11020083 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19089 TILSON AVE CONTRACTOR:TAIPING WANG PERMIT NO:11020083
OWNER'S NAME: TAIPING WANG 19089 TILSON AVE DATE ISSUED:04/08/2011
OWNER'S PHONE: CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONr (—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.#
MECH I— RESIDENTIAL F COMMERCIAL
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: DEMO EXISTING HOME,1662 SF
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
1 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. Sq.Ft Floor Area: Valuation:$8000
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
permit is issued. APN Number:37508056.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature Date
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 hereby affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection,1 agree to remove all new materials for
. inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
wil I do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
instruct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Ow�
AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
1 certify that I have read this application and state that the above information is Lender's Name
correct.1 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 Lender's Address
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 may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply 1 understand my plans shall be used as public records.
with all non-point source regulations er the Cupertino Municipal Code,Section
9.18. Licensed Professional
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Signature
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CITY OF CUPERTINO �6b
DEMO \\�
CUPERTINO PERMIT APPLICATION FORM
APN# � 5 Jr p r 5� Date:
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Building Address:
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Mailing Address (if different from building address):
Owner's Name: Phone:
L/6 0�Vt 2rA
Contractor: olPhone
Fax:
Contractor License #:
Cupertino Business License #:
Contact: Phone:
Fax/e-mail:
Residential [�( Sq Footage i (0 6 Z Commercial ❑ Sq Footage
Job Description:
Valuation:
Project Size: Counter ❑ Express ❑ Standard [Z/ Large ❑ Major ❑
Please complete relevant portions of the Green Building Checklist& attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Residential B 1SFDWL-DEM
1DEMOPRES Pool Demo Residential B 1SFPOOL-DEM
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICRE Seismic Residential B
Revised 12/06/10
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: $067 � PERMIT# Od
OWNER'S NAME: Ot % / �'j qv( PHONE# O
GENERAL CONTRACTOR: 6' BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Ow r/C- ntractor Si ture Date
oe
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IN ACCORDANCE WITyDr '
H CL�PERTINO CODE`,;AND ORDINANOCL:
IDA : — '_
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SIGNED---- _ O
Thi,, set of Plansand —_
tm kept on the job atPii;r?),. ns 6'."UST
z unla ul to make any chanq;-, anw is►�s,�
on me x^epa written per; alonrfro�ml ' I 0
the uildirty t�epartment,City of Cupertin .
The stamping of flys Plan and g t
SHA-L NOT be held to y icatior
pertlit or to be anuli I�
nl7+oval of the violation of any �r3rovisions
ail any Cdy Ordinance or Stair ..,,
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FEB 22 2011'
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RES
/oENTI4L GOMMERC/-1 INGUSi R,P�
DATE 2�
I,j �• MILEAGE
OPERATOR A
Pest Control `` r
START TIME +�
ACCOUNTING OFFICE
6800 SIERRA LANE•DUBLIN,CA 94568 STOP TIME
1-800-DAY-NITE(187000-329-6483).www.800daynite.com
NAME ! A f//Y-1 ^^rJG V -�/I��/ ORDER# ACCOUNT#.
ADDRESS I N 1 11 S N .4W
CITY STATE ZIP
PHONE( ) ; ROUTE M C' l
GUARANTEED FOR,,AVINIMUM PERIOD OF MONTHS. THE FIRST MONTHS,
SERVICE WILL BE ��� AND $
FOR EVERY FOLLOWING MONTHS SERVICE. THIS WILL BE ON AUTOMATIC SERVICE UNTIL
CANCELLED IN WRITING. CUSTOMER AGREES TO PAY 60%OF THE REMAINING CONTRACT BALANCE IF SERVICE IS .
CANCELLED PRIOR TO THE EXPIRATION OF THE 1 YEAR TERM.
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TYPE OF SERVICE/T RGE PEST:. eL=
NOTES: 2ts
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NC-A 6-01 C)6NcG- eery
3NATURE cab u -0rj A
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SCHEDULED FOR: / a - REF-D BY: X STREET: SOLD BY: CO . Y
Day& Nite Pest Control and its service technicians are licensed by the Structural Pest Control Board
PLEASE SEE REVERSE SIDE BEFORE SIGNING
Terms: Payable net 30 days.After 30 days a$2.00 or 1.5%service fee may be added which ever is greater.$20.00 will be charged for returned checks.
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333• building cDcuperino.orq
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS �i �ON � APN !!
! a
OWNER NAME OWNER ADDRESS
1 V VANUOLo Coave y -ez-
DESCRIPTION OF WORK:
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
1.,1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
th construction and are not hiring a licensed Contractor to assume this responsibility.
-lub. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
n tubers on permits and contracts.
LAI J. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars($500), including labor and materials, I may be
considered an"employer" under state and federal law.
"'(�6. I understand if I am considered an"employer" under state and federal law, I must register with the state and
{ederal government, withhold payroll taxes, provide workers'compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
`__�__7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
a y financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
f 9. I understand I may obtain more information regarding my obligations as an"employer"from the Internal
Revenue Service, the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors'State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed
contractors.
`�t10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by II applicable laws and requirements that govern Owner-Builders as well as employers.
lel 2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property,you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's si nat
Property Owner's Signature: Date:
-
------------------------------------------------------------ -------------------------------------------------------------------------------
(NOTE: The following Authorization Form is requi d to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
1 declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature. I
c ' /
Property Owner's Signature: Date:
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OwnerBuilderFonn 2010.doc revised 04114110
f
City of Cupertino
Public Works Department
10300 Torre Ave.
Cupertino CA 95014
• (408)777-3354
Debris Bins
Debris from a project in Cupertino can be collected and disposed of in either:
I. a Los Altos Garbage Co.bin(call 725-4020 to order), OR
2. a bin owned by the project's general contractor or demolition contractor, and hauled by a vehicle
owned and registered to that contractor(contractor should be prepared to prove ownership), OR
I a private track with a bed, but no bin
The Los Altos Garbage Company is the only debris bin service provider
franchised to do business in Cupertino.
Bins from other leasing companies may not be used in Cupertino.
Please check all that apply:
❑ I will use a Los Altos Garbage Company bin
I will use a bin and truck owned by the general contractor or the demolition contractor.
❑ I will use a private truck, and not drop a bin.
Recyclable Materials
Recyclable materials may be collected in private debris binsbo�r.containers leased
from ANY company, as long as the materials are both:
1. separated by type of material into separate containers,.AND
2. are not contaminated by garbage.
Separated recyclable materials are materials that are separated into individual containers, each
containing just one type of recyclable material. Typical examples of recyclable materials
include: metal,wood, concrete, steel-reinforced concrete, asphalt, tree trimmings, white goods,
toilets (hardware removed),rocks and clean fill dirt. Separated recyclables must ultimately be
recycled or otherwise reused, and not disposed of in a landfill.
Contractor should be prepared to provide the name and phone number of any recycling companies being
used on the project. A list of local recycling companies can be found at: www.recyclestuff.oriz.
..................................................................0.......0..................
C � _
Signature: / Date:
Name (printed): �a i 1( ant
Title:
• Phone: 4;0 S9
Project address:
a �� Q
This form to remain in the project's building permit file for the duration of the project.
Revised 1/03
abatement analytics
COMPLETION REPORT
FOR
19089 TILSON AVENUIE AVENUE
CUPERTINO, CA
March 5, 2011
On March 4, 2011, 1 visited the property location at 19089 Tilson Avenue, Cupertino ,
CA, to perform a final visual inspection of the asbestos abatement.
Your hired Alliance Environmental., a state registered asbestos abatement contractor to
conduct the asbestos removal at that location.
Per the asbestos inspection performed February 24, 2011, 440 sq. ft. of 9"X 9" floor tile
and 1,020 sq. ft. of homogenous mastic had an asbestos content greater than 1%, thus
requiring removal prior to demolition. Upon inspection of these areas, I found that these
materials had been completely removed and no residual material remained.
Based on this visual inspection and the survey report, it is my belief that the building has
no other asbestos containing materials greater than 1% and can be demolished. The
demolition contractor should be advised that wet methods should be employed for dust
suppression and he should contact me if any additional suspect asbestos containing
materials should be encountered during the course of demolition. An asbestos survey
does not consist of demolition of walls and ceilings, where additional material may exist.
9ctfully su itted,
Jim ryan
Cert fled Asbestos Consultant fLA
Cal-OSHA Registration # 00-2811, expires 9/20/11
p.o. box 1392, campbell, ca 95009 phone/fax 408-264-1230
Pacific Gas and
Electric Company'
10900 No.Blaney Avenue
Cupertino,CA 95014
City of Cupertino
10300 Torre Avenue
Cupertino, Ca. 95014
To Whom It May Concern:
SUBJECT REMOVAL OF GAS AND / OR ELECTRIC FACILITIES
The gas and electric facilities have been removed and / or abandoned at:
Axe on 330 Ly
If you have any further questions, please contact me at (4080725-3325
Sincerely,
Service Planning
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