15040221 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 401 CONTRACTOR:20800 VALLEY GREEN PERMIT NO: 15040221
DRIVE
OWNER'S NAME: 20800 VALLEY GREEN DRIVE PO BOX 1368 DATE ISSUED:04/29/2015
OWNER'S PHONE: 4082530200 CARLSBAD,CA 92018 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL E]
APT 401-INSTALL(N)WASHER&DRYER HOOK UPS
License Class Lic.#
Contractor 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 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. Sq.Ft Floor Area: Valuation:$500
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 APN Number:32609040 401 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 D AST CALLED INSPECTION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 3
granting of this permit. Additionally,the applicant understands and will c sue ate:
with all non-point source regulations per the Cupertino Municipal Code,Section
918.
RE-ROOFS:
Signature Date 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.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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,
Susiness&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section5505,25533,an 25534. ?
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent`` Date:'` i
permit is issued.
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 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 Lender's Address
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
918.
Signature Date 'O — -1
GENERALPERMIT APPLICATION e 0\
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDINGMEP
DIVISION \�O
10300 TORRE AVENUE•CUPERTINO.CA 95014-3255
GtJt'EFi7tNb (408)777-3228•FAX(408)777_3333•buildino(acupertino oramisc
[PLUMBING ❑MECHATIICAL []ELEClR1CAL MISCELLANEOUS
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0135 PHONE E-MAIL
STREET ADDRESS 9Y CITY ATE ZIP. FAX
CONTACT NAME G�� f l{ 3
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OWNER ❑ OWNER-Btm-DER O OwNERAGEW D CONTRACTOR ❑CONIRACTORAGENr' D ARcHmCT ❑EN
GWEER D DEVELOPER ❑TENANT
CONTRACTOR NAME n��
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ARCWTEMENGINEER NAME LTCENSENUMBEIt `
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COMPANY NAME E MAIL
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USE OF DSFDorDUPLEB ❑ mum-FAM Y PROJECCIIiWTLDLAND ❑ YES PROJEC7TN ❑YES 1S BLDGAN 13 YES
BUI DING ❑COMMERCIAL THE
URBAN JNTERFACE AREA ❑NO FLOODZONE b NO IS TIM A NOME? ❑NO -
DESCRIPTION OF WORK
f
4 i
TOTAL VALUATION:
By my signature below,I certify to each of the followi • the roe ~: :~y:
application and the information I have property nY o"�^�Crr authorized a c props I have read this J '
provided is eorr est i have read the Description of Work and v It is acc a r
ordinances and state taws rotating to ilding construction I a h Ize representatives of Cu g PIY with all applicable total
Cupertino to enter the above-idi property for inspection purposes.
Signature of Applicant/Agen
Date
SUPPLEMENTAL INFORMATION REQUIRED -:
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M P-A sr-4pp 2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 20800 VALLEY GREEN DR DATE: 04/29/2015 REVIEWED BY: MELISSA
APN: 32609040.401 BP#: *VALUATION: $500
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY Multi-Family Dwelling Buildina is PENTAMATION 1 RMAP1
USE: 1 >3 Stories 0 Yes E) No PERMIT TYPE:
WORK [&EI401 - INSTALL N WASHER & DRYER HOOK UPS
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Other Appliance/Equip 113APPLOT 2 # $144
TOTALS:
"'1"!] $144.00
aNOW
Mech.Plan Check0.0 hrs $0.00 I'Iztmb.11ho;Che:
Mech.Permit Fee: IMPERIIIIT 'F€r nh,7'C:�miil Fee f>t?>r..t3r>>=ai F,;,;
Other Mech.Insp. 0.0 hrs $48.00 t; he.?. f€m.;b Ll I
Lech,sMiS , i`¢^i:': 1'D/Lari). HlCC;..hitp. Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These,fees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE MISC ITEMS
Phan CheckC°case
PME Plan Check: $0.00
'f u.
PME Unit Fee: $144.00
PME Permit Fee: $48.00
on rrlicficjnr. T;r
Administrative Fee: 1ADMIN $45.00
Work Without Permit? 0 Yes E) No $0.00
Travel Documentation Fee: ITRAVDOC $48.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
11,11 `c $2
$0.00 ' TOTAL FEE: $286.501
86 50
Revised: 04/01/2015
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO. (408)777-3228-FAX(408)777-3333•buildin4a�cuoerfino oro
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS
20 APN BP#
OWNER NAIAE 2.
' 0 VN R ADDRESS
Lam. V_
DESCRIPTION OF WORK: ie,-
We are providing you with an Owner-Builder Acknowledgment and information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read,initiated your understanding of each provision, signed,and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFiCATiON OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Bui der"building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. 1,as an Owner-Builder,may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on m
y property. My homeowner's insurance
provide coverage for those injuries.I am willfully acting as an Owner-Builder and am aware of the limits of my may not
insurance coverage for injuries to workers on my property.
2.1 understand building permits are not required to be signed b
the construction and are not hiring a licensed Contractor to assume his responsibility.
unless they are responsible for
i understand as an"Owner-Builder"I am the responsible party of record on the permit. I understand that I ma
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her y
name instead of my own.
5 (/4. 1 understand Contractors are required by law to be licensed and bondedin California an
numbers on permits and contracts. d to list their license
y L` 5. I understand if I employ or othenMrise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars($500), including labor and materials, I may be
considered an"employer"under state and federal law.
S V6.I understand if 1 am considered an"employer"under state and federal law, I must register with the
federal government,withhold payroll taxes,provide workers'compensation disabilityg state and
nce, and contribe to
unemployment compensation for each"employee."1 also understand my failure to bide by these laws may subject
me to serious financial risk.
5 Lf 7. I understand under California Contractors'State License Law,an Owner-Builder whobuilds _
fami
residential structures cannot legally build them with the intent to offer them for sale, unless a#wok islperformed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
8. 1 understand as an Owner-Builder if 1 sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OlvnerBuildeiForm 20I0.doc revised 04114110
V! 9: I understand 1 may obtain more information regarding my obligations as an"employer"from the Internal
Revenue Service,the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand i may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB(2752)or www.csib.ca.gov for more information about licensed
contractors.
�10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
11. i agree that, as the party legally and financially responsible for this proposed construction activity,
by all applicable laws and requirements that govern Owner-Builders as well as employers. l will abide
5z,2. I agree to notify the issuer of this form immediately of any additions, deletions, or chanes
anof the
information I have provided on this form.Licensed contractors are regulated by laws designed to prootect the public. If
You contract with someone who does not have a license,the Contractors'State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint.Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or fine is injured while working on your property,you may be held liable for damages. If
You obtain a permit as Owner.Builder and wish to hire Contractors,you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ_)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note.A copy of the property owner's driver's license,
form notarization, or other verification acceptable to fhe m maybe required to be presented when the permit is issued
to veil the ro ert owner's si natu_e.
Property Owner's Signature: - —
--Date: �
(NOTE. The following Authorization f=orm is required to be eomplefed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORiZATCON OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which 1 understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for,sign,and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent
Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personalty filled out the
above information and certify its accuracy.Note.A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature:
Date:
Oi+aierBuildeiFor7n-2010.doc;erised 04/14/10
Address
1
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 Qcugertino.org
Pnrmif Nn / (t- /lel —6722— J
PURPOSE
tallation of all required Smoke and Carbon M zo- Aar=lns for
This affidavit is a self -certification for the ins
compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 where now iyio race �o $ r
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 dwellirng units exceeds
$1000.00, CRC Section R31.4 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 X X
bedroom(s)
On ever level of a dwellin unit includingbasements X X
X
Within each sleeping room
Carbon Monoxide alarrns 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, alann(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.
1 have read and
mer (or Owner Ag ht's) Name:
)� va ,T G Si
ontractor Name:
e to comply with the terms and
aturef.......... I -A, --7-/T/_-7 ...............
of this statement
Date: 0.
nature................. .........................-.......................Lic.#...................................... Date: ...................
Smoke and CO form.doc revised 03/18114
0
CUPERTINO
Owner Name
Address
Please refer to the attached. Calitorma Civil Code Sections 1101.1— 1101.8 which -are part of this Certification fdrin: .
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333'-' buildinQ(a cuoertino org `
1. Is your real property a registered historical site?.
❑ Yes. Civil Code Sections 1101.1 through 1101.8 do not apply.' Sign below and skip the ra o t e for
Owner' Signature: Date:
KNO Go to Question 2.
�- / 2�
�i
2. Does your real property have a licensedlumber certifying fyiilg that, due to the age or configuration of the property or its
plumbing, installation of water -conserving plumbing fixtures isnot technically feasible?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do'not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Sign below and skip the rest of the form
Owner' Signature: Date:
To Go to Question 3.
3. Is water service pennanentl.y disconnected for your building? '
❑ Yes Civil Code Sections 1101.1 through. 1101.8 do not apply. Sign below and skip the rest of the form.
Owner' Signature: I Date:
No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ No My real property is built and available for use'or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 don t apply. Sign below and skip the rest of the form.
Owner' Signature: (5,W4,,/,6 Date:
X
Yes My real property is built and available for use or.occu ancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Refer to the attached.
❑ Myproperty is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing
fixtures to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1,
2017, all non-compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless
of whether property undergoes alterations or improvements).
❑ Myproperty is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water -
conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
improvements).
❑ Myproperty is a c07nmerci.al real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
SB40 7 2014.doc revised 03/18/14
0
On or before January 1,' 2019, all non-compliant plumbing fixtures `shall be replaced with water- conserving
plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
improvements).
1/We, the owner(s) of this property, certify under penalty of perjury that non-compliant plumbing fixtures have been replaced
with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101.1 through 1101.8, the current
California Plumbing Code and California Green Building Standards Code, and manufacturer's installation requirements, and
that the water -conserving plumbing fixtures comply with there u' ements as indicated in the table below.
Owner's (or Owner Agent's) Signature: Date:
Upon completing and signing this Certificate, please.,return it to the Building Division in order to final your permit..
1. If the existing plumbing ttxture water usageiuow rate is equal w ut LUWC;l LIMIL L11C. 116 11� -u I—)
SB4072014.doc revised 03/18/14
Kori-Complianti
_., ... .. Water -Conserving Plumbing Fixture.
_
Plumbing Fixture,
(Fixture Complying with Current Code Applicable.to New -Construction)
Maximum
Water Usage/Flow
Rate
Fixture Type
2013 CPC Ch. 4
- 2013 CPC Ch. 4
2013 CPC Ch. 4
-Water Usage2013
CALGreen Div. 4.3
2013 CALGreen Div. 4.3
2013-CALGreen Div. 5.3-
/Flow Rate
Single -Family
Multi -Family
Commercial
Residential
Residential
Water Cldsets
Exceed 1.6
Single flush toilets: 1.28 gallons/flush
(Toilets)
Gallons/flush
Dual flush toilets: 1.28 gallons/flush effective flush volume (the composite,
average flush volume of two reduced flushes and one full flush
Urinals
Exceed 1.0
0.5 gallons/flush
Gallons/flush
Shoerheads
w
Exceed 2.5
2.0 gallons per minute 80 psi. Also certified to the performance cri teria of
@
gallons per minute
U.S. EPA WaterSense Specification for Showerheads
(A hand-held shower is considered a showerhead.)
For multiple showerheads serving one shower, the combined flow rate of all
showerheads and/or other -shower outlets controlled by a single valve shall not
exceed 2.0 gallons per minute @ 80 psi, or the shower shall be designed to
allow only one shower outlet to be in operation at a time.
Faucets –
Exceed 2.2 gallons
Maximum 1.5 gallons per
Within units:
0.5 gallons per minute @ 60
Lavatory
per minute
minute @ 60 psi; -minimum
Maximum 1.5 gallons
psi
Faucets
0.8 gallons per minute @
per minute @ 60 psi;
20 psi
minimum 0.8 gallons
per minute @ 20 psi
In common and public
use areas: 0.5 gallons
per minute @ 60 psi
1.8 gallons per minute
60 psi
Faucets –
Exceed 2.2 gallons
1.8 gallons per minute @
1.8 gallons per minute
1.8 gallons per ininute @ 60
Kitchen
per minute
60 psi
@ 60 psi
psi
Faucets
May temporarily increase
May temporarily
up to 2.2 gallons per
increase up to 2.2
minute @ 60 psi, and must
gallons per minute @
default to maximum
60 psi, and must '
1.8 gallons per minute @
default to maximum
60 psi
1.8 gallons per minute
Where faucets meeting
@ 60 psi
the above are unavailable,
Where faucets meeting
aerators or other means
the above are
may be used to achieve
unavailable, aerators or
reduction.
other means may be
used to achieve
reduction.
1. If the existing plumbing ttxture water usageiuow rate is equal w ut LUWC;l LIMIL L11C. 116 11� -u I—)
SB4072014.doc revised 03/18/14