14050104I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22400 JANICE AVE I CCO EOM T_ RAN TOOR.: TBD - -'tO I PERMIT NO: 14050104 I
OWNER'S NAME: HSU HUI -CHI AND LAI HSIU -CHEN ET AL f Raj AW 4 CLik e Pur4AIDATE ISSUED: 05/16/2014
OWNER'S PHONE: 4086881357
❑ LICENSED CONTRACTOR'S DECLARATION
License Classes 3 Lic. # / /
Contractor ��la Wit' Date �� / r Z�
I hereby affirm that I am licensed under th 1 ro pte
n r 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:
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.
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 1� / 2 P
Signgn ature Date � r
❑ OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
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
TPHONE NO:
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL
REPLACE SEWER LINE
Sq. Ft Floor Area: I Valuation: $2000
APN Number: 35701051 00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 D=OM LAST CALLED INSPE/CT/I``ON.
Issued by: Date: �•1 �'` J�
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:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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.
Owner or authorized agent: :TX,,�4 Date: J
CONSTRUCTION LENDING AGENCY
f h f ce of
become subject to the Worker's Compensation provisions of the Labor Code, I must I I hereby affirm that there is a construction lending agency or t e per Orman
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
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.
Signature Date
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
XF
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300TORRE AVENUE • CUPERTINO, CA 95014 -3255 ((��
(408) 777 -3228 • FAX (408) 777 -3333 • buildina(a)cugertino.org 4"
17 DTTThATIrKTn F7A/7rr-TATSTr'AT. I— IP.T.R..CTRTCAL nMISCELLANEOUS
PROJECT ADDRESS f� I APN #
61 O
A U •
OWNTER NAME f PHONE
E-MAIL
TC/ ((/j>b
J
STREET ADDRESS CITY, STATE, ZIP_ .
I FAX
CONTACT NAME PHONE
E -MAII
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ owmm- BUrII'ArE^R ❑ M;1NERAGE1,7 ❑ CONMUCrOR ❑ CONPRACTORAGENT ❑ ARCHITECT ❑`ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR N U l ��
LICENSE NfJD�ER
LICENSE TYPE �j�
V
BUS. LIC #
COMPANY N,
E -MAIL,
FAX .=
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHI TECT/ENGINEER NAME LICEAISE NUMBER.
BUS. LIC #
COMPANY NAME
E MAII
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI- FAMQ,Y
PROJECT IN WILDLAND ❑ YES
PROJECT IN ❑ YES
IS THE BLDG AN ❑ YEs
BUILAJNG: ❑ COMMERCIAL -
URBAN BSIERFACE AREA ❑ NO
FLOOD ZONE ❑ NO
EICF= HOME? ❑ NO
DESCRIPTION OF WORK
r
TOTAL VALUATION. -ETYE
x wry. ar 3 .
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the pr perty filer's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to b ' ing co ptruction. I authorize representatives of Cupertino to enter the above - identified property for inspection purposes.
Signature of Applicant/Agent:
Date:
UPPLEMENTAL INFORMATION REQUIRED
20
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MEPA1iscApp_2011.doc revised 06121111
CITY OF CUPERTINO
IV UcT71V4 A r1r"1? 112ITII nlVTQl()N
ADDRESS: 22400 janice ave
DATE:
REVIEWED BY: Mendez
APN:
BP #:
*VALUATION: $2,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
SFD or Duplex
Plumb. Plan Check 0.0 hrs
PENTAMATION 1 RPSS
PERMIT TYPE: i
USE:
$0.00
Permit Fee:
$0.00
WORK
re lace sewer line
IPPERMIT
if e. P'erim,,
SCOPE
Other Plumb Insp. 0.0 hrs
NOTE: This estimate does not mctude fees aue to otner Departments (i.e. 1-turtning,
__ .. _._:•_z�- _._a _ . t., a f:....r, ! ,.,r.nf tt,o Pont for nddn'1 info_
Utstrier, etc.). inese ees ure v weu V/L e /GFEE ITEMS (Fee Resolution 11 -053 E . 7( /f 1/13)
s
QTY/FEE
MISC ITEMS
Plan Check Fee:
° }_....
1 # Plumbing
$24.00 iPRSEWER Sewer, Sanitary
Suppl. PC Fee: (j) Reg. ® OT
0.0 1
Plumb. Plan Check 0.0 hrs
$0.00
f , ,f , Pion 0 :,crk
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee: Reg. 0 OT
t'er/Wf Fee: Plumb. Permit Fee:
IPPERMIT
if e. P'erim,,
Jrfre tP��. I�;v2
Other Plumb Insp. 0.0 hrs
$47.00
Utl2er t zt c P dsI>. Li
$47.00
. {1ii- vriic2ion T,L, :
Administrative Fee: IADMIN
-_
$44.00
NOTE: This estimate does not mctude fees aue to otner Departments (i.e. 1-turtning,
__ .. _._:•_z�- _._a _ . t., a f:....r, ! ,.,r.nf tt,o Pont for nddn'1 info_
Utstrier, etc.). inese ees ure v weu V/L e /GFEE ITEMS (Fee Resolution 11 -053 E . 7( /f 1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
1 # Plumbing
$24.00 iPRSEWER Sewer, Sanitary
Suppl. PC Fee: (j) Reg. ® OT
0.0 1
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee: Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$47.00
. {1ii- vriic2ion T,L, :
Administrative Fee: IADMIN
-_
$44.00
0
E)
Work Without Permit? 0 Yes E No
$0.00
Advanced Planning Fee:
$0.00
Select a Non - Residential
Building or Structure
Travel Documentation Fee: ITRAVDOC
$47.00
Strong Motion Fee: iBSE1SMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
BTOTAIS.
$139.50
$24.00 TOTAL FEE:
$163.50
Kevisea: u4iu /zu,4
Address Z1
SMOKE / CARBON MONOXIDE ALARMS FILE
OWNER CERTIFICATE OF COMPLIANCE_2��
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 •FAX (408) 777 -3333 • building
a- gugertino.org
o Uan,c2 AIle,
,5-010
PURPOSE
This affidavit is a self- certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single - family and multi- family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and /or Carbon
Monoxide Alarms be installed in the following locations:
AREA
SMOKE ALARM
CO ALARM.
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On every level of a dwelling unit including basements
X
X
Within each sleeping room
X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel- burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above - referenced property, I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
I have read and agree to comply with the terms an s o Ts statement
Owner (or Owner Agent's) Name:
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Si natur ........ .... .. ............................................................ ............................... Date: ......... ......
Contractor Name%
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Si nature. .................. .. ............................... Lic.# ........... �..................... Date .. .�.. .
Smoke and CO form. doc revised 03118114