15080098M
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21331 COLUMBUS AVE CONTRACTOR [� 06,hl PERMIT NO: 15080098
OWNER'S NAME: CINDI AND PETER MA
DATE ISSUED: 08/12/2015
I OWNER'S PHONE: 4083130703 1 . I PHONE NO: I
5d LICENSED CONTRACTOR'S DEC�jLA/R�A/TION
License ClasLie. #� ✓ (/ VJ, n `
Contractor -rt c 1 BC�/i G, Date_W__, 1 Ls 1
I hereby affirm that I am licensed under the provisions of Chapter 99��
(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.
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. e_;,�
Signature / Date L
❑ 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
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
UPGRADE (E) 100 AMP PANEL TO (N) 200 AMP PANEL,
SAME LOCATION
Sq. Ft Floor Area: I Valuation: $2000
APN Number: 36204002.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ANCE OR
180 DAYS FROM SPECT ON.
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,p 25534.
Owner or authorized agent: Date: `
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of
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 I
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CUPERTINO
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building aalcupertino.ora
O 0�
LJ PLUTA3IIvG /❑ MECHANICAL ELECTRICAL ❑MISCELLANEOUS
2,1331
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PROJECT ADDRESS / 33 I � VW �fl IO 11& / (/ I APN n
OWNERNAIvIE !y%%� F' i f A tl' n ^ PHONE 6 jiAIL�
STREET 6 DDRES: ��C�//�( CITY, STATE, ZIP(W&-rjjV j / n,/(��i/� //� FAX
CONTACT NAME jJCtM Q,�7� ` _) PHONE 4,6:F_6 67_,�)4/ E-TvLAIL
STREET.ADDRESS 1 �/�QD r,„,� /� CITY, STATE, ZIP � , Ok-i T6 -3 ^ FAX
❑ OFR.'FR ❑ OWNER -BUILDER ❑ OWNERAawr ❑ CONTRACTOR ❑ CO?TRACTOR.AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DE=VELOPER ❑ TEN.AIvi
LICENSE TVOER®"O'me_f
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COMPANY N.A]JE /J
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STREET ADDRESS164- ov � _ �J� � M � �
CITY, STATE, ZIP OS / LS � � �
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I PHONE
ARCHITECT/ENGINE,ER NAME LICENSE NUMBER
I BUS. LIC n
COMPAI YNAME
E-IVIAIL
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STREET ADDRESS
CITY, STATE, ZIP
PHONE,
USE OF El sFD or DUPLEX 13 MULTI-FATffi.Y . PROJECT LN MIDLAND El YES PROJECT IN ❑YES
BUIIDING: ❑ COMmERCIAL I URBAN.' D?TERFACE AREA ❑ NO FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? E3 NO
DESCRIPTION OF WORK
TOTAL VALUATIO
By my signature below, I certify to each of the following: I am the property owner or au aaen
application and the information I have provided is correct. I have read the Description of Work and verify it is
ordinances and state laws relating to buildingcon on. I authorize representatives of Cupertino to enter the
Signature of Applicant/Agent: ; _ Date:
a . I have read this
property for inspection purposes.
'AL INTFORMATION REQUIRED c�F, 0 t < '�Li
.MEPA7iscApp_2011. doc revised 06121111
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.MEPA7iscApp_2011. doc revised 06121111
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CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
APPLIANCE / EQUIP TYPE
21331 COLUMBUS AVE
DATE: 08/12/2015
REVIEWED BY: MELISSA
ImADDRESS:
APN: 362 04 002
BP#:
"VALUATION: 1$2,000
xPERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: SFD or DuplexT
Amps
PENTAMATION
PERMIT TYPE: 1 REAP A
WORK
UPGRADE E 100 AMP PANEL TON 200 AMP PANEL SAME LOCATION
SCOPE
Suppl. Irl p Fe c
APPLIANCE / EQUIP TYPE
FEE ID
Phuuh. Plan Cheek
QTY
UNITS
BP FEES
Elec. Permit Fee: IEPERMIT
Services
1 ERT<200
Other Elec. Insp. 0.0 �rs$48.00
200
Amps
$48
Permit Fee>:
Suppl. Irl p Fe c
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? Yes (j) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the vreliminary information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution II -053 Ef. 717!13)
,Meeh, Plan Check
Phuuh. Plan Cheek
Elec. Plan Check 0.0 hrs $0.00
tfech. Peru:it Fee'
Plumb. F
Elec. Permit Fee: IEPERMIT
Ocher Heck Insh,
Other Plurnt) Insp-
Other Elec. Insp. 0.0 �rs$48.00
PME Plan Check:
$0.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the vreliminary information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution II -053 Ef. 717!13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl..K., Ifee
PME Plan Check:
$0.00
Permit Fee>:
Suppl. Irl p Fe c
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? Yes (j) No
$0.00
Advanced Planning
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$190.50
$0.00 TOTAL FEE:
$190.50
Revised: 07/02/2015
CUPERTINO
Address
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a.cupertino.ora
Perm
2-1331 COL-0mb us
1508,00(7"?"
i! of Alarms Smoke: *5 Carbon
�L[:I F1) I eT`IL TIII� CEI' l IE IC
V
N ) TO,THE,Bt
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 #Qcomply vvjdrt_h`e_te`rfns and conditions okhls statement
Owner (or Owner Agent's) Name:
r�
Signature. ........... .................................... Da e: ... ..(�.......
-Trontractor Name:
Signature...................................................................Lic.#...................................... Date:...................
Smoke and CO form.doc remised 03/18/14