14060142CITY OF CUPERTINO BUILDING PERMIT
Bt ILDING ADDRESS: 21721 COLUMBUS AVE CONTRACTOR: SIGNATURE ROOFING INC I PERMIT NO: 14060142
OWNER'S NAME: WAL fON JOSEPH H AND FAITH C
OWNF,R'S PHONE: 4089962496
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic.#
Contractor
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.
1 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 18.
Signature Date I
❑ OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 (Sec.7044,
BnSInCSS & Professions Code)
1. 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.
1 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 ofthe Labor Code, 1 must
fl rthwith comply with such provisions or this permit shall be deemed revoked.
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
5.55 O'NEILL AVE, #16 DATE ISSUED: 06/23/2014
BELMONT, CA 94002 PHONE, NO- (800)644 -7410
BUILDING PERMIT INFO BLDG r- ELECT i PLUMB
MECH F RESIDENTIAL r COMMERCIAL F
JOB DESCRIPTION. REMOVE SHAKE. INSTALL 7/16 - 30 SQ
Sq. Ft Floor Area: 0 1 Valuation: $14500
APN Number: 35618038.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
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(x) 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:
Date:
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
.( r t
A t
K
Page 3 of 4
CITY OF CUPERTINO BUILDING PERMIT INSPECTION CARD 1
FAITH C
(JWNER'S PHONE: 4089962496 (CITY: CUPERTINO [CONTRACTOR PHONE: 6505985444 1
DATION/PIERS/H.D.S, UILDING PERMIT INFO:
BLDG ❑ ELECT ❑ PLUMB ❑ MECH ❑ RESIDENTIAL ❑
GROUND OMMERCIAL
ET BACK -CERT
JOB DESCRIPTION:
GE MOVE SHAKE. INSTALL 7/16
3/PREGUNITE
NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED WILDLAND URBAN INTERFACE FIRE AREA ❑
DnpnTn M /CT AD ER#
PLUMBING
FRAMING
RFLOOR INSULATION
: NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SHEATHING
H PLUMBING
& SHOWER PAN
H MECHANICAL
H ELECTRICAL/POOL
TO ARRANGE INSPECTION
Call 777 -3228 between 7:30 am and 3:30 pm Monday through Friday, at
least 24 hours
before required inspection. Job address and Permit Numbers are needed
when
requesting an inspection.
CUPERTINO SANITARY DISTRICT
Closed circuit video inspection of property line cleanout, Point of connection
and street lateral required prior to passing FINAL CITY PLUMBING
INSPECTION. Cali the District (408 -253 -7071) for an appointment.
NO BUILDING FINALS INSPECTIONS UNTIL ALL REQUIRED
BUSINESS LICENSES ARE OBTAINED
PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE
OR 180 DAYS FROM LAST CALLED INSPECTION.
IMPORTANT
When a permit has expired, a charge totaling one -half the fees to obtain a new permit must
be Paid in order to reactivate the Permit. If a permit has been expired for more than
one year, a charge totaling the full fees to obtain a new permit must be paid
to reactivate the permit.
NOTES:
SPECIAL INSPECTIONS Inspector: Date:
ROOF INSPECTIONS
PRE- INSPECTION: Inspector:
Date:
TEAR -OFF:
Inspector: "q 06 _�_
Date: /,)
PLYWOOD:
Inspector:
Dato —�g
BATTENS:
Inspector:
Date:
NSULATION /VENTILATION IN PROGRESS: Inspector: jy Date:
OVER NO WORK UNTIL ABOVE HAS BEEN SIGNED /
�
FINAL: Inspector: C� C• Date:
x.
r
http:// ecupertino .org /egovplus /Permit_app /PERMIT APP.ASPX ?permit _ no = 14060142 6/23/2014
Address
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT gEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 - FAX (408) 777 -3333 • building alcupertino.oro
Permit
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 and conditions of this statement
Owner (or Owner Agent's) Na e: I�
O...A.4010 ^�-
Si natur ...4 /. . ............................... Date:l . ....
Contractor Name:
Sinature .................................... ............................... Licl ....... ............................... Date:...................
r e Smoke and CO form.doc revised 03118114
&f.
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
GUPERTINO 10300 TORRE AVENUE CUPERTINO, CA 95014-3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildino(acupertino.org
/ Z I ermit No. (� G'j `•// C
Add*
ddress l CO C V h s vl # of Alarms Smoke: Carbon Monoxide:
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
in�talled 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.
FN
I have read and agree to comply with the terms and conditions of this statement
00wner (or Ownert' )
rum r'
p /
Signature ............ ..... ...." ... ..................Y. ....\ �.4 ....... ................. .............. oat � ....�.
Contractor Name:
eN
r
6'.e
� J
�
eU °e ,el/
S ig nature. ........ Lic. #�(J�
........... . ............................... ..... ............................... Date:.. ...............
Ora
Smoke and COform.doc revised 03118114