15050187 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1148 DERBYSHIRE DR CONTRACTOR:WALTER DOUGLAS PERMIT NO: 15050187
BECK AND RONALD EUGE
OWNER'S NAME:
CUPERTINO,CA 95014-5072 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
REPLACE(E)WATER HEATER,SAME LOCATION
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:$2119
1 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:36221024 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 DAYS FROM LED 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 Date: Z�2L
granting of this permit. Additionally,the applicant understands and will comply
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.
lam" OWNER-BUILDER DECLARATION
r 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
#,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,
Buiness&Professions Code)
I
as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
etruct 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,
Date:S— :
permit is issued.
w Rr c rtify that in the performance of the work for which this permit is issued,I shall
R-0 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(See.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- Cupertino Municipal Code,Section Licensed Professional
9 18.
Signature Date
GENERAL PERMIT APPLICATION _ MEF,
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333• building(a)cupertino.org
CUPERI-tN0 J �O
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U PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS//
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O'IVIQERNAME iY L: �C`� — PHONE j�4/ '��� ' E-MAIL
STREETADDRESS//y5,p� ,,,V L oK, CITY, 5�7y�Ij�� l ,[J /7-'JV (i FIAX��>
CONTACT NAME PH OI� �/ /� (/� E-MAIL
STREETADDRESS C_ CITY,STATE,ZIP FAX
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ON%TR ❑ ONTTER-BUILDER ❑ OWNER AGENT ❑ CONURACTOR ❑coNrRACTORAGENr ❑ ARCHITECT ❑ENGII.'EER • ❑ DEVELOPER ❑ TENANT
CONIC C OR T • C- ^I ,� LI SE NUMBER c' LICII�SE TYPE BUS.LIC 4 ,I, `���
COMP y 1 / ,�j(d1� s E- (MAIL 7 FAX s'P`J�I 4-)-S-)
STREET ADDRESSf),q CITY,FOTE,ZIP C/ q 5WOPHONE/
ARCHITECVENGINEER NAME v�;I k y7 , LICENSE NUMBER l- BUS.oLIC#
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COMPANY NAME ;n L�4 E-MAIL FAX 97 2 � )� S/
STREET ADDRESS/fin a Y ��aCITY,STATE ZI /(; 9 yyo y /HONE
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USE OF ❑SFD.,DUPLEX ❑ MULTI-FAII.Y PROJECT IN WBALAND EIYES PR CT IN ❑YES IS THE BLDG AN El YES
BUIIALNIG: ❑COMMERCIAL URBAN INITRFACEAREA ❑ NO FLOOD ZONE ❑NO EICHLERHOMEI ❑ NO
DESCRIPTION OF WORK
V^ TLC �.
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TOTAL VALUATION: EI �Y a
U i?.�,r
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on owner' ave read this
application and the information I have provided is correct. I have read the Descrition of Work and verify it is accu ee to comply with all applicable local
ordinances and state laws relating o build' �cons ction. I a orize represen fives of Cupertino to enter the tabove-identified
dproperty for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL IT ORMATION REQUIRED � �;ocE csEb isi :
IN
OVER THE COURTERx���'
RgA M �
A7EPA4"1JcApp_2011.doc revised 06121111
CITY OF CUPERTINO
19 FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 1148 DERBYSHIRE DR DATE: 05/29/2015 REVIEWED BY: MELISSA
APN: 36221024 BP#: "VALUATION: $2,119
PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition /Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK REPLACE E WATER HEATER SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $29
TOTALS: $29.00
:Meeh. Ilan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
Mech. Permit Fire: Plumb.Permit Fee: 1PPERMIT /slec. Permit Fee:
Other Hech. Insp. Other Plumb Insp. 0.0 hrs $48.00 Other Elec.Insp.
19ech.Insp.Fee: Phernb. Insp. Fee: Elec.Insp.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 E(f. 7/1/131 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
;Supp/. PC fee T-=
PME Plan Check: $0.00
Permit.Fee:
Suppl. 177sp Fee
PME Unit Fee: $29.00
PME Permit Fee: $48.00
Construction Tax:
Administrative Fee: 1ADMIN $45.00
Work Without Permit? 0 Yes (F) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $48.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
�. :. r SUBTOTAtis•.; $
171 50 $0.00 '
�; TO 'AL FEE:
Revised: 05/07/2015
V OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•building cDcupertino.org —
CUPERTINO
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 .. APN 2 _ 2-1- /�Z BP# /✓U SO
f/4 p s , 0/0�- 6.. 0
.OWNER NAME
�
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.)
1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
1";wilder' building permit that erroneously implies that the property owner is providing his or her own labor and material
,ersonally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
aid unlicensed erson and his or her employees while working on mproperty. M homeowners insurance may not
� , P9 YY Y
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
ins rance coverage for injuries to workers on my property.
2..1 understand building permits are not required to be signed by property owners unless they are responsible for
thie;=construction and are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
pp ntect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
►^1�'�t' �4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
n Embers on permits and contracts.
[: h
I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tctp)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.
6. 1 understand if I am considered an"employer" under state and federal law, I must register with the state and
federal al government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
u ployment compensation for each "employee." I also understand my failure to abide by these laws may subject
o serious financial risk.
T
17. 1 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
9- 1
is;performed under contract with a licensed general building Contractor.
� 8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
lny financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm_2010.doc revised 04/14/10
i
9. 1 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,
andtihe California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
Lid' "se Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
co''tractors.
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
a (he party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by` all applicable laws and requirements that govern Owner-Builders as well as employers.
�anti
JIL
12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
informatioml have-provided on-this form. Licensed contractors are regulated by-laws designed to protect.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 maybe in civil court. If 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
Y66-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 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:
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which I 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 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:
OwnerBuilderForm 2010.doc revised 04/14/10
WATER -CONSERVING PLUMBING FIXTUR^2� _fS
OWNER CERTIFICATE OF COMPLIANCE r::
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(
"_- Pennit No.
Address
Please refer to the attached California Civil Code Sections 1101.1— 1101.8 which are part of this Certification form.
Is your real properly a registered historical site?
❑ Yes Civil Code Sections 110 1. 1 through 110 1. 8 do of apply. Sign below and skip the rest of the form.
--'
_ Owgeer- Si' aatuie * ✓ �Da- ie �a/���
r?. Go to Question 2.
2. 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.
❑ The licensed plumber's certification has been provided to the Building Division.
Sign below and skip the rest of the forn.
OwnWer�, Signature D}ate �i/y
4N Go to Question 3. ?
3. Is water service permanently 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.
--� -----� i
OwnerzSignatuie��% 'Date�y/
Go to Question 4.
4. Is your real properly 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 Sectionsl lC� 1
U101. apply. Sign below and skip the rest of the form.
LJ Xe's' My real property is built and available for use or occupancy on or before January 1; 1994.
Civil Code Sections 1101.1 through 110 1. 8 apply. Refer to the attached.
IONTy 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
r-fixtuies,�t,o,� be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1,
2017, ali non-compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless
` `of whether property undergoes alterations or improvements).
❑ Myproperty is a multifarnaily 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-
conseiving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
improvements).
❑ Myproperly 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 M,
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
SB407 201 S. doe revised 0210411.1
R
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 properly, undergoes alterations or
improvements).
I/We, the owner(s) of this property, certify under penalty of perjury that non-compliant plumbing fixtures',? l�be replaced
prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sectrons 101.1 through
1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's installation
reouirements; and that the water -conserving plumbing fl)"es m-nply witlythe requirements as indicated in the table below.
® rs .js (or Owner Agent's) Signature: Date: '"
Upon completing and signing this Certificate, please return it to the 5uilctmg .0 vision in ower to renal your permit.
fthe existing plurribing fixture i atex usage/flow rate is equal to or loci er than the_ figure shown i� tis not required to be upg ade
SB40 7 2 015. doc revised 02104/15
ons ompliant
Water -Conserving Plumbing Fixture
Fixture
(Fixture Complyingwith Current Code Applicable to New Construction)
' i Maximum
Water Usage/Flow
Rate
, 't 2013 CPC Ch. 4
2013 CPC Ch. 4
2013 CPC Ch. 4
Fixture Type
yP
Water Usa e
g
/Flow Rate
_ 1 2013 CALGreen Div. 4.3
2013 CALGreen Div. 4.3
2013 CALGreen Div. 5.3
Single -Family
Multi -Family
Commercial
Residential
Residential
Water Closets
"4Exceed 1.6
Single flush toilets: 1.28 gallons/flush
(Toilets),
G_
Dual flush toilets: 1.28 gallons/flush effective flush volume (the composite,
'
avers e flush volume of two reduced flushes and one full flush
Urinals
`Exceed 1.0
0.5 gallons/flush
.'Gallons/flush
I
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
I-
iexceed 2.0 gallons per minute @ 80 psi, or the shower shall be designed to
r..
fallow only one shower outlet to be in operation at a time.
Faucets —
;Exceed 2.2 gallons,,
Qaximum 1.5 gallons per
Within units:
0.5 gallons per minute @ 60
Lavatory
-LLper 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
l
per minute @ 60 psi
i
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
L -..;--
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
l
the above are unavailable,
Where faucets meeting
r.; t t
aerators_ or other means
the above..a.r'
maybe"Used to achieve
unavailable, aerators or
a .
reduction.
other. means may be
a
z
}
, .::..:: .;
used to°achieve
i i
- — --- -y�_t
reduction.
fthe existing plurribing fixture i atex usage/flow rate is equal to or loci er than the_ figure shown i� tis not required to be upg ade
SB40 7 2 015. doc revised 02104/15
Address
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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.orq
F�-ice
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.
1 have read and aaree to comoly with the terms and conditions of this statement
Ow_n_er (or Owner A(g��
Signature...................................................................Lic.#...................................... Date: ...................
s,0�/r,r514u.�-b 2//rJi� RALtf5 f&-�\ I L15 Q)
Smoke and CO form.doc revised 03/18/14