15060038 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 470 CONTRACTOR:20800 VALLEY GREEN PERMIT NO: 15060038
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
APT 470-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:32609040.470 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 WITIHN 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 DA 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 6
granting of this permit. Additionally,the applicant understands and will co Issued
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
struct 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 25505,25 533,at,M 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agen Date:
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 pe [he Cupertino Municipal Code,Section Licensed Professional
918.
Signa Date � ��
GENERAL:PERMIT APPLICATION
COMMUNITY DEVELOPM MEP
ENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUi'1~F2ti Itdb (408)777-3228•FAX(408)777-3333•building(ftupertino orq
l U�OU 3Y MISC
❑PLUMBTNG ❑MECHANICAL [:]ELECTRICAL MISCELLANEOUS
PROIEcr ADDit>:.ss - APN a 3
OWNER NAME PHONE
E-MAIL
STREETADDRESS2 /� p� C Y, STATE,ZIP L•
C �/r. / �// j FAX
CONTACT NAME
L.1 A P 0-IE E-MAIL
nG17 Or. CIFAX
WNER 1OWNER-BUILDER ❑ OWNERAGEzrr 11CONIRACroR 11 CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER 13 DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER O LICENSETYPE BUS.LTC N a 5
COMPANY NA ` E-MAIL l J/(
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STREET ADD` S 2 p P ONL
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ARCHtTECT/ENGTNEERNRME LICENSENUMBER BUS.LIC tI
COMPANY NAME E-MAIL FAX
STREET ADDRESS CI Y,STATE,ZIP
• PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WB.DLAND ❑ YES PROTECT IN ❑YES lS THE BLDG AN ❑YES
DUILDI N11 ❑COMMERCIAL 'URBAN INTERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
GO (O f3 L bc 1/
TOTAL VALUATION:
By my signature below,I Certify to each of the following: I am the property owner or authorized a96"(11 party owner's behalf. I have read.this
application and ttte information I have provided is correct. I have red the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to b •ding const ction. I autho it representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: /f s�/S—
SUPPLEMENTAL INFORMA
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..CPAdiscApp 2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 20800 VALLEY GREEN DR#470 DATE: 06/05/2015 REVIEWED BY: MELISSA
APN: 326 09 040 BP#: *VALUATION: $500
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY Building is PENTAMATION
USE: Multi-Family Dwelling >3 Stories 0 Yes Q No PERMIT TYPE: 1 RMAP
WORK APT 470 - INSTALL N WASHER & DRYER HOOK UPS
SCOPE
i
Mech.Plan Check0.0 hrs $0.00 I'tz¢mb.Mai?f,he£:�" Fi C,P,'Cia-C:'/red
Mech.Permit Fee: 1MPERMIT ,71i"I�i. Pern"ir f'e"": l te£:.per,mil l'cf
Other Mech.Insp. El hrs $48.00 (;).rher
t1e£:r,Ins/'.I c'e: I'lirrr;i..lzrs',7..t
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitmy Sewer District,School
District,etc.). These fees are based on the prelinduar information available and are only an estimate. Contact the De t for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1113,) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 # Mechanical
Suppl.PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 $144.00 1BAPPLOT Other Appliance/Equip
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: $48.00
Administrative Fee: 1ADMIN $45.00 0
Work Without Permit? 0 Yes No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential G)
Travel Documentation Fee: ITRAVDOC $48.00 Building or Structure 0
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS:,; $142.50 $144.00 TOTAL FEE: $286.50
Revised: 05/07/2015
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
AQ-J10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CU P ERTI NG (40B)777-3228- FAX(408)777-3333-building(a)cuoertino ory
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
-196& t�=AA
OWNER NAME � t3P/S OG�0075 O
095 U
DESCRIPTION OF WORK:
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 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.)
5 y/_1- i understand a frequent practice of unlicensed persons is to have the property owner obtain an "
Builder"building permit that erroneously implies that the roe p his Owner-
r and mater
personally. I,as an Owner-Builder, may be held liable and subject o serious financial risk for injuries sustainedial
an unlicensed person and his or her employees while working on m
y pro7perty. 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.
!L/ understand building permits are not required to be signed byroe owners u
the construction and are not hiring a licensed Contractor to assume this responsibility. unless they are responsible for
5,�3. 1 understand as an"Owner-Builder' I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own,
t4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
�5. I understand if I employ or otherwise engage an
persons,
total value of my construction is at least five hund ed dollars ($500),t including labor andlmate gals, I may bes,and the
considered an "employer"under state and federal law.
JI/6. i understand if i am considered an"employer" under state and federal law, I must register with
federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contributeetaond
unemployment compensation for each"employee" I also understand my failure to abide by these laws may subject
me to serious financial risk.
Ur7. I understand under California Contractors'State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed 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.
LV-8. I understand aS an Owner-Builder if I 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.
OwnelBuildeiFontt ,2010.doc revised 04114110
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
contractors, understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
5-iL-10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand
am the party legally and financially responsible for proposed construction activity at the site address listed above.that I
dI agree that, as the party legally and financially responsible for this proposed constructio
by all applicable laws and requirements that govern Owner-Builders as well as employers. n activity, I will abide
3 IJ 12. 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 he 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 firm is injured while workingon our properly,
You obtain a permit as Owner-Builder and wish to hire Contractors, you will be resp ns b eeld forliable verifyingfordamagesw ether 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 form notarization, or other verification acceptable to the city maybe required to be presented when'ther permitiver's !is nsued
to VerifY the ro ert y owner's -gnature.
Property Owner's Signature:
Date:
(NOTE: The following Authorization Form is required to be completed by the propertw
y oner only we
-h-e- designating
agent of the property owner to apply for a construction permit for the Owner-Builder). an
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 hereby
authorize the following person(s)to act as my agent(s) to apply for, sign, and file he documents ne essaryty, lto 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 issue
signature. d to verify the property owner's
Property Owner's Signature:
Date:
ot,areiBuildeiFornz 2010.doc revised 04114110
Owner Name
Address
WATER -CONSERVING PLUI�[BING FfXTURES
(o 171l
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(4 18) 777-3228 • FAX (408) 777-333T- buildingPcuoertino.org
Permit No l YeIQ6 l)_ Al
Please refer to the attached California Civil Code Sections 1101.1— 1101.8 xhich-are part of this Certification f& m.-
.
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 rest of the form.
Owner' Signature: Date: i-
X'No
Go to Question 2.
2. Does your real property have a licensed plumber certifying that, e 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.
❑ The licensed plumber's certification has been provided to the Building Division.
Sign below and skip the rest of the form
Owner' Signature: Date:
KNo Go to Question 3. , r
(� 5
3. Is water service pennanentl.y disconnected for your building.
❑ Yes Civil Code Sections 11011 through 1101.8 do not apply. Signbelow and skip the rest of the form.
Owner' Signature: / Date:
X1To Go to Question 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 do not apply. Sign below and skip the rest of the form.
Owlier' Signature:Date:
Yes My real property is built and available for use or,occuPancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Refer to the attached.
[V' My propertyis 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
fvctures to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1,
.201?, all non-compliant plumbing fixtures shall be replaced with water -conserving pluinbing fixtures (regardless
of whether property undergoes alterations or improvements).
[IMy property is a nazdt family residential real properly. 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).
ElMypropertyis 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.doc revised 03/18/14
r
On or beforc1anuary l;' 20.19,' all non-compliant plumbing fixtures shall be replaced with water- conserving
.On
fixtures throughout the, building (regardless of whether property undergoes alterations or
improvements).
UWe, the owner(s) of this property, certify under penalty of perjury that non-compliant plumbing fixtures have been replaced
with water-conserying 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
t verse or ter-Owconserving plumbing futures comply with -the rgquirements as indicated in the table below.
Ovrner'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..
..
Noh-Compliant
Plu mbing Fixturel•
Fixture -Type- " -
- Water Usage
/Flow Rate
Water Closets I Exceed 1.6
(Toilets) Gallons/flush
Urinals Exceed 1.0
Gallons/flush
Showerheads Exceed 2.5
gallons per minute
.Faucets — Exceed 2.2 gallons
Lavatory per minute
Faucets
:..:,:...... Water -Conserving Plumbing Fixture_
(Fixture C6`mplying with Current Code Applicable.to NeW.Construction)
Maximum Water Usage/Flow e/Flow Rate
2013 CPC Ch. 4 2013 CPC Ch. 4 2013 CPC Ch. 4
2013 CALGreen Div. 4.3 2013 CALGreen Div. 4.3 2013 -CALL- '" Div. 5.3-:
Single=Family Multi -Family Commercial
Residential Residential
Single flush toilets: 1.28 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)
0.5 gallons/flush
2.0 gallons per minute @ 80 osi. Also certified to the performance criteria of
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.
Maximum 1.5 gallons per Within units: 0.5 gallons per minute @ 60
minute @ 60 psi;'minimumMaximum 1.5 gallons psi
0.8 gallons per minute @ per minute @ 60 psi;
20 psi minimum 0.8 gallons
per minute @ 20 psi
SB4072014.doc revised 03118114 "
In common and public
use areas: 0.5 gallons
per minute @ 60 psi }
1.8 gallons per minute
Faucets — Exceed 2.2 gallons 1.8 gallons per minute
Kitchen per minute 60 si @
p
60 psi
1 8 gallons per minute 1.8 gallons per minute 60
@
Faucets May temporarily increase
@ 60 psi psi
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
Where faucets meeting
1.8 gallons per minute
@ 60 psi .
- the above are unavailable,
Where faucets meeting
aerators or other means
the above are
may be used to achieve
reduction.
unavailable, aerators or
other means may be
used to achieve
ucti
I. If the existing plumbing fixture water usage/flow rate is equal to or lowerd than. the figure shown, it is
not required to be upgraded.
SB4072014.doc revised 03118114 "
Lo
Address
SMOKE 1 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(5_)cupertino.org
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 R3.14 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
CO ALARM
Outside of each separate sleeping area in the inunediate vicinity of theX
bedroom(s)
MX
On ever level of a dwellin unit includin basements
X
Within each sleeping room
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, 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 cravrl
space. Refer to CRC Section 8314 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 agree to comply with the terms ang conamons or tn�s sla�enieni
Owner (or Owner Agent') Name:
.�/...... Date:Si nature...............fj...f
Contractor Name:
sianature...................................................................Lic.#...................................... Date: .............
Smoke and CO form.doc revised 03/18114
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