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15080108I CITY OF CUPERTINO BUILDING PERMIT I IBUILDING ADDRESS: 20337 CLAY ST I CONSTRUCT ON ANTHONY HODDER I PERMIT NO: 15080108 I I OWNER'S NAME: NAKASHOJI RICK H AND LISA M 17504 BOLLINGER RD I DATE ISSUED: 08/13/2015 1 OWNER'S PHONE: 4085154744 1 CUPERTINO, CA 95014 1 PHONE NO: (408) 257-4317 I 9 LICENSED CONTRACTOR'S /DECLARATION License Class P.;O- I/ Lic. # —T "T (o St Contractor. `, (U Date 40 ^ 7 2— ^ `—C �- 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: 1. 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,r e rformance 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 eep harmless the City of Cupertino against liabilities, judgments, C costs, and e e es which may accrue against said City in consequence of the granting o iermit. A ditionally, the appinderstands and will comply with all non -p int Zs�wce rig a ns per the Cue Co-n�cipal Co/de, Section 9.18. e Signat re ❑ OWNER -BUILDER DECLARATION 1 hereby affirm that I ant exempt from the Contractor's License Law for one of the following two reasons: 1. 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) 2. 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: 1. 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. 2. 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. s. 1 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. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. 1 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 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ BATHROOM REMODEL (75 S.F.) REV # 1 - ADD PANEL UPGRADE TO (N) 200 AMP PANEL, SAME LOCATION - ISSUED 10/12/15 Sq. Ft Floor Area: I Valuation: $10000 APN Number: 36938018.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERM SUANCE OR 180 DAYS FROM ED INSPECTION. ae 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. 1 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 Emai ' nts as defined by the Bay Area Air Quality Management District I will ain ompliance with the Cupertino Municipal Code, Chapter 9.12 and the Saf e, Sections 255 5 25533, and 25534. r e1�.,a h iz�- nt /O� 2 2o( 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 CUPERTINO F-1 vpw rn>J C7u i Ir-rT()1J CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION. - 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255' (408) 777-3228 - FAX (408) 777-3333 - building (c>)oupertino.orq ❑ ADDITION ❑ ALTERATION / TI D �VISIO/ DEFERRED ORIGINAL PERMIT r 1570 3.6 10 PROTECf ADDRESS 0 3 3) -7 � % �j � �, Tyz ?�`�^ APN # OWNPA /�.�- 1 ( c f✓ V 5�r - `C 7 E.M gIL STRT aR? CITY, STATIeZi�L I FAX / / l'Z CONTACT PHONE�. E-MAIL ST �S V � J � CITY TATE, ZIP FAX 1:1OWNER ❑. OWNER -BUILDER ❑ OVTTER AGENT ❑ CONTRACTOR 13CONTRACTOR AGENT ElARCHITECT ElENGINEER 11DEVELOPER ❑ T -NANT CONTRACAR NAIvf _ j I�Ei�',SE NUISBER I LICF1\1KYPE BUS. LIC 9 iY/IVAMEC-CCSE-MAIL 3. COMP FAX STREETJ�� /3c) y �ATE,ZIPCITY1 � �-Z PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP I ( PHOIIE �v DESCRIPTION OF WORK — ` C -Ae 4,1 01 EXISTING USE PROPOSED USE j CONSTR TYPE I I STORIES I USE TYPE ( OCC. I SQ.FT. VALUATION (S) =TG NEW FLOOR DEMO TOTAL -T AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: El DETACH ❑ AT TACH DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ❑ NO ADDITION? []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN LVED._ TOT.SL VALUATION: PLANNING APPL ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO By my signature below, I certify to ch of the following: I am the property o er or a e pro L alf. I have read this application and the information I h 'e ovided is,co ect. I have read the Description of 'Work and eri _rate. I aaree to c ply wit licable local ordinances and state laws relating o b Idinst ction. I authorize ep senV�,f Cupertino enter the a -ide tified erty for inspection rposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL II\TF0R2-,1ATI0N QUIRED � � '� � ti � >£ 5 ���tOi3'TIrG;SLIP New SFD or Multifamily dwellings: Apply for demolition permit for �, e OAR THE_COIIItTER s �ti t ❑ BUIIDLNTG PL4N REVIEF3' existing building(s). Demolition permit is required prior to issuance of building =F �..� �_ i 3 ��i�TSI.'1�. 1£. permit for new building. a r_sC .d� Ess y �Y y Commercial Bldgs: Provide a completed Hazardous Materials Disclosure sT.�I�TDaxD� ❑ PUBL7cwoRxs"�- form if any Hazardous Materials are being used as part of this project. .;,vim'} — t r� OEDE>'I Copy of Planning Approval Letter or Meeting with Planning prior to � �-t���" submittal of Buildina Permit application.1r MA70R �, �-� ,���-SA7�'TTARI�SER'ER-DISTRICT �-- �• E3�1'IR0It1ViEN T_4L HE AtiTFi . s B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 20337 CLAY ST DATE: 10/12/2015 REVIEWED BY: MELISSA APN: 369 38 018 1 BP#: 15080108 *VALUATION: I$o *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP2 USE: PERMIT TYPE: A WORK REV# 1 -ADD PANEL UPGRADE TON 200 AMP PANEL, SAME LOCATION -ISSUED 10/12/15 SCOPE APPLIANCE / EQUIP TYPE FEE ID Mfand"' llaw ( iwch' QTY UNITS BP FEES I Elec. Permit Fee: ]EPERMIT Services 1 ERT<200 Other Elec. Insp. 0.0 hrs 1 $48.00 200 Amps $48 Permil fi'ee.- Su 1?1)1. PME Unit Fee: $48.00 PME Permit Fee: $48.00 F I Administrative Fee: JADMIN $45.00 Work Without Permit? 0 Yes 0 No $0.00 TOTALS: -T Travel Documentation Fee: I TRA VDOC $48.00 Strong- Motion Fee: NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, tire, Sanitary Sewer vistrictNchoot n;vor;njo nfn I 719"r" inns "r" %"cad rbra iha nraHjP";jiiyry ;xifnrmfyiifi" fyiwil"hla typhi lira n"Iv ii" actimlyto 1—nPitart tho Dont fnr addn 11 infn- FEE ITEMS (Fee Resolution 11-053 Elf 711113) Alech, Nan C/wck Mfand"' llaw ( iwch' Elec. Plan Check [-0.-0 ] hrs $0.001 1 Meeh. Permit Fee: Plumb, I'ei-mit Fee: I Elec. Permit Fee: ]EPERMIT Other.A4ech.1risp. Other Plumih Insp. Other Elec. Insp. 0.0 hrs 1 $48.00 Fee PME Plan Check: $0.00 NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, tire, Sanitary Sewer vistrictNchoot n;vor;njo nfn I 719"r" inns "r" %"cad rbra iha nraHjP";jiiyry ;xifnrmfyiifi" fyiwil"hla typhi lira n"Iv ii" actimlyto 1—nPitart tho Dont fnr addn 11 infn- FEE ITEMS (Fee Resolution 11-053 Elf 711113) FEE QTY/FEE MISC ITEMS Phin Check Ji ee.' SulwL PC' 1"(X F71 PME Plan Check: $0.00 Permil fi'ee.- Su 1?1)1. PME Unit Fee: $48.00 PME Permit Fee: $48.00 F I Administrative Fee: JADMIN $45.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: I TRA VDOC $48.00 Strong- Motion Fee: $0.00 Select an Administrative Item 1 Bldg Stds Commission Fee: $0.00 SUBTOTALS: 1 $189.001 $0.00 TOTAL FEE: $189.00 Revised: 10/01/2015 P'. CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20337 CLAY ST IR CONTRACTOR: ANTHONY HODDER PERMIT NO: 15080108 CONSTRUCTION OWNER'S NAME: NAKASHOR RICK H AND LISA M 7504 BOLLINGER RD DATE ISSUED: 08/13/2015 OWN 'S PHONE: 4085154744 CUPERTINO, CA 95014 PHONE NO: (408) 257-4317 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ' / `;; `1 BATHROOM REMODEL (75 S.F.) License Class Lic. # G 6CL' AV- ' — / 3 -� 5� Contractor 74- 't, 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 Sq. Ft Floor Area: Valuation: $10000 of the work for which this permit is issued. terformance ave and will maintain Worker's Compensation Insurance, as provided for by ctibn 3700 of the Labor Code, for the performance of the work for which this APN Number: 36938018.00 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 S FROM LAST CALLED INSPgCTIPN. indemnify and harmless the City of Cupertino against liabilities, judgments, costs, and ex nee which may accrue against said City in consequence of the Date: granting of is pe it. Additionally, the applicant u derstands and will comply Issued by: with all n -poin source m9u i s per the C ert' o ru 'pal Code, Section RE -ROOFS: 9.18. ^` Signatu / J 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, Business & Professions Code) 1, 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. I 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 255 (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 se quipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined the ay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance w' h th Cuperti unicipal C d , Cha er 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code ecti s 25 5 33, and 25 Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized age ate: permit is issued. I certify that in the performance of the work for which this permit is issued, I shall l3 —2o1 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 perform an cc 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 9.18. Signature Date CUPERTINO CONSTRUCTION PERMIT APPLICATION 1%5010S - COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(o1cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # T ZZ) 36q �PRO APNoil- 1-0 M /,JA 5 H 0_71 PHO E-MAIL tOaEc !�-i SA- A S Ulf ST:,SDS / -7 C /� S_r-a CLI- CITY,�B'�3, P J (J FAX CONTACT NAME/ � PHONFA Va STREET , D L ,STA ZIP7 5-0 Ir FAX ❑ OWNERJ ❑ OlVNER-BUILDER ❑ OWNER AGENT -0 CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONT R NAME t 1 I - �1 GYVQy LI7 EgEly( CMTYPE BUS. LIC #L CO NY NA E E-MAIL FAX STRFA D SS CIT TATE, ZI / PHONE C9 ARCHITECTIENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK -e- eEXISTING EXISTINGUSE PROPOSED USE CONSTR. TYPE # SThRIES 1 USE TYPE OCC. SQ.FT. VALUATION ($) EXISTGNEW AREA 7§111 FLOOR AREA DEMO AREA TOTAL NET AREA ) / vv0 C/ v BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJDETACH []ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ❑ NO ADDITION? ❑ NO PRE -APPLICATION 1-1 YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RL55flytD BY: TOTAL VALUATICLN: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO By my signature below, 1 certify to eac of th following: I am the property owner or authorize agent to act on the property owner's behalf. I have read this application and the information I hav vid is correct. have read the Description of ork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating t uildi construc to . /I authorize representab s o Cupert' o tj enter the above ' tified property for inspection pu oses. 9, Signature ofApplicanUAgent VL Zate: �� 0� SUPPLEMENTAL INFORMATION REQUIRLD PLAN CHECK TYPE ROUTING SLIP OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑'PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLICwORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO 15060108 �J1 FEE ESTIMATOR — BUILDING DIVISION 191 ADDRESS: 20337 CLAY STREET DATE: 08/13/2015 REVIEWED BY: PAUL Tech. Permit 1'ec: APN: 369 38 017 BP#: *VALUATION: $10,000 °PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex USE: !Mf, flee: PENTAMATION 1 R3SFDREM PERMIT TYPE. WORK Bathroom Remodel 75 S.F. SCOPE 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 Preliminary information available and are onlV an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/13,) sch, Plan Check Plumb. flan Check Isfec. Plan Check Tech. Permit 1'ec: Plumb, Peri'Wt Fee Tlee. Permit Fee: ;op, f)ther°Plum bInsp. Suppl. PC Fee: Q Reg. 0 OT !Mf, flee: hrs 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 Preliminary information available and are onlV an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/13,) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.001= s.f. $645.00 Remodel, Bath (<=300 sf) IREMRESBAT Suppl. PC Fee: Q Reg. 0 OT 1 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 'onstruction 1Ca: cfmirtistrati�re Fee: E) Work Without Permit? Q Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure � 'r`rfi=>>l1)i�c'tt�trcr'ttttltr�tt 1t'c'.i: Strong Motion Fee: IBSEISMICR $1.30 Select an Administrative Item ommission Fee: IBCBSC $1.00 SUBTOTALS: t $2.30 L$645.00 TOTAL FEE. -7 $647.30 Revised: 07/02/2015 }'7a4i14')Jy - 6uizuag anals 'W,4 9 L: LC,: Z: L 5107 RT9r;V NOu,:raILSNOo NZCCOH - N3aaOH J.NO.L C[EfAIZ[offa i'VNaNMS 110109 5101 v �e I I'OHS"c�l''�N `d51 "1 >IOIZ{ qq of ao llw*d of . xi -e ueld sly}jo 6uldwe4s a41 lelolj4O 5ulpllne e41 woa; lenoidde jnogj!m 'woa}a.agj es uo suol}ejap, ao sadueyo sl 31 •uoljonj}suoo bulanp slis qot uoiReollloeds pue sueld;o }as slyl ]AOHddV a - NOISIAIa ONia'llne AdO 13A3a . LINMADO -LSH 'rn;� - v noz 3Wci ICNVH HS NMOHS d0 S"7,IVM ln0 9N I ON I MS -tea 17=NIA /M IG079N� '6GMOHS -19 CiA�.L S/S S>IN I S HSni�/'1'�9 8Z I - 51 i1 ` d611�1"T��00 � LZN14'7O J.IINV/� M3N 14NVIldWdO Daoa boj► W*a jr&gWOHS aacldOW 1OH M3N ado o z-sa'v`�H 2��MOHs 9 iM N3MOHS gill MZN SIR h l 9fiv �^4K XT(�� ;ueu4jedep 6ulpllne ►' AdO ONUOdnO I Address m s 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.org Permit No. i10 0 # of Marms Rmnke'I O..arhnn Mnnnxidc' 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 comely with the terms and conditions oWWS, statement Owner (or Owner en 's) N me !...:3....... Sidnature...... .... ....�:....6. ................. ................, .................. ... Date.. Contractor Name: 1 680 'Signature ................................................. .......... Lic.# ...................................... Date:................... Smoke and COform.doc revised 03118/14 WATER -CONSERVING PLUMBING 'FIXTURES f` OWNER CERTIFICATE OF COMPLIANCE f COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building aOcupertino.org yy ---caner_=anze�ft�'ermitNo l PER' CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE, HAS BEEN SI +) AND RETURN- ED Tp THE BUILDING I;IVISION Please refer to the attached California Civil Code Sections 1101.1-1101.8 which are part of this Certification form. 1 s Is your real property a registered historical site? El Yes Civil Code Sections 110 1. 1 through 1101 do not apply. Sign below and skip the rest of the form. Owner' Signature: k ,0L-% ,, Date: 131 lNo Go to Question 2. t. j Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible? Yes Civil Code Sections 1101.1 through 1101.8 do not apply. 0 The licensed plumber's certification has been 'provided to the Building Division. Sign below and skip the rest of the form. El My property 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). p My property 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 bereplaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). El My property is a commercial 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. SB4072015.doc revised 02104115 Owner' Signature: Date: y 1 No Go to Question 3. 3- Is water service permanently disconnected for your building? Yes Civil Code Sections 1101.1 through T101.8 do not apply. Signbelow and skip the rest of the form. �,� Owner' Signature:` Date: �l I Go 4. i C� 17 No to Question Is your real property built and available for use or occupancy on or before January 1, 1994? PL No My real property is built and available for use or occupancy after January 1, 1994. Civil Code Sections 1101.1 through 1101.8 do not apply. Si below and skip the rest of the form. Owner' Signature: , yr Date: 1l El Yes My real property is built and availa e for use or occupancy on or before January 1 1994. Civil Code Sections 110 1. 1 through 1101.8 apply. Refer to the attached. El My property 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). p My property 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 bereplaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). El My property is a commercial 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. SB4072015.doc revised 02104115