BLD-2023-2586_SignedPermitBUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: APN: PERMIT NO:
OWNER’S NAME: OWNER’S PHONE:
CONTRACTOR: CONTRACTOR PHONE:
DATE ISSUED: ISSUED BY: VALUATION:
JOB DESCRIPTION:
LICENSED CONTRACTOR’S DECLARATION:
CONTRACTOR: LICENSED CLASS: LICENSED NO: EXP 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 three declarations:
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 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.
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.
EPA LEAD-SAFE DISCLOSURE
An EPA Lead-Safe Certified Renovator will be responsible for this project.
Certified Firm Name: _____________________________________________ Firm Certification No: ____________________________
No EPA Lead-Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work which this permit is issued
(Section 3097, Civil Code).
Yes No
Lender’s Name: ________________________________
Lender’s Address: _______________________________
APPLICATION 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, judgements, 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.
Signature ___________________________________________ Date ______________________________
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 365 DAYS AFTER ITS ISSUANCE,
OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 365 DAYS AFTER THE TIME THE WORK IS COMMENCED.
21710 LOMITA AVE 357 18 002 BLD-2023-2586
ELLSWORTH STEVEN TRUSTEE & ET AL
NEIGHBORS ROOFING
Jasmine Archbold 15500
NEIGHBORS ROOFING 1071133 11/30/2024
Everardo Lopez
Nov 20, 2023
4
4
4
4
Nov 20, 2023
SMOKE; CARBON MONOXIDE ALARMS
I SELF -CERTIFICATION OF COMPLIANCE
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Thz. affidavit is a -
%v ith 2022 Califo i4 RES 7iilltun firr th,.• rt yuirt.ct `'iin:+kc and t_arhzm +innaxt;ie 1':.larrn
mA-$et:idrastial Codt� tCltC } SectitJrt R.71'
-1"tau trig • also omqui ru c 3 giant the itl4-i Ctur ocrtsc into the• reKid R ai5' ?vltr_re no, intvri()r acl'k'S5 for ih5l]f Ctt071ti 15 Teclu iTl Z{,
C3t7 stlp verification of. & Co alarm. ty�cr (i'r on -Kitt veri ficatiun in lieu of rvmpittion of this affidavit.
�9tlired tt•ht-n in F t ctitin area is within the residence.
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Existing sinP,lo- farnill and multi -family davcilings shall l+r
Alarms must be models aPPreved and lisietl h Provided with Smoke Alarms and Carbon Monoxide alarm, y tile State fire rrr5
non$"�tld-Ant t:t1*tl af_ �r . ; 1. Marrthal, found at fit tp' 1 t.;trn tart r:vdill€crlili-
listed in acayrdanoc with (# , t s?#J)}; ttttl.Zl t titll:L1~Jul yi14f11)t1LSLi(tt,_mr,ll:_lik tin
L �17. Combination smoke and carbon mcJnoxldc alarms ;hall he Permittedr to a aused in lieu
be
of srnE,ke alarms. Provld�.cj they are litited in accordance with UL 217 and de alarms
shall the valuation of a useotv�,
alterations, or repairs to existing dNti-etlied iunits c exceedsordance it?plt, 1Ul-le
AlarMs and,tor Carbon Monoxide Alarms be installEd and funce�ioti ing inRtlCie f Itio Section
locations:R15 requires that smoke
i 1 —.— ht E I Co AL�i
each ,lee in
p $ rOUal- MOM smoke alarms matt -- $ '( 1 li—i;tcnully horn ttk diver be instatled not less than s fert: Or nl*erynl; ni .. b,.[hr x.m ghat cuntuim M bathtub ar shower, irom the tip n( it,
bla.Jc .�r a �'erline-susp,.t%drd (paddle) fan, and h ,ri,%tal p th ..—
has n'�y; "r `.�e1�$ �S'srcm and Shall be installed nt+tsidr of t(,e d �n the su PPiV rrtiid V'Ir rre �a futr''r.
t1�1 a]T
�ddihnrul m, err Ct airflow (rum those r hte t i r--.=_— -_ � rc�rnrntc Or ctari (iialtOn rw-c hPjrA?Z_
On every level of a dwe
_lling unit including basemets nand habitable attics f7utside each s — — -- _
eparate sterping area in the ilnniediale vicinity of the ----t— — -- _—! _
t'edrrrom(s). i
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— — — — --- -- L X
si�'C?TF.—: Carbon Monoxide alarms are not required in dwellings which do rtgj contain
duus
rust leave an attaf hcd garage. fuel -burning appliances an4i Cbtiat
In existing dwelling units with no commercial electrical su
maybe solely, battery operated. In existing dcvellit�g writs, alarms arc pertniptttec3 to alms' the stroke and Co alarmt;,'l
repairs or alteration,, � scileby battery ctperated where
basernent, or crawl space. Refer to CRC Section R314 &of 1anti R315- An electrical hl finishes or there is no access by me ,. ai attic,
c-t?nrte�cted to the building electrical systern. permit is requited for alarms which nustbe
"As Owner or Owner's appointed agent of the listed property, 1 hereby certify that the alarlit(s) referenced above tare
tltsteilled in accordance with the manufacturer's instructions and in compliance Witli the California Residential Ccicies."
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