ZIP FAX U
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IN OWNER ❑ OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE
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COMPANY NAME
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STREET ADDRESS CITY,STATE,ZIP PHONE
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DESCRIPTION OF WORK /V¢W too
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RESIDENTIAL -3 #DWELLING k l £ to salt hra USE ONLl. `� v,' x' k ' � a"
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FLOOR AREA 4t19 y UNTfS a ` RMS A PE E
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TYPEOF CONSTRUCTION #STORIES g '
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ECIEtY fli5 � i . mitaz� TO A� VALUATION:A MD JOB NUMBER REV )B.
J#: ,E e�4 ` ° Elt o , 000. 00. . . •
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By my signature below,I certify to each of the following: I am the property owner or autho' ed ag-.t ct 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 ven 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.
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Signature of Applicant/Agent: . %.J+- Date: i 2/ 6 ,/a- I 7
SUPPLEMENTAL INFORMATION REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT JSE I' V r
��''��o�+xcE IrsE oNLx�� '
1'J.Provide Job Number from Bay Area Air Quality Management District www.baaqmd.org @ 415-749-4762. & �1 CUECK TYPENw ,
Provide ,,.copies of a site plan showing protection for any trees 10"in diameter or more at 3'above grade. 14iin4 SSU k m 4
Iji`STANDARD
& ,! •iovide letter from PG&E(408-725-3325)stating all gas and electric has been disconnected. ,T. f, p s
�1�CLARGE I V a)s
/ 'Tanning Dept clearance to verify building is not considered an historical landmark.Allow 10 business days.
r w[] MA30R t
t •rovide letter of clearance of all vermin from a licensed pest control contractor. , �Re F i s
A•aicant shall • •e Publ. De...,:: n a !: 1 e. .• e dwelling i. ec ion. e ,,
Provide signed Debris Bin and Recyclable Materials form. " O M ,O3`
Commercial Buildings Only: Provide Fire Dept clearance for fire suppression/alarm system review.
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DemoApp 2016.doc revised 03/29/16