15060037 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 454 CONTRACTOR:20800 VALLEY GREEN PERMIT NO: 15060037
DRIVE
OWNER'S NAME: 20800 VALLEY GREEN DRIVE PO BOX 1368 DATE ISSUED:06/05/2015
OWNER'S PHONE: 4082530200 CARLSBAD,CA 92018 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL E]
APT 454-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 454 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 + RMIT 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 saveFued
180 DAY ALLED 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 6
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.
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,
Business&Professions Code)
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 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,Sections 25505,25533,an 5534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agen �27 :D
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 CONSTRUCTION LENDING AGENCY
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 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 pe the Cupertino Municipal Code,Section Licensed Professional
9 18.
Signat re Date
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION MEF
10300 TORRE AVENUE•CUPERTINO. CA 95014-3255
WP511'I'INO (408)777-3228•FAX(408)777-3333•building(�cupertino orq I
❑PLLrnrslNc /SO�Da 3�
❑MECHANICAL ❑ELECTRICAL MIS
PROJECT'ADDRESS CELLANEOUS
APN N
OWNER NAME
P ONE E-MAIL
o _off®Q
STREET ADDRESS
/I C ESTATE ZIP. FAX
CONTACT
�/
FAX
OWNER -❑ OWNERDU[I.DER ❑ OWNERAGENr ❑ CONTRACTOR ❑COMRACTORAGENr ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAMrLICENSENUMBER
LiCENSETYPE BUS.LICH
COMPANY NA
_ E-MAIL F
STREET ADDRESS
�@ C STATE.ZIP
�� L PHONE
� D
ARCHITECTJENGINEER NAME LICENSENUMBHR
BUS.LIC 9
COMPANYNAME
E-MAIL FAX
STREETADDRESS
C1TY,STATF ZIP PHONE
use OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND
DUIDIN.G.. ❑COMMERCIAL ❑ YES PROJECTIN ❑YES 1STHEBIDGAN ❑YES
URBAN INTERFACE AREA ❑NO FLOODZONE ❑N11 O EICHI ER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION:
B m signature
Y Y g below,I certify tthis
o each of the following. I am�Ity owner or authorized agent to act o
n the application and the information I have provided is correeL I have read the Description of Work and verify it is accurate.pI agree tocrty ccomplyawith all appllf. I have icable local'
ordinances and state laws relating to building const 1''on I auAror• c representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent:
Date:
SUPPLEMENTAL INFORMA'riM REQUIRED :_..,.<::. ^::.•,
�=OFFICE:USE Oi5L1rs��- a-
. •�*�'-� ;;��;�=ii �� :�; ._.a�C�L�aSY4i-^i•%ter ter:...
.•.•�j i 6OV,LFi,2FIF;COUNTERar.;;.,•:� .-
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ItFSS
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Ad PMiscApp 2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20800 VALLEY GREEN DR#454 DATE: 06/05/2015 REVIEWED BY: MELISSA
APN: 326 09 040 BP#: *VALUATION: $500
^•PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY Multi-Family Dwelling Buildina is PENTAMATION 1 RMAP1
USE: 1 >3 Stories 0 Yes Q No PERMIT TYPE:
WORK APT 454 - INSTALL N WASHER 8, DRYER HOOK UPS
SCOPE
u ,
Mech.Plan Check 0.0 hrs $0.00 Plumb.Plaut Check I i c.plat:"
Mech.Permit Fee: 1MPERMIT 11!iwin.1'en;iii 1= X;ie::.l'er,alir l.�O:
Other Mech.Insp. Omer Ph r,'d,h.p. Li Other:"Iee,Insp"
Ihsp,free: Ef
I Phimb.
l iq).Fee: Elec.11rsr.1"ec.
NOTE:This estimate does not include fees due to other Depm7ments(Le.Planning,Public Works,Fire,Sanitmy Server District,School
District,etc.). These ees are based on the prelitnina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 � # Mechanical
Suppl.PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 $144.00 IBAPPLOT Other Appliance/Equip
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:O Reg. 0 OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $48.00
(7onstructiort Tax:
Administrative Fee: IADMIN $45.00 0
Work Without Permit? 0 Yes 0 No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRAVD0C $48.00 Building or Structure 0
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
AS-, $142.50 $144.00 TOTAL FEE::' $286.50
Revised: 05/07/2015
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTING (408)777-3228•FAX(408)777_3333•buildino ar7cuoertino ora
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
specified at: prty
improvements speci
SITE ADDRESS �/'
� (15, APN 2 2 BP#
OWNER NAM v 1c -5
Ol'VNER ADDR S
DESCRIPTION OF WORK:
Gk�J o.
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,initialed your understanding of each provision, signed,and
returned this form to us at our official address indicated. An agent ofthe 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
Builder"building permit that erroneously implies that the roe have the property owner obtain an "Owner-
s or hr own laor and
personally. I,as an Owner-Builder, may be held liable and subject o serious rfinan wner is cal I risk orany injuries sustainedmaterial
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. i am willfully acting as an Owner-Builder and am aware of the limits of my
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 this re spons biliperty ty unless they are responsible for
a3. I understand as an"Owner-Builder'i am the responsible party of record on the permit. I understand
that I
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her may
Cnam/e instead of my own.
Jy 4. i understand Contractors are required by law to be licensed and bonded in Californiaand to list their license
numbers on permits and contracts.
understand if I employ or otherwise 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"understate and federal law.
L41-6. i understand if I am considered an"employer' under state and federal law, I must register
federal govemment,withhold payroll taxes with the state and
ty insurance, and contribute to
unemployment compensationforeach"employee." also understand my failucompensation re bide by these laws may subject
me to serious financial risk. y
7.( understand under California Contractors'State License Law, an Owner-Build
er who residential structures cannot legally build them with the intent to offer them for sale, unless allbuilds work islperfor eld 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.
�t3.1 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.
O1r»eJBililderFol7ii 2010.doc revised 04114110
V-LL Y.i understand I 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 Co
License Board (CSLB) at 1-800-321-CSLB(2752)or www.cslb.ca.
contractors. 90V for more information about licensed
ntractors'State
,
—410. 1 am aware of and consent to an Owner-Builder buildin
m the party legally and financially responsible for 9 Permit applied for in my name, and understand that 1
proposed construction activity at the site address listed above.
agree that, as the party legally and financially responsible for this proposed construction
by all applicable laws and requirements that govern Owner-Builders as well as employers. activity, I will abide
S12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form.Licensed contractors are regulated by laws designed to protect the public. if
9
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 firm 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 co
py of the Property ownersform notarization, or other verification acceptable to the city may be required to be presented when'ther iverpermitr is is sued
to vert the ro ert owner's si nature.
Property Owner's Signature: _
Date: - —/-�
------------
(NOTE. ---------------------------------------------------------------------------------------------------------------------------------
The following Authorization Form is required to be completed by the property owner only when designatin an
agent of the property owner to apply for a construction permit for the Owner-Builder), g
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is m
y personal authorize the following person(s) to act as my agent(s)to apply for, sign, and file he do umentspne essaryla
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 personally 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:
o14rre16rrildel For7r7^2010.doc revised 04/19/10
SMOKE I CARBON MONOXIDE ALARMS FILE
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 'r�1
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTIKO
(408) 777-3228 •FAX (408) 777-3333 • buildinga()cupertino orq
// Permit No /. -c Mz2 J
Address ���Q(i b/ lll��L_��? i'�i J �r' f06ls``/ # of Alarms Smoke :3 Carbon Monoxide: c2-
PURPOSE
2
PURPOSE
tallation of all required Smoke and Carbon Monoxide Alarms 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 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 R3.1.4 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 every level of a dwelling.unit including basements X X
Within each sleepinZ room X
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, 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 Ag , t's) Name: /f
I_ ✓ .... - -- ��/b.e//�") /% �............................................. Date: 6.".l '1
ame:
Lic.#...................................... Date: ...................
Smoke and COform.doc revised 03/18/14
N
`FCUPERTINO
Owner Name
Address
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'-' buildina(a)cuoertino ora
Z lJ ADO C%G��
Please refer to the attached California Civil Code Sections 1101.1— 1101.8 which -are partof this Certification fdr
In. .
I. Is your real property a registered historical site?.
❑ Yes. Civil Code Sections 1101.1 through 1101.8 do not apply."S ign. below and skip the rest of the form '
Owner' Signature: Date:
No Go to Question 2,
2. Does your real property have a licensedlumber cefti
p Eying 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 110 1. 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:
f k� No Go to Question 3.
3. Is water service pennanentl.y
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Sign below and skip the rest of the form.
Owner' Signature: Date:
XI\0 Go to Question 4.
4. Is your real property built and 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 do not apply. Sign below and skip the rest of the form.
Owner' Signature:
on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Refer to the attached.
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-cornpliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless
of whether property undergoes alterations or improvements).
❑ 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 be replaced with water -
conserving plumbing fixtures tlu•oughout the building (regardless of whether property undergoes alterations or
improvements).
❑ Mypropertyis 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.
SB407 2014. doerevised 03/18114
17
r
On or before January 1;' 2019,` all non-compliant pfumbing fixtures shall be replaced with water- conserving
plumbing fixtures . throughout the building (regardless of whether property undergoes alterations or
impro-cements).
I/We, the owners) 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-conservini, plumbing fixtures indicated in the table below.
Owners (or Owner Agent's) Signature: — Dater -/
Upon completing and signing this Certificate, please retain it to the Building Division in order to final your permit..
:..:_....::
..Novi -Compliant .:.
:..
„ ,.. .. Water-Cons.etving Plumbing Fixture _
(Fixture Complying with Current Code Applicable.to New..Construction)
Plumbin Fixturel,
Maximum
Water Usage/Flow
Rate
Fixture Type
2013 CPC Ch. 4
2013 CPC Ch. 4
2013 CPC Ch. 4
Water Usage
2013 CALGreen Div. 4.3
2013 CALGreen Div. 4.3
2013-CALGreen Div. 5.3 -
/Flow Rate
Single=Family
Multi -Family
Commercial
Residential
Residential
Water Closets
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
Showerheads
Exceed 2.5
2.0 gallons per minute @ 80 psi. Also certified to the performance criteria 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.
—
Exceed 2.2 gallons
Maximum 1.5 gallons per
Within units:
0.5 gallons per minute @ 60
.Faucets
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 minute @ 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
maybe used to achieve
unavailable, aerators or
reduction.
other means may be
used to achieve
reduction.
1. If the existing plumbing tixture xaier usageinew 1dLG 16 �.gUai w U1 ,U W l «I—L
SB4072014.doc remised 03/18/14