15060015 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10861 MAXINE AVE CONTRACTOR: PERMIT NO: 15060015
OWNER'S NAME:
, LW) 3 J PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
REMOVE AND REPLACE WATER HEATER(40 GALLON)
License Class Lie.#
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:$1700
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:32602015 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 180FROM LAST CALLED INSPE CTWN.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, n ®I
costs,and expenses which may accrue against said City in consequence of the Issued by: �(
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:
Ria ereby affirm that I am exempt from the Contractor's License Law for one of
he 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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
;,• 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,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agents - - NAWK,s Date:—� -
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 per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature
GENERAL PERMIT APPLICATION ' MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE^CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333• building()cupertino.org
CUPERTINO M I
PLUMBING ❑MECHANICAL [:]ELECTRICAL
❑ELECTRICAL ❑MISCELL�A�NEO
US
PROJECT ADDRESS APNR 3/ L �� / .
t
OW1N'ERNANM }� PHONE ����' 11701 E-MAIL
CITY, STATE, FAX
CONTACT NAME � PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
OW14ER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR - 11COhTRACTORAGMQ1T ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TEN.1W — 4I,'T
CONTRACTOR NAME _ LICENSE NUMBER 7
LICENSE TYPE BUS.LIC
#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEERLAAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF fI tl-D or DUPLEX ❑ 77TI-F7 PROJECT IN WILDLAND ❑ YES - PROJECT IN El YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE 11RNO EICHLER HOME? NO
DESCRIPTION OF WORK
TOTAL VALUATION: / O a®— yRECEIVEDBY ` �(( �hy r4 r
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to//building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature ofA licant/Agent: h
a
SUPPLEMENTAL INIFORMATION REQUIRED `
. DFI SCE L1SE;O ' i' a ZI,;
c. �0 ER THIrCOUtiTERn .
> .
�"a �, �fEXPRESS� � � g
R"Ir
?�s$AADARI) <
M, ARGE
MEPMiscApp_20.11.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10861 MAXINE DRIVE DATE: 06/02/2015 REVIEWED BY: PAUL
APN: 326 02 015 BP#: "VALUATION: 1$1,700
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Du lex PENTAMATION PRWHEATR
USE: p PERMIT TYPE:
WORK REMOVE AND REPLACE WATER HEATER 40 GALLON
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $29
TOTALS: $29.00
Mech. !Tart Check Plumb.Plan Check 0.0 hrs $0.00 h'lec...Ylun Check
;blech. Per•ri�it Fee: Plumb.Permit Fee: IPPERMIT Elec.Permit Fee:
Other Alech. Insp. Other Plumb Insp. 0.0 hrs $48.00 Otlier Flec,Insp.
Llech.Inq).Fee: Phinib. Insp. Fee: L(.-.Insp.Fee:
Ld
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). 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 . 711/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Supp/. PC Fee
PME Plan Check: $0.00
Permit Fee:
Sup]-d. Lisp Fee
PME Unit Fee: $29.00
PME Permit Fee: $48.00
Construction Tax:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? 0 Yes (j) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $48.00 A
Strong;Motion.Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALSc $171.50 $0.00 TOTAL FEE:''
a
Revised: 05/07/2015
OWNER-BUILDER DISCLOSURE FORM
LM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228- FAX(408)777-3333•building CcDcugertino.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: I
SITE ADDRESS :.... .. :.QPN_� ry-) �l✓ BP#
..OWNER
V
DESCRIPTION OF WORK:'
We are providing you with ad 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.)
Y I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on 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.
4W. I understand building permits are not required to be signed by property owners unless they are responsible for
econstruction and are not hiring a licensed Contractor to assume this responsibility.
' I 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.
4`I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
_..-�I_ I 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" under state and federal'law.
"` I understand if I am considered an"employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers'compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
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.
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.
OwneYBuildeYForm 2010.doc revised 04/14/10
M . I understand I may obtain more information regarding my obligations as an "employer" from the Internal
venuee Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed
contractors.
, 0. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
I 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.
2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
I
formation i 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. Itis 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 maybe held liable for damages. If
you-obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not-
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property 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 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:
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
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE FILE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
C lJ P E RT I N 0 10300 TORRE AVENUE • CU PERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org/
Address
2
W.
#0
M
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 a:
$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
JC, X1121
—
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 comply with the terms and conditions of this statement
caner (or Owner AVrvs) Narne:
t
^
,..�...............
Contractor Name:
Sinature...................................................................Lic.#...................................... Date: ...................
Smoke and CO.form.doc revised 03/18/14
CUPERTINO.
Owner Name
Address
WATER -CONSERVING PLUMBING FIXTU
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
Please refer to the attached California Civil Code Sections 1101.1-1101.8 which are part of this Certification form.
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.
o'��=-.
OwnerSignature:t.,
_r�, ���,;� �:'�_� Date:
Go to 2.
Question
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-conseiving plumbing fixtures is not technically feasible?
❑ Yes
Civil Code Sections 1101.1 through 1101.8 do not apply.
El The licensed plumber's certification has been provided to the Building Division.
Sign below and skip the rest of the form.
Owner' Signature:�* ` R Date:
-� -s"'
V;,No
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.
-M No
Owner' Signature: Date:
Go to Question 4. s
f&m
-
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.
Owner' Signature: *��'� Date: !e,.
s My real property is built anailable for use or occupancy on or before January 1, 1994.F L
Civil Code Sections 1101.1 through 1101.8 apply. Refer to the attached.
r 0 y pr operty is a single family residential real properly. See Civil Code Section 1101.4.
afi7r January 1, 2014, building alterations or improvements shall require all non-compliant plumbing
;fitiues tube replaced with water -conserving plumbing fixtures throughout the building. On or before January 1,
201 , fi on -compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless
o%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 throughout the building (regardless of whether property undergoes alterations or
improvements).
My property is a con7n7ercial real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
SB40 7 2015. doe revised 02/04/15
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).
I/We, the owner(s) of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be replaced
prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101.1 through
1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's installation
requirements, and that the water -conserving lambing fixtures comply_ wi the reIN
irements as ' dicated in thetableielouv,
Owner's or Owner Agent's) SI nature: ' ' Vr i9 � "`� � 0a AV2?
Upon completing and signing this Certificate, please return it—to the Building Division in order to final your pen -nit.
1. If the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgraded.
SB4072015.doc revised 02/04115
a
Non -Compliant
Water -Conserving Plumbing Fixture
Plumbing Fixture
(Fixture Complying with Current Code Applicable to New Construction)
Maximum Water Usage/Flow Rate
Fixture Type
Water Usage
2013 CPC Ch. 4
2013 CPC Ch. 4
2013 CPC Ch. 4
/Flow Rate
2013 CALGreen Div. 4.3
2013 CALGreen Div. 4.3
2013 CALGreen Div. 5.3
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.
Faucets —
Exceed 2.2 gallons
Maximum 1.5 gallons per
. Within units:
0.5 gallons per minute @ 60
Lavatory
per minute
minute @ 60 psi; minimum
Maximum 1.5 gallons
psi
Faucets
0.8 gallons per minute @
per minute @ 60 psi;
20 psi
minimum 0.8 gallons
per minute @ 20 psi
In common and public
use areas: 0.5 gallons
per minute @ 60 psi
1.8 gallons per minute
60 psi
Faucets —
Exceed 2.2 gallons
1.8 gallons per minute @
1.8. ,gallons per minute
1.8 gallons per minute @ 60
Kitchen
per minute
60 psi
@ 6,0 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 perminute @
default to,,maximum
60 psi,,and, must.
'1.8 gallons per minute. @..
default to, -maximum
60 psi
1.8 gallons perminute
Where faucets meeting
@ 60,psi
the above are unavailable,
Wher6,faucefs meeting
aerators or other meahs
the,abOVe" are
maybe use to achieve
;'unavailable, aerators or
reduction'-'
other means. maybe
used to`achieve
seduction:."
1. If the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgraded.
SB4072015.doc revised 02/04115
a