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15070037CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: 15070037 937 COTTONWOOD DR CUPERTINO CA 95014 (369 17 044) HOMEOWNER BUILDER OWNER'S NAME: SHEN TIINGYANG AND FU LIJIE OWNER'S PHONE: 408-930-7633 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor HOMEOWNER BUILDER Date 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. I hereby affirm under penalty of perjury one of the following two declarations: 1. 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. 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. 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 and state laws relating to building construction, and hereby authorize 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 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 9.18. ISSUED: 04/15/2016 PHONE NO: PERMIT INFO: BLDG _ ELECT _ PLUMB MECH _ RESIDENTIAL — COMMERCIAL JOB DESCRIPTION: ADD 855 S.F. TO CREATE 2 (I) BEDROOMS & 1 (I) BATHROOM. REMODEL (E) KITCHEN (200 S.F.) & ENLARGE (E) BATHROOM (15 S.F.) RE -ROOF (E) 12 SQ'S Sq. Ft Floor Area: Valuation: $150000.00 APN Number: Occupancy Type: 369 17 044 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 4/15/2016 Issued by: AbbyAyende j A Q4�L Date: 04/15/2016 —9—N I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for � ,sale (Sec.7044, Business & Professions Code) G% as owner of the property, am exclusively contracting with licensed u contractors to construct the project (Sec.7044, Business & Professions Code). 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 Compensation, as provided for by Section 3700 of the Labor Code, for the 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. / . I certify that in the performance of the work for which this permit is issued, I �/ shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is correct. I 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 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 granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date 4/15/2016 RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: 4/15/2016 "SU HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. r, ror authorized agent: Date: 4/15/2016 V CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT' BUILDING DIVISION 10300 TORRE AVENUE' CUPERTINO, CA 95014-3255 ❑C U P _ T[ t 0: (408) 777-3228' FAX (4 08) 777-3333 ' building —cupertno.org �/5-0� 0 NEW CONSTRUCTION FADDITTON . (-1 AT.-r7RATTCIN/TT I-7 RRVTST(1TJ /TIFFFDDFTI n1RV'_ttSAT D= l rrr y PR07ECT ADDRESS437 Qcr�-TW 4, I APN 9 )C(— OWNERNAME q � Jlr- FO PHONE O�5 a9-50®-1(6331 E-MAIL CITY, STATE, Z `" FAX STREET ADDRESS - 4 _� b ` 1, Lx CONTACT NAMEf PHONE E-MAIL N _- cut 3fi70 STREET ADDRESS 4%0q5 CITY, STATE, ZIP FAX OWPMR ❑. OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ARCHITECT El ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME q� LICENSENUMBER I LICENSE TYPE I BUS. LIC 9 COMPANY NAS E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/E. INEER NAME LICENSE NUN,BER BUS. LIC # COMPAN NAME IE -MAIL C-' Z4 Iv 1 �— � 6 FAX Y STREET ADDRESS 3 Zt s_ � �Af1 $n �d7 i CITY, STATE, zip `g ,� S'®[4 PHONE DESCRIPTION OF WORK p� ^�1 ['!v" ry� y 6 6 ctel EXISTING USE r— yl— PROPOSED USE CONSTR.TYPE 5I�-y.- I V � 'STORIES USE TYPE OCC. I SQ.FT. VALUATION ($) _� AREA G C (� 1 NEW AREA 00J k i 0 i DEI, �" TOTAL NEI' AREA BATHROOM: REMODEL AREA . KITCHEN REMODEL AREA" OTHER REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA 7 Q GARAGE AREA: DETACH I ATTACH - Z 9S ', DWELLINGWJ S: IS A SECOND UNIT SECOND STORY EI _. BEING ADDED? NO ADDITION? VC PRE -APPLICATION WTS IF PES, PROVIDE COPY OF IS THE BLDG AN '` TOTAL VALUAO PLANNINGAPPLO ❑NO PLANNING APPROVAL LETTER I EICHLERHOME? _ By my signature below, I certify to each of the following: I am the property o„no ' ed agent to ac property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Tgwenfy itis accurate. I agree to comply with all applicable local ordinances and state lays relating to building constructio thorize representatives of Cupertino to enter the above-"dentified property for inspection purposes. Signature ApplicantlAgent: Date: of SUPPLEMENTAL IATFORMATION REQUIRED RE Q = y PI Ai\ CHECFOTSEE _ LL� _AW ' I�Tew SFD or Multifamily d«=ellings: Apply for demolition permit for `❑ OYERTiCOUItTER y 2IBUIIDJI�GPLANREVSE4i Y existing building(s). Demolition permit is required prior to issuance of building - - 1 = fl ExP�Ess ' permit for new building. x��PLI,in�PLA?v�wt Q STANDARD Commercial Bldgs: Provide a completed Hazardous Materials Disclosure fl ruBlc�oRFcs _ form if any Hazardous Materials are being used as part of this project. %PIRG �IRE7l _ Copy of Planning Approval Letter or Meeting with PIanning prior to �vYe17am OR1At. L sERvzsa submittal of Building Permit application. v- Bldg 1pp 2011. doc revised 06/21/11 EN CITY OF CUPERTINO Fm --7 FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 937 COTTONWOOD DR DATE: 07/07/2015 REVIEWED BY: MELISSA lia APN: 36917 044 BP#: *VALUATION: 1$150,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY USE: SFD or Duplex 2nd Unit? f Yes • No OTC.? •, ®Yes � No PENTAMATION PERMIT TYPE: 1R3SFDADD WORK ADD 855 S.F. TO CREATE 2 N BEDROOMS & 1 N BATHROOM. REMODEL E KITCHEN 200 SCOPE S.F.) & ENLARGE (E) BATHROOM (15 S.F.) RE -ROOF (E) 12 SQ'S OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.E R-3 (Custom) II-B1111-B,IV,V-B 855 $2,654.00 1R3PLNCK $1,666.00 IR3INSP I TOTALS: I 855 I $2,654.00 4vm I $1,666.00 I �1ViECII, HOI�R,� � �e�- N� ��I�,Y� r Yew • � E�� LTR�X esri 'leo .ilech..l'larr Check 1'( imb. Plan (.'heck Elec. flan ('heck _ A11,11 Permit Fee: Plumb. Permit Fee: Elea Permit Fee: t Ther alech. InsFz t)fhe� Plut�th ImpLJ (�t1 er.Elee. Insl�. t•C'::iT. hisp. hee: Is/f1mb, h7sp. Fee: Elec. Ins. Pee: NUTE: This estimate does not include fees due to other Departments (i.e. Planning, Public works, Dire, Sanitary Newer ViStrtct, Jcnool ni.cirrt_ etr_ 1. These fvvc are hn.ceil an the nreliminary infarmatian available and are only an estimate. Contact the Dent for addn'1 tufo. FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,654.00 EKI s.f. $645.00 Remodel, Kitchen (<=300 sf) IREMRESKIT Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 1 15 1 s.f. $645.00 Remodel, Bath (<=300 sf) 1 IREMRESBAT Permit Fee: $1,666.00 Suppl. Insp. Feer Reg. Q OT 0.0 hrs $0.00 1,200 s.£ Re -roof $204.00 IREROOFRES PME Unit Fee: $0.00 PME Permit Fee: $0.00 ct,mS'truction ./ax: Administrative Fee: E) Work Without Permit? 0 Yes •) No $0.00 Advanced Planning Fee: IPLLONGR $119.70 Select a Non -Residential Building or Structure G Travel Df)L'tGmenfallon Fees: Strom Motion. Fee: IBSEISMICR $19.50 Select an Administrative Item Bldg Stds Commission. Fee: IBCBSC $6.00 = 4SUBT0TALS $4,465.20 $1,494.00T $5,959.20 Revised: 07/02/2015 74,V -k CUPERTINO Date: 7/8/15 Building Department CITY OF CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 950143255 TELEPHONE: (408) 777-3228 • FAX: (408) 777-3333 OUTSIDE AGENCY PLAN CHECKING FEES Agency Name: 4 -LEAF Permit Number: 15070037 (Addition/Remodel) Project Address: 937 COTTONWOOD DR Plan Check Fees: $1,725.10 Hourly plan check fees: Number of hours: Plan check based: 1St & 2nd plan checks included in initial plan check fee: $1,725.10 (Agency Fee -65% already calculated) 3rd plus plan checks: Number of hrs ($143.00 per hr, 2hr min. minus 10%) Please attach this form with the number of hours spent on the 3rd plus plan checks and send with the plan check comments or if plans are approved, with the plans & approval letter. Please email the plan check comments to: Melissan@cupertino.org 'Please do not give plan check comments directly to the customer. We don't give out the comments until we have all of them back from each department. Cupertino Union School District 10301 Vista Drive, Cupertino, CA 95014 Tel (408) 252-3000 • Fax (408) 865-0326 Developer Impact Fee Compliance The Cupertino Union School District has adopted Resolution Nos. 1403 and 1404, imposing developer impact fee pursuant to Government Code 53080. Building Permit Request The City of C1,4O. ih\,-; has received a request for a Building Permit described as follows: residential Development Project L] Commercial/Industrial Development Project Name of Developer: L1�1e- ` Project Address: I �..v t 1,�X1, Description: 0('Wbokk ce 'ogM -1i Square Footage: ILL Lot/Parcel #: i' T -0q (-) Permit #: Date: L4 k 114 By: `'� 4 \ \( Cit Authorized Representative Square footage will be verified by the city prior to issuance of a building permit; fees may be adjusted accordingly. Important Notice: Cupertino Union School District gives no credit for total demolition of existing square footage area, which makes way for new construction as mandated in the Government Code Sections 53080, 53080.6 and 65995. SCHOOL DISTRICT DEVELOPER IMPACT FEE CERTIFICATE OF COMPLIANCE The authorized representative of the Cupertino Union School District has reviewed the City Of Building Permit Request described above and hereby certifies that the developer or authorized representative has met the requirements of the District's Developer Impact Fee requirements. Dated: Certificate not valid without District seal, initial, and date. Authorized Representative Cupertino Union School District Fee: $ Check No.: Facilities Planning - White City - Yellow Requestor - Pink Accounting - Gold FREMONT UNION HIGH SCHOOL DISTRICT 589 WEST FREMONT AVENUE SUNNYVALE, CALIFORNIA 94087 408-522-2200 Developer Impact Fee Compliance Building permits will not be issued without a completed Certificate of Compliance Building Permit Application The City of Vhit has received a request for a Building Permit described as follows: _ New Residential Development _ Residential Addition (501) sq. ft. or more _ Commercial Development Name of Owner / Developer: Project Address: Qlf1 CCA -b -v A)f+1 aP Lot/Parcel # Square Footage: Description: UU(�11�1Q�11 r 21`1 Permit / Plan Check # C7 001, Date: "t ! 1'S //1 �lti By: l.0A k kX(A'k-- / Building Inspector Square footage verified by the city prior to issuance of a building permit; fees may be adjusted accordingly. Feeder Elementary District SCHOOL DISTRICT DEVELOPER IMPACT FEE CERTIFICATE OF COMPLIANCE The authorized representative /of the Fremont Union High School District has reviewed the City of I j ' r" -n \' Ll tn %� Building Permit Request described above and hereby certifies that the developer or authorized representative has met the requirements of the District's Developer Impact Fee requirements. Dated: �� " �� By. Certificate not valid without District Seal, Initial, and Date Fremont Union High School District Authorized Representative Fee Distribution: Facilities Planning —White City — Yellow Requestor — Pink Accounting — Gold Dev. Impact Fee Compliance (Rev. 11/22/05) [12/08 — 10001 CUPERTINO OWNER -BUILDER D[SCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - buildinaecuoertino.ora 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 ✓: _ .....APN...A 3P#'�� OWNER NAME l �; .Ft, OWNER ADDRESS J DESCRIPTION OF WORK: -rkq N N��pyy� r �. iJCZ 71 We are providing you with an Ownet-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 Own er-Builder. lire 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.) X1. I 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. I. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. 3. 1 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. ,k4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the to al 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. I understand if I am considered an "employer" under state and federal law, I must register with the state and fe eral 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. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family sidential 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„I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for a 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 0/14/10 19. 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 Califomia Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CS LB) at 1-800-321-CSLB (2752) or wv✓w.cslb.ca.gov for more information about licensed contractors. 0. 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. Jb11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide all applicable laws and requirements that govern Owner -Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the inormation l 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 niay be unable to assist you with any financial loss you may sustain as a. result of a complaint -Your only remedy against unlicensed Contractors maybe in civil court. Itis 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 maybe 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 note those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following constructioh 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 signature. Property Owner's Signature: Date: I 2°( --- -------------------------- --- ------------------------------------------------------------------------------------------------------------- (NOTE: The follov✓ing Authorization Form is required to be completed by the property ov✓ner 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: Address of Authorized Agent: Tel No I 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 properly 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. Property Owner's Signature: Date: OwnerBuilderForm 1010.doo revised 04/1;/10