B-2018-0243 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-201.8-0243
10351 PALO VISTA RD CUPERTINO, CA 95014 (357 03 024)110349 PALO VISTA RD Tracy Hsu ( TJ Living
CUPERTINO, CA 95014-2714 (357 03 024) Trust )
10349 Palo Vista Rd
Cupertino, CA 95014
OWNER'S NAME: ) DATE ISSUED: 06/04/2018
OWNER'S PHONE: PHONE NO: None
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO;
License Class Lic. #
Contractor Tracy Hsu ( T/i_, Living Trust Date X 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:
(N) TWO-STORY SINGLE FAMILY DWELLING - (4057 SF);
I hereby affirm under penalty of perjury one of the following two declarations: ATTACHED GARAGE - (447 SF); COVERED PORCH - (671 SF);
1. I have and will maintain a certificate of consent to self-insure for Worker's CARPORT - (23 8 SF)
Compensation, as provided for by Section 3700 of the Labor Code, for the (N) ATTACHED SECOND DWELLING UNIT - (615 SF);
performance of the work for which this permit is issued. REV # 1 - REVISE LANDSCAPE DESIGN - ISSUED 10. 18, 18
2. I have and will maintain Worker's Compensation Insurance, as provided for by REV # 2 - REMOVE ONE BATHROOM FROM SECOND UNIT -
Section 3700 of the Labor Code, for the performance of the work for which this ISSUED 1 0. 18. 18
permit is issued.
Sq. Ft Floor Area: 4672 Valuation: $900000.00
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 3.5703 024 R-3 (Custom)
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.
Additionally, the applicant understands and will comply with all non-point WITHIN 184 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. -
Signature Date 10.18.18 Issued by: Sean Hatch
Date: 06/04/2018
OWNER-BUILDER DECLARATION
I her by affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is
. I, as owner of theproperty, or m em to employees with wages as their sole
Y p Y g 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.
sale (Sec.7044, Business & Professions Code)
I, as owner of the property, am exclusively contracting with ticensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code), Date: 1.0.18.1.8
I hereby affirm under penalty of perjury.one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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. 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
I certify that in the performance of the work for which this pen-nit is issued, I Health &Safety Code, Section 25532(a) should I store or handle hazardous
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
Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I
exemption, I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Labor Code, I must forthwith comply with such provisions or this permit shall the Health & Safety Code` Sections 25505, 25533, and25 0.34.
be deemed revoked.
Owner or authorized agent: -
APPLICANT CERTIFICATION Date: 10.18.18
I certify that I have read this application and state that the above information is CONSTRUCT ON LE DIN AGE CY
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there,is a construction len ing 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, 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 DECLARATION
Code, Section 9.18. 1 understand my plans shall be used as public records.
Signature - ate 10.18.18 Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0243
10351 PALO VISTA RD CUPERTINO,CA 95014(357 03 024)1 t0349 PALO VISTA RD Tracy Hsu(T/j Living
CUPERTINO,CA 95014-2714(357 03 024) Trust)
10349 Palo Vista Rd
Cupertino,CA 95014
OWNER'SNAME: DATE ISSUED:06/04/2018
OWNER'S PHONE: PHONE NO:None
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lie.#
Contractor Tracy Hsu(T/j Living Trust)Date X BLDG_ELECT_PLUMB
MECFT X RESIDENTIAL COMMERCIAL
1 hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that ory
license is in full farce and effect. JOB DESCRIPTION:
(N)TWO-STORY SINGLE FAMILY DWELLING-(4057 SF);
I hereby affirm under penalty of perjury one of the following two declarations: ATTACHED GARAGE-(447 SF);COVERED PORCH-(671 SF);
1. I have and will maintain a certificate of consent to self-insure for Worker's CARPORT-(238 SF)
Compensation,as provided for by Section 3700 of the Labor Cade,for the (N)ATTACHED SECOND DWELLING UNIT-(615 SF);
performance of the work for which this permit is issued,
z. 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
permit is issued. Sq.Ft Floor Area:4672 Valuation:$900000.00
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 35703 024 R-3(Custom)
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 WORI{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
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 06/04/2018 Issued by:Jasmine Archbold
Date:06/04/2018
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractm's License Law far one of the RF.-ROOFS•
following two reasons: All roofs shall be inspected prior to any roofing material being installed.Its roof is
( I,as owner of the property,or my employees with wages as their sole hieLil.d 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.
sale(Sec.7044,Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed Signature ofApplicam:
contractors to construct the project(Sec,7044,Business&Professions Cade). Date:06/04/2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
-ri I have and will maintain a Certificate of Consent to self-lusme for Worker',
�( 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 far which this California Health&Safety Code,Sections 25505,25533,and b5534.I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certify that in the performance of fhe work For which this permit is issued,l Health&Safety Code,Section 25532(x)should 1 store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
air emitumimnts as dcfroal by the Bay Arco 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 became subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,2 33,aadaad 25534
Labor Code,I must forthwith comply with such provisions or this permit shall �\°
APPLICANT CERT'IFICAT'ION Date:06/0412018
I 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 building construction,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 DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 0 610 412 0 1 8 professional