B-2018-0151 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0151
20106 JOHN DR CUPERTINO,CA 95014-4415(369 34 024) DE ANZA BUILDERS
CAMPBELL,CA 95008
OWNER'S NAME:QU XIAORONG AND PAN PINGYI DATE ISSUED:04/17/2018
OWNER'S PHONE: PHONE NO:(409)8654222
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic,#943227
Contractor DE ANZA BUILDERS Date 02/29/2020 X BLDG X 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 trust my
Incense is in full force and effect. JOB DESCRIPTION:
ONE STORY ADDITION(857 S.F.);(N)COVERED PORCH(68 S.F.);
1 hereby affirm under penalty of perjury one of tine following two declarations: FIRST FLOOR INTERIOR REMODEL(973 ST);KITCHEN REMODEL
i. I have and will maintain a certificate of consent to self-insure for Worker's (140 S.F.);(N)EV CHARGING STATION IN GARAGE;ELECTRICAL
Compensation,as provided forby Section 3700 of the Labor Code,for the PANEL UPGRADE(200 AMP).
performance of the work for which this permit is issued.
2. I have and will nmintsin Worker's Compensation Insurance,as provided for by REV#1-ENLARGE THE COFERED CEILING AT LIVING ROOM AND
Section 3700 of the Labor Code,for the performance of the work for which this KITCHEN AND REMOVE WALL;RELOCATE WTR HTR AND
permit is issued. FURNACE;REVISE WINDOW TO DOOR AT MASTER;REVISE
APPLICANT CERTIFICATION WINDOW AT KITCHEN TO GARDEN WINDOW;RELOCATE DOOR
I certify that I have read this application and state that the above AT NOOK;REVISE DOOR AT MASTER;REMOVE..WALL AT
information is corre . so
to comply with all city and county ordinances LAUNDRY.
and slate laws rel
Ing
to wilding construction,and hereby authorize
representatives of thI ity o enter upon the above mentioned properly far Sq.Ft Flom•Area:857 Valuation:$284000,00
inspection purpos s. (We agree to save indemnify and keep harmless the
City of Cupertino galnst abilities,judgments,costs,and expenses which
may accrue again t said ily in consequence of the granting of this permit. APN IN ber: Occupancy Type:
Additionally,the ap lican understands and will comply with all non-point 369 34 024 R-3(Custom)
"on"
regula ons er tl a Cupertino Municipal Code,Section 9.18.
Signature Data 07-9-2018 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
OWNrR-BUILDER DECLARATION 180 DAYS FROM LAST CALLED INSPECTION.
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: Issued by:Abby Ayende
t. 1,as owner of the property,or my employees with wages as their sole Data:04/17/2018
compensation,will do the work,and the structure is not intended or offered for
sale(Scc.7044,Business&Professions Code) RE-ROOFS:
2. 1,as owner ofthe property,am exclusively contracting with licensed All roofs shall be inspected prior to any roofing material being installed.If.roof is
contractors to construct the project(See.7044,Business&Professions Code), installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm underpenalty ty ofperJnrayona of the following three declarationsinspection,
r. 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 Cotte,for the Signature of Applic,at
performance of the work for which this permit is issued. Date:07-9-2018
2. 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
permit is issued.
a. I certify that in the performance of the work for which this permit is issued,I HAZARDOUS MATERIALS DISCLOSURE
shall not employ any person many manner so as to become subject to the I have read the hazardous materials to a rats under Chapter 6.95 of the
Worker's Compensation laws of California.If,after making this certificate of California health&Safety Cade,Sect' 25533,and 25534.1 will
exemption,I become subject to the Worker's Compensation provisions of the maintuin compliance with the Cupertino luNdp 1 Code,Chapter 9.12 and the
Labor Code,I must Forthwith comply with such provisions or this permit shall Health&Safol Cade,Section 25532(e should stare or Imndle bavurdous
be deemed revoked, material.Additionally,shoulA I use equi ment or devices which emit hazardous
air contaminants as defined by the Bay A ea Ah, uality Management District I
APPLICANT CERTIFICATION will maintain compliance with the Curer no M nielpal Code,Chapter 9.12 and
I certify that I have read this application and state that the above information Is the Heaith&Safety Co Secti as 505,25533,and 25534.
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 Owner or authorized agent:
to save Indemnify and keep harmless the City of Cupertino against liabilities, Date:07-9-2018
Judgments,casts,and expenses which may accrue against sold City InCONSTRUCTION LENINGAGENCY
consequence of the granting of this permit.Additionally,the applicant understands I hereby affirm that there Is a construction le ding agency for the performance
and will comply with all non-point source regulations per the Cupertino Municipal of work's for which this permit is issued(Sec.3097,Civ C.)
Cade,Section 9.18. Lender's Name
Lender's Address
Signature Date 07-9-2018
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2018-0151
20106 JOHN DR CUPERTINO, CA 95014-4415 (369 34 024)
DE ANZA BUILDERS
CAMPBELL, CA 95008
OWNER'S NAME: QU XIAORONG AND PAN PINGYI
DATE ISSUED: 04/17/2018
OWNER'S PHONE:
PHONE NO: (
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class 5 Lic. #943227
Contractor DE ANZA BUILDERS Date 02/29/2020
X BLDG X 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:
ONE STORY ADDITION (857 S.F.); (N) COVERED PORCH (68 S.F.);
I hereby affirm under penalty of perjury one of the following two declarations:
FIRST FLOOR INTERIOR REMODEL (973 S.F.); KITCHEN REMODEL
I have and will maintain a certificate of consent to self -insure for Worker's
(140 S.F.); (N) EV CHARGING STATION IN GARAGE; ELECTRICAL
Compensation, as provided for by Section 3700 of the Labor Code, for the
PANEL UPGRADE (200 AMP).
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
REV#2 - SECOND STORY RE -WIRE - ISSUED 08-28-2018
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
REV#1 - ENLARGE THE COFERED CEILING AT LIVING ROOM AND
APPLICANT CERTIFICATION
KITCHEN AND REMOVE WALL; RELOCATE WTR HTR AND
I certify that I have read this application and state that the above
FURNACE; REVISE WINDOW TO DOOR AT MASTER; REVISE
information is correct. I agree to comply with all city and county ordinances
WINDOW AT KITCHEN TO GARDEN WINDOW; RELOCATE DOOR
and state laws relating to building construction, and hereby authorize
AT NOOK; REVISE DOOR AT MASTER; REMOVE WALL AT
representatives o ity to enter upon the above mentioned property for
LAUNDRY. ISSUED 7.9.18
inspection purpo es. e) agree to save indemnify and keep harmless the
Sq. Ft Floor Area: 857
Valuation: $284000.00
City of Cupertino gains liabilities, judgments, costs, and expenses which
may accrue again t said ity in consequence of the granting of this permit.
Additionally, the a plican understands and will comply with ail non -point
APN Number:
Occupancy Type:
source regulad Municipal Code, Section 9.18.
369 34 024
R-3 (Custom)
Signature Date 08/28/2018
PERMIT EXPIRES IF WORK IS NOT STARTED
OWNER BUILDER DE LARATION
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:
t. 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
Issued by: Abby AAyende
sale (Sec.7044, Business & Professions Code)
Date: 04/17/2018
z. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
RE -ROOFS:
I hereby affirm under penalty of perjury one of the following three declarations:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
r. I have and will maintain a Certificate of Consent to self -insure for Worker's
installed without first obtaining an inspection, I agree to remove all new materials for
Compensation, as provided for by Section 3700 of the Labor Code, for the
inspection.
performance of the work for which this permit is issued.
z. I have and will maintain Worker's Compensation Insurance, as provided for by
Signature of Applicant:
Section 3700 of the Labor Code, for the performance of the work for which this
Date: 08/28/2018
permit is issued.
3. I certify that in the performance of the work for which this permit is issued, I
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
exemption, I become subject to the Worker's Compensation provisions of the
I have read the hazardous materials requirements under Chapter 6.95 of the
Labor Code, I must forthwith comply with such provisions or this permit shall
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
be deemed revoked.
icipal Code, Chapter 9.12 and the
maintain compliance with the CupertinoFN
APPLICANT CERTIFICATION
Health & Safety Code, Section 25532(a sho ld I store or handle hazardous
I certify that I have read this application and state that the above information is
material. Additionally, should I use equi men r devices which emit hazardous
correct. I agree to comply with all city and county ordinances and state laws
air contaminants as defined by the Bay A ea Ai Quality Management District I
relating to building construction, and hereby authorize representatives of this city
will maintain compliance with the Cup r no M nicipal Code, Chapter 9.12 and
to enter upon the above mentioned property for inspection purposes. (We) agree
the Health &Safety Code, a ti ns 2 O5, 25533, and 25534.
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Owner or authorized agent:
consequence of the granting of this permit. Additionally, the applicant understands
Date: 08/28/2018
and will comply with all non -point source regulations per the Cupertino Municipal
CONSTRUCTION LEN IN AGENCY
Code, Section 9.18.
1 hereby affirm that there is a construction le ding agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Signature Date 08/28/2018
Lender's Address
ARCHITECT'S DECLARATION