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B-2016-3125 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3125 20100 FOREST AVE CUPERTINO,CA 95014-2009(316 23003) BELFOR USA GROUP INC BIRMINGHAM,MI 48009 OWNER'S NAME: DENG YUETANG AND PENG SOPHIA XIAOFANG DATE ISSUED:11/15/2016 OWNER'S PHONE:408-398-5561 PHONE NO:(248)594-3188 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class a Lic.#810553 Contractor BELFOR USA GROUP INC Date 07/31/2018 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 in full force and effect. JOB DESCRIPTION: REPLACE FIRE DAMAGE SIDING AT GARAGE(677 S.F.);REROOF; I hereby affirm under penalty of perjury one of the following two declarations: TEAR OFF;COMP SHINGLES(10 SQ) m. 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 , ,,- erformance of the work for which this permit is issued. , �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: Valuation:$35000.00 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 316 23 003 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 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. v' ._Sight t r ;,,,,(4. OP r/ Date 11/15/2016 Issued by:AbbyAyende Date:11/15/2016 1 'i!)_' : 11. 1 I he ry 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 1. I,as owner of the property,or my employees with wages as their sole 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) 2. 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:11/15/2016 I hereby affirm under penalty of perjury one,of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER i. 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 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 s. I certify that in the performance of the work for which this permit 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 air contaminants as defined by the Bay Area 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 become subject to the Worker's Compensation provisions of the the Health&Safety r de,Sections 2 505,3 and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owor authorized age• p,���' , •_...._,APPLICANT CERTIFICATION G Date:11/15/2016 I certify that I have read this application and state that the above information is t►^ yt • a s s'l1 h ' °� correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that the a construction lending agency for the performance • relating to building construction,and hereby authorize representatives of this city of work's for which thi .ermit 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. I understand my plans shall be used as public records. Signature Date 11/15/2016 Licensed Professional . - U - )25 ' CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION `! 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333• buildino cubertino.orq CUPERTINO 0 NEW CONSTRUCTION 0 ADDITION 0 ALTERATION/TI 0 REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS a O/©O fems f Avg APN 311e- 23-00 OWNER NAME , P E-MAIL liLOf, G /eA'6- f..'8')3?rf-55 �o.l STREET ADDRESS 1 ' CITY, STATE,ZIP FAX CONTACT NAME 3-4,We- PHONE E-IMAIL If STREET ADDRESS CITY,STATE,ZIP 1 FAX 0 OWNER 0 OWNER-HUH-DER 0 OWNER AGENT ACONTRACTOR 0 CONTRACTOR AGENT 0 ARCTIITECT 0 ENGL H_R. 0 DEVEI OPER 0 TENANT CONT 4ME LICENSE NUMBER LICEN TYPE BLS.LIC COMPANY NAME j 11 / ,�pp E , 4 o gGGIQI'/�Ca C_ P 5, 1(FAa ST•rETAD1' SS ,, n GITyt3TATE; i •HO'\TE 2, i 1' -w. ,aV V- _ 4w c25t 5'i`/ 1 /2. -2yy • CHITECT/ENGLNE NATE I LICENSE NUMBER BUS.LIC j� !'S COMPANY NAME E-MAIL FAX ST ET.ADo.cNESS R CI ,STATE,ZIP 1?, - DESCRIPTION OF ArORIC Foff a ei__ 1iil °e' gee-veil4,- ,�C e .a( e( ,ffeerk/6- Ai,"12iftei7___Lpd____ EXISTIN?G USE ' PROPOSED USE CONSTR.TYRE t STORIES USE TYPE OCC. SQ.FT. VALUATION(5) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER - -REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA I DECK AREA TOTALDECI:PORCH AREA GARAGE AREA: ❑DETACH _ 0 ATTACH DWELLING UNITS: ISA SECOND UNIT DYES SECOND STORY DYES - -- BELNG ADDED? 0 NO ADDITION? 0 NO PRE-APPLICATIONDYES EYES..PROVIDE COPY OF IS THE BLDG AN 0 YES -:NEC T ", y <. TOTAL VALUATION: PLANNIII:GAPPL.. ❑NO PLA_NNING•APPROVALLEIIER EICHLERHOME? D NO N Ii.,,,.-N:,..-:. .i..=,. ^ _w By my signature below,I certify to each of the.followine: I am the property owner or authorized agent to act on the property owner's behalf, have read this application and the information I lave provide, 's correct. I have read the Description of Work and verify it is accurate. I agee to comply with all applicable local ordinances and state laws relat to buildin strut',%.. au•o '.e representatives of Cupertino to enter the above-identified -operty for inspection purposes. Si-iatureofApplicant'Aa nt: .„/,.. �>� , ��- Date: G SUPPLE_/NTAL INFORMATI•N REQUIRED �; ,: i Witt: CHECK SIPE':_.. .ry+.: ,,..;,ROTITING SLIP..:xl .. .. New SFD or Mult 1:roily dwellings: Apply for demolition permit forl,_] 61ER THE COUNTER ❑ BLS L InG PLA,..4"11 existing building(s). [emolition permit is required prior to issuance of building permit for new building. 0 rE\PRESs Plk:M.D\GPLnE\IES . . Commercial Bldgs: Provide a completed Hazardous Materials Disclosure L7 STANDARL� IC W ORDS, form if any Hazardous Materials are being used as part of this project. h D PUN,..:. LARGE i ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to E ALZIOR r 5:.-tITARl SEN,,ERDSTRICT i submittal of Building Permit application. l T , 1:031vAA . ;L:E IROI\TiEALHEALTH. A BldgApp_2011.doc revised 06/21:11 •