D-2016-0366CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: D-2016-0366
10200 JOHNSON AVE CUPERTINO, CA 95014-3812 (375 25 066)
(DE ANZA BUILDERS)
SAN JOSE, CA 95129
OWNEWS NAME: MATHEW THOMAS
DATE ISSUED: 03111/2016
OWNER'S PHONE: 408-261-8820
PHONE NO: 408-499-8391
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class ]a Lic. #943227
Contractor (DE ANZA BUILDERS ) Date 03/11/2016
_ BLDG _ ELECT _• PLUMB
lk%ECH RESIDENTIAL COMMERCIAL
_
I hereby affirm that I am licensed Harder the previsions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business & Professions Code and that nay
license Is In frill force and effect,
JOB DESCRIPTION:
DV_M0 (E) 1300 S.F. SFD
I hereby affirm under penalty of perjury one of the following two 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.
! 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
Sq. Ft Floor Area:
Valuation: $12500.00
this permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
occupancy Type;
information is correct. l agree to comply with all city and county
375 25 066
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 upartino against liabilities, judgments, costs, and
PERMIT EXPIRES IF WORD IS NOT STARTED
e against said City in consequence of the
expenses4non-
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting oitionally, the applicant understands and will
comply wiurce regulations per the Cupertino Municipal
180 DAYS F OM LAST C SPECTION.
Code, SeIssued
by:Signature
Date 03/11/2016
Date: 03/11/2 lOWN-T
O
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
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
following two reasons:
inspection.
x. 1, 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 (Seo.7044, Business & Professions Code)
Signature ofApplicamt:
2. I, as owner ofthe property, am exclusively contacting with licensed
Date: 03/11120 6
contractors to construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I herchy affirm ander penalty of perjury one of the following three declarations:
x. 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 tine
HAZARDOUS MATERIALS DISCLtiSURE
performance of tiro work for which this permit is issued.
I have read fire hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with tine Cupertino Municipal Code, Chapter 9,12 and the
Health & Safety Code, Section 25532(&) should I store or brindle hazardous
this permit is issued.
material. Additionally, should I use equip t or devices which emit hazardous
S. I certify that in the performance of the work for which this permit is issued, I
air contaminants as defined try the Bay Are r Quality Management District I
shall not employ any person in any in, so as to become subject to the
Evill maintain compliance witty tlae Cnpeatin M micipal Code, Chapter 9.12 and
Worker's Compensation laws of California, If, after making this certificate of
the Health & Safety Code,88 otic r 25 05, 25533, and 25534.
exemption, I become subject to tho Worker's Compensation provisions of the
Labor Code, -I must forthwith comply with such provisions or this permit shall
Owner or authorized agent'
be deemed revoked.
Date: 0311112016
APPLICANT CERTIFICATION
Nt 7 I N I C: NC
I hereby affirm that there Is a construction le ding agency for the performance
I certify that I have read this application and state that the above Information is
of work's for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree to comply with all city and county ordinances and state laws
Lender's Name
relating to building construction, and hereby authorize representatives of this city
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Address
to save Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
DECLARATION
consequence of the granting of this permit Additionally, the applicant
.RCHrTFCT'4
I understand my plans shall be used as public records.
understands and will comply with all non -point source regulations per the
Cupertino Municipal Code, Section 9.18.
Licensed
Professlonal
Signature Date 03111!2016
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT e BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3250
�C.fi�ERTECt® (408) 777-3228 - FAX (408) 777-3333 • buildinca0cupertino.orq ID I Z0 ] ,r'
PROJECT ADDRESS t} L yy y�
� i,J '-� iso•-v--� o r.. �J •-t
....d � ICJ
OWNERNAME L
PHONEE
I -MAI c
0"", ZIa1'y6C6'e'0
iTUW- �i t�v,a��s>3'3��d w�r�i cow
STREET ADDRESS A CITY, STATE, ZIP( FAX r -----
D70 `�t�4r Cure t
v -40u d$ad L7 e✓ t3 i
CONTACT NAME v�L e-
iT",
PHON
N-E.rti}'St�'. ®�''�''`� .a..c7
STREETADDRESS�d � p
C Y, STATE, W
�r�,r-='�`� ='�.
FAX
��'~r-'
Irk ti`.'tx..
�i •�. t'_ �•• �.� i'`z.
❑ owmR ❑ oAwER BUILDER, ❑ OWNER AGENT ❑ CowrRACTOR Cl CONTRACTOR AGENT ® ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACI'ORNAME `
Y ��lL� t�cLV me t•�
LICENSE
"�`�t73�z�
TLICENSET E
EUS. LIC# j (� 81
Q O f
COMPANYNAME `� `� E F
E-MAIL
dot ��2C..vtrs-y���i)„CS's3
FAX ...Y—-...�...
STREETu
?,4 �{7
C1T �]Szt". o °'1C � t � 3 +G cj
F R
lltih 1N C�
v_ L�
-L J
DESCRIPTION OF WORK
RESIDENTIAL
_7
#DWELLING
tom=�
Yv'3`_itc%
�j`�Ci �
FLOOR AREA. 1 �V{
UNITS
^.�srq'�>`irN2'a. - - - �:x••"�- - - `-Y _sem_ - -
'__ -,�... '�;;•�,;_.3�e•�-� - -- ��u- A`�- �s';�,�--
= _ _ _ _
�"'"F`'
.L.'-n.'-i.tSaAa,+3':rA:t���1•:',CL_m_
{' -, �E_�{
�-`•-":�S.
A�.'F".;s;i•_ti'�
�5[�R-�__ts:Y_;_v_F.�`__�_
``yr'i.`Y_'L;:`Yx`.'��^�W--.';�ri'l
1' r.:'?'-�rte.mo•l.a3r-u�i:Y:sJ"_Y'`._:n�Y__-'�;u,��s= r:..tak'.^k:'=
_
'tl
-r�__a>'-"t'Ya"�-`a�7n-i.'-.•�n's�-`=v_ =��l
''z_..uCOMMERCIAL
FL_`
AREA
.`i.s'•aS:,:?`.h'+a'+
,�.=vYTi`�s- _"'--5<�'rC,Fr'
x�y.T�V:�+��
;rs:✓lzK.'+:_
�M;
.i • -H :5} i {. 1� +::
pFLOOR
tvYi't�':'x.�r.�
~ 1 iY4 _ #:. r`l t=
.
TYPE 4F CONSTRUCTION
#STORMS
-- ��,: - - - - �;;r=_� _ �ri ` _
�•_3 �
:vt _ _ �,i".• - •.;yM..
t h
�5`
:i3�.•°`la
A MD JOB NUMBERBX'
?3._+" - %F? r i' '
TOTAL VALUATION:
coo
By my signature below, I certify to each oft a fo owing; I am the prope owxe r authorized a act on the erty owner's b lf. I have read this
application and the infrnmation I have provid is orrect. I have read' the Description of Work and verify itis te, I agree to comply 'th all applicable local
wtiinances and state laws relating to buil ing ons ruction. I authorize representatives of Cupertino to a ab�o7ve-identified property for i tion purposes.
`? - V "
SignatumofApplicant/Agent: Date:
SUPPLEMENTAL INFORMATIO QUMED PRIOR TO ISSUANCE OF DEMOLITION PF,RMIT
glo Fi`c usi ;pnx; ?;
Provide Job Number from Bay Area Air Quality Management District wtvw.baagmd.GrO @ 415-749-4762.
•;Y°*.i..!}�i_�i:PI•vY 4liaat.I{_ s ii �' -'i l':
C an showing protection for an trees 10"
Provide three copies (Residential) or six copies (Commerical) of a site pl o p y
' b�XPFtE9s r - =- • --'"
L,
in diameter or more at 3' above grade.
Provide letter from PG&B (408-725-3325) stating all gas and electric has been disconnected
_
'� yCI.,.;,1.4fAJ{1R'��%f•?I- u. _:. v::�. i'.":`;.S4j.
Provide a letter of inspection, tests; and abatement of any Hazardous Materials. Letter to be initiated by person(s)
sj
certified in asbestos, mercury and/or hazardous material examination.
Planning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days.
]Provide letter of clearance of all vermin from a licensed pest control contractor.
If
Applicant shall call the Public Works Department at 408-777-3104 and schedule a "habitable dwelling inspection.
=- _ , 4 , r;: { _,`R
Provide signed Debris Bin and Recyclable Materials form
_
DemoApp 2013,docrevised 02113113
PROCEDURE CHECKLIST FOR DEMOLITION PERMITS
2 COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
ALBERT SALVADOR, P..E,, C,B4O:, BUILDING OFFICIAL
CUPFRTINO 10304 TORRE AVENUE a CUPERTINQ, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildingQcuperting.org
PURPOSE
The demolition application should be applied for before or at the sane tune as the new construction
pennit application (these are separate permit applications and fees). Permit fees are due at the time of
the applioationlplan submittal. The new construction permit will not be issued until the demolition
permit is issued, unless a letter obtained from the Building Department is submitted stating that "The
existing house will not be demolished until the new construction. permit is issued", The letter needs to
be signed. by both the property owner and general contractor.
REQUIREMENTS
To obtain a demolition permit in the City of Cupertino, please complete a Demolition germit
application along. with each of the following requirements as it applies to your specific project.
_1. Three (3j col2ies of aSite Mennolition plan for Residential or six (6) copies for
Commercial will be required showing any trees 1.0 inches in diameter at 3 feet
above grade on the subject property, and what means will be taken to protect
these trees.
2. PG&E 7aatist be contacted AS EARLY AS POSSIBLE prior to d-emolitioii-to
schedule the abandonment. Contact PG&E at (408) 725-3325. A letter -from
PG&E shall be provided to the City, stating that all gas and electric IZas been
disconnected. (This step can be time consuming, so it is important to begin the
process immediately) I.- Q111 -3AB `1162
S. Provide Job Nunnber from Bay Area. Air Quality Management District
ww-w.baagmd.gov @ 415-749-4762:
7
ve -
Check to see if the building is considered aan historical lan ark. Obtain. clearance
fro.in the Coiim-Lunity Developjnent Plaiatirng Departri nnt. Allow 10 vsorkun
days,
Provide a letter of clearance of all verlyd n from a licensed pest .control contractor,
.Important: Prior to the issuance of t1' i ernolifi n permit, the applicant must call
the Public Works Department at (40 )777-3104 and arrange a "habitable divellutg"
inspection. -
Debris bin and Recyclh-ig sheet: read, sign and date, The sheet wilt rennaiun in the
project's building permit file for the duration of the project.
h g. Conimercial orily-prior to issuance of the demolition permit, the Fire Department
must review the plans for fire suppression/ alarm systems that shall remain in
service or be modified during Demolition or that shall be replaced with the new
construction.
DewoPraceclure.doc revised 2/13113
'U cific Gas and
Electric Company
DATE: 03111/16.
CITY OF CUPERTINO
10300 TORRE AVE
CUPERTINO CA 95014
10900 No. Bigney Avenue
Cupertino, CA 95014
SUBJECT: REMOVAL OF GAS SERVICES (CUT @D MAIN IN THE STREET) ON:
-
10200 Johnson Ave on 03/08ZI6
SUBJECT: ELECTRIC SERVICES WAS CUT AT POLE ON -
10200 Johnson Ave on 02/11/16
If you have any further questions, please contact me at (408) 725-2076
Sincerely,
Mark Kennedy
Pacific Gas & Electric Company
DeAnza Service Planning
408/725-2076
21I Christich Lane #103
Campbell, CA 95008
Date: February 2, 2016
1
Re: Property Address: 10200 Johnson Avenue, Cupertino, CA 95014
To whom it may concern:
The property at the above location was inspected today for any infestation of rodents. No
active infestation was found. If you have any further questions, please call our office at
(408) 866-6609.
Mike Stadmiller
Branch 11 Field Representative
Ap- I - ! t2 Lt0, TM Z,�
Clty of Cuppertmo
public works Department
Environmental Programs Division
103.00 Torre Ave
Cupertino, CA -95014
(408) 777-3354
:Construction "and Den�.oliiLion te6yeling Diversion
Regiiireme-iits--and:Nlnstructioiis
• Ir.
Covered projects, or all construction, demolition and renovation projects that are 34000 square feet or more
are required to complete a Waste Maraagexneiirplah for the City of (�uperti.no demonstrating that 050% of the
material generated is recycled, in compliance With ordii ance :CMC 16,72,050.:: At the conclusion of the project
a Construction Recycling Report must be filed with the Pu_ blip Works DepaLlme6t(Environrxrental Division'
showing the tons recycled and disposed by material type, Use-J.onnage infb=oon from weight tags provided
by facilities to quantify total estimated waste'and percentages for materials, Weight Tags of all material
recycled and disposed must be submitted with the final report in order to° receive a Final Building
rovider f'raii
Debris from a prof act 3,0.00 square feet or more in Cupertino can be collected and
disposed by using:
Please check all that. apply:
11 am. not using a R6cology debris. bin, however, the proj-eet is less than .3,000 s,f,, e.g. buildings, patios, .
sidewalks, driveways.
❑ 1 will use a Recology debris bin. By .Agreement with the City, Recology will prepare my required
Waste Managernent Plan & Recycling Report, Contact Recology: (408} 725-4020.
❑ I am not using a Recology, debris biri, I w ill provide -t tee. following submittals to the City's Public
Works Department, showing that 1 have recycled at least•60% of all construction demolition inaterial:
,Ask for the Construction & Demolition. Recycling Packet from the Building Department and
complete the folloiving.
✓ Submit a Construvtlon cand.Denzolltiorz Waste Managentent Flan with your buildingpern2it
application. Mb, eefor this ptai2. Fonru are available at the.Batildi.rig/Public IVorks counter and online-
atta7i4ni,,caperti72o.orgler7viroiimental, Report the tonnage recycled and *disposed, byn2ateriat type.
Recyclhigfacititles nutst be selectedftoin the" City's approved Ust-i%f Reqycling Resoarrce,s.
✓ Submit a. Constr
]Department will
Works Counter e
Signature:
Naive:
Title:
Phone:
Project
Recycling Report form, The report is required before the Building
tie a ftnal inspection, The report forn2 is available at the BuildinglFatblic
irae �tiryviv,ctar�er-ti.rro or�/etrvironrnetatctl_,
hate: -L - t — 1 ko
`bias-foroi to remain iii the, project's building permit file.for the duratian of the project.
Rinsed 317112 . - 1
x
Tou Bar Equipment
2535 Pulgas Ave
East Palo: Alto, -CA 94303
2/17/2.016
Job No. 45783
Invoic&No: 3TD98
The Bay Area Air Quality Management District .(BAAQMD) acknowledges rec-cipt of your payment and:
Your Asbestos Removal or Demolition Plan described as; Demolition
Site address 1-10,11430 QV',N">ObIJ A.v e, -
Start Date
Completion Date February 29, 2016 - 6\kC -2,004
Removal amounts of friableACM. o Nnear feet 0 square feet -.0 cubic feet
Should it becoriie necessajy=to revise this plan, please do so in the -spaces provided -below and immediately
copy The District by fax or by -mail,
REGULATION 11—_2 REVISION
J# 4S783,
REVISION # START DAM- - COMPLETION DATE
1 1 r
2
3
4
NOTE, This form is not -intended as a Verification of either the completeness ofyour'original notification
Or Of its -cOMPliance -With BAXQMV Regulation 11-2. Y))ou have any questions ab'
but this
_--acknowle- 2ent, please call our _Oj,face at f415).74-0-4-762.
::
_711
RegulatiOn 11, Rule 2
COMPLIANCE &
DAY ARRA
:ENFORCEMENT.'
Acknowledgement of
Aj.-PQ_UA:I.rrY
DIVISION
Notificadand
bn
AJ
MGUMEW
MA
P
Payment of Fees
Tou Bar Equipment
2535 Pulgas Ave
East Palo: Alto, -CA 94303
2/17/2.016
Job No. 45783
Invoic&No: 3TD98
The Bay Area Air Quality Management District .(BAAQMD) acknowledges rec-cipt of your payment and:
Your Asbestos Removal or Demolition Plan described as; Demolition
Site address 1-10,11430 QV',N">ObIJ A.v e, -
Start Date
Completion Date February 29, 2016 - 6\kC -2,004
Removal amounts of friableACM. o Nnear feet 0 square feet -.0 cubic feet
Should it becoriie necessajy=to revise this plan, please do so in the -spaces provided -below and immediately
copy The District by fax or by -mail,
REGULATION 11—_2 REVISION
J# 4S783,
REVISION # START DAM- - COMPLETION DATE
1 1 r
2
3
4
NOTE, This form is not -intended as a Verification of either the completeness ofyour'original notification
Or Of its -cOMPliance -With BAXQMV Regulation 11-2. Y))ou have any questions ab'
but this
_--acknowle- 2ent, please call our _Oj,face at f415).74-0-4-762.
::
_711
0
0
J . W. H . Asbestos
REMOVAL. SERVICES
IC',ES
GSLB No. 777430 OSHA No. 270
This is to certify that J.W.H. Asbestos Removal Services has completed the removal of the
asbestos contracted for at the following job location:
10200 Johnson Ave, Cupertino, CA 95014
In accordance with J.W.H. Asbestos Removal Services proposal signed/dated February 4,
2016. This notice conforms to and is in strict compliance with all applicable standards and
regulations. This provision of completion is our acknowledgment by authorized signature
that all services that have been contracted for are completed as specified at the above
referenced property location.
Jolil. Howell
J. Asbestos Removal Services
710 E. PAcGlincy Lane 94111, Campbell, CA 95008
2016
Date
Tdh 408.374-1123 Fan: 408-374-1059