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
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STREET ADDRESS
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EJ CONTRACTOR NAME OW NE&BUILDER COMPANY NAME LICE 58 NUMBER LICENSE TYPE
STREET ADDRESS CITY,STATE,ZIP
E-MAIL PHONE
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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