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naw::-ui,: CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0157 11801 DOROTHY ANNE WAY UNIT 3 CUPERTINO,CA(36609043) OWNER BUILDER OWNER'S NAME:CHANG LONG REALTY DEVELOPMENT LLC ET AL DATE ISSUED:10/03/2017 OWNER'S PHONE:408-891-6633 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.# Contractor OWNER BUILDER 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 to full force and effect. SOB DESCRIPTION: TO CLEAR CODE ENFORCEMENT:UNIT 3(ADOBE HOUSE)- I hereby affirm under penalty of perjury one of the following two declarations: REPLACE(4)WINDOWS;DEMOLISH FENCE BETWEEN ADOBE 1. 1 have and will maintain a certificate of consent to self-insure for Worker's HOUSE AND GREEN HOUSE(22 L.F.);MODIFY FENCE AT PATIO(14 Compensation,as provided for by Section 3700 of the Labor Code,for the L.F.). performance of the work for which this permit is issued. REV#1-CHANGE WINDOW;ADD GRID TO(E)WINDOW-ISSUED z. I have and will maintain Worker's Compensation Insurance,as provided for by 4/3/2018 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, Sq.Ft Floor Area: Valuation:$1500.00 APPLICANT CERTIFICATION I certify that 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 366 09 043 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 1S0 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 413/2018 Issued by:AbbyAyende Date:10/03/2017 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is r. 1,as owner of the property,or my employees with wages as their sole installed without fust 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. sale(See.7044,Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:4/3/2018 I hereby affirm under penalty of perjury one of the fallowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 Code,for the performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE z. I 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 the Labor Code,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 s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Cade,Section 25532(a)should I store or handle hazardous shall not employ any person in any manner so as to become subject to Ore material,Additionally,should I use equipment or devices which craft hazardous air contaminants as defined by the Bay Area AU 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:413/2018 1 certify that I have read this 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 buildingconstruction,and hereby authorize representatives of this city of work's for which this permit Is Issued(Sec.3097,Civ C.) to enter upon the above mentioned property for Inspection purposes, (We)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, 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 DECLARATfoN Code,Section 9.18. 1 understand my plans shall be used as public records. Signature ��i- Dated L=::id CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 0 (408)777-3228• building@cupertino.org PEMIT aB- 7 01'� CUPERTINO REV# DEF#_ ❑NEW CONSTRUCTION ❑ADDITION ❑ALTERATION❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA PROJECT ADDRESS I APN# /D�ra'tG, H ww,L. Luca- 344- 07.. 043 OWNER NAME PHONE E-MAI Gzld�.r_odre STREET ADDRESS 1/t�0! 'der f"a•f�. /�✓!%+v*rPi-1� a_ Rl2'r.>-a �'�S't1 f ' EJ CONTRACTOR NAME OW NE&BUILDER COMPANY NAME LICE 58 NUMBER LICENSE TYPE STREET ADDRESS CITY,STATE,ZIP E-MAIL PHONE ITS.LIC b y1yfta3r314-2 4'"-1.1 Gov+, ❑ARCHITECL rVOWNER 0 OWNER AGENT❑CONTRACTOR AGENT❑ENGINEER❑DEVELOPER El TENANT CONTACT NAME '[ ��ee E-MAE- STREET ADDRESS CITY,STATE,ZIP PFIONE DESCRIPTON vFa�i �wsa�.� A,1.t r;� EISINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY ❑INDUSTRIAL ❑COMMERCIAL EXISTINGUSE BXISTINGSF NEWIMORSF PORCHSF DECKSF DEMOSF STORIES# TOTALNETSP USE TYPE OCC SQ.Fr. VALUATION($) REMODEL REE40DEL KITCHEN I REMODEL OTHR GARAGE ❑ATTACHED BATI[ROOM SF SF �1.'COND1T0RYA..-CN SF ❑DETACHED EXISING ❑YES EICHLER DYES ❑YES FIRE SPRINKLERS 0 NO 0 NO ❑NO DWELLING SECONDDWELLING ❑yES O ATTACHED❑DETACHED OTHER UNITS® UNI.1'ADDH'ON: ❑NO SA POOLS ❑FIBERGLASS 0 VINYLLINED❑GUNITE 0 PREFABRICATED POOL-sr SPA-sF SPAATTACHED AYES ❑NO TOTAL-SP R$�ENED BY: 1 TOTAL VALUATION: Corruncrelul ov MullrPourny BuiMMcs viflr Public svriuurrine Pools reuui­Dannrf nrt afFa v' ra m7 Hantlnvp­l RE-ROOP EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES[:]WOOD SHAKES[_]WOOD SHIN LES❑ LR OTHER(SPECIFY) REMOVE/REPLACE❑NO IF NO PLYWOOD ❑'�' ❑3/S•' PLYWOOD TYPE: PITCH; ROOE CLASS �YHS 4O LAYERS 1T-IICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER '12 A PROPOSED ROOF TYPE:OBUILT-UPROOF DASPHALTSHINGLES OWOODSHAKES OWOODSHINGLES DOTHER *Provide a signed copy of the Cupertino's Tear-Off Policy Sr not SQUARES 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. I acknowledge and authorize all information contained on this application form to be made available for public record. Signature of Applicant/Agent: Date: /t SUPPLEMENTAL INFORMATION REQUIRED *New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction. *Commercial 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. *HOA-Provide a letter of approval from the Home Owner's Association BldgApp_2017.doc revised 08101117