15090131 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21315 RUMFORD DR CONTRACTOR:DAYANENI PERMIT NO: 15090131
BHOGESWARA R TRUSTEE&ET
OWNER'S NAME: DAYANENI BHOGESWARA R TRUSTEE&ET 21155 LAURETTA DR DATE ISSUED:09/21/2015
OWNER'S PHONE: 4083689633 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REPLACE(E)FURNACE WITH(N)IN CLOSET;REPLACE
License Class Lic.# DUCTING;ADD(N)A/C IN(N)LOCATION+IN-J ALL(N)
eANa-
5AiY(f-- L ZCM 100
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing Nith 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: Sq.Ft Floor Area: Valuation:$15000
t. 1 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 APN Number:32641043.00 Occupancy Type:
performance of the work for which this permit is issued.
2 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
permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I certify that I have read this application and state that the above information is 180 DAYS FROM LAST CALLED INSP C ON.
correct.I agree to comply with all city and county ordinances and state laws relatint-
to building construction,and hereby authorize representatives of this city to enter �� /`� � L' - Date:
Upon the above mentioned property for inspection purposes. (We)agree to save Issued by: '�
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply with
all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
Signature Date 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
t. 1,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 HAZARDOUS MATERIALS DISCLOSURE
VIsale(Sec 7044,Business&Professions Code) 1 have read the hazardous materials requirements under Chapter 6.95 of the
,as owner of the property,am exclusively contracting with licensed contractors to California health&Safety Code,Sections 25505,25533,and 25534. I will maintain
construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(x)should 1 store or handle hazardous material.
hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air
t. 1 have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will
Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
health&Safety Code,Sections 25505,25533,and 25534.
performance of the work for which this permit is issued.
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by O er o iz agen
Section 3700 of the Labor Code,for the performance of the work for which this Date: a I I
permit is issued.
rtify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,1 for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
revoked. Lender's Address
APPLICANT CERTIFICATION ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is I understand my plans shall be used as public records.
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 I icensed Professional
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply with
all non-point source egulation per the Cupertino Municipal Code,Section 9.18.
Signature Dat f"? -2-t L'<
wv,�: GENERAL PERMIT APPLICATION `0131MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BU!LDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CUPERTIh10 (408)777-3228• FAX(408)777-3333• buildino(Dcuoertino.or4
❑PLUMBING VMECHANICALE
❑ LECTRICAL ❑MISCELLANTEOliS
PROJECT ADDRESS 13 S � ve APN S
u V✓NER NAMEH t�-G j=S(l Pl kAZ�D)�yp �I PHONE E-1✓L�IL C W Q�M�C'O
o g 3 bSl-`f 3:� �l n o�-
STREET A DDRESS -0yCITY,STATE,ZIP Cj {� 4i��l
y� q ^� , � \ I FAX
CONTACT NAME RAL)
�J J A y�N E ` PHONE 14D O� >t2)- C&�J3 E MA� (
STREET ADDRESS 1��� tA1� 5k '--T-rAr J)'f' -T CTTY,STATE, ZIP 1L4 P J Pte) Al V i
❑ OWR.'r'R OATNER-BUILDER ❑ OWNER AGENT ❑ CONMUCTOR ❑CONTRACTORAGENT ❑ ARM=CT ❑Z'40DI P, ❑ DrvELOPER ❑ 1_ N-7
CONTRACTOR KOLME I LICENSE NUMBER LICENSE TYPE BUS.LIC
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINTER NAMiE LICENSE NUMBER BUS.LIC
COMPANY NAME E-MAIL
FAY,
STREET ADDRESS CITY,STATE,ZTP PHONE
USE OF ❑SFD DI DUFM ❑ 1✓1 LTI-F.4;.^.I.Y PRCMCT IN WL�-DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN El YES
BU"IIDLNG: ❑COMMERCIAL URBAN INTF3LFACE AREA (3 NO FLOOD ZONE ❑NO EICHLER HOME? ❑ -0
DESCRIPTION OF WORK o.1 p G 1'�r1 CTM-6 AC
Q B P W&- u iP6640e ff4Ai L OV- On AMP fir' Z-v C4r-t o--tj �
TOTAL VALUATION:
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 m nstrucf IpAkorizerepresentatives of Cupertino to enter the above-identified ropelty for inspection purposes.
Signature of Applicant/Agent: Date: 2.1 2 6 ( 9✓
SUPPLEMENTAL INF'ORIMATION REQUIRED OFFICE OSE ONLV
OTI,-THE-COC'CTE 2
EXPRESS
STAN-1).-LRD
❑ L%RCE
MEPA1iscApp_2011.doe remised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21315 Rumford Dr. DATE: 09/21/2015 REVIEWED BY: PAUL
APN: 326 41 043 BP#: VALUATION: 1$15,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PENTAMATION FURN/AC
USE: PERMIT TYPE:
PRIMARY SFD or Duplex
WORK Replace E furnace with N in Closet Replace Ducting; Add N A/C in N location; Install N Sub
SCOPE panel (Same Location)
Mech. Plan Check0.0 hrs $0.00 /'inn>ib. i'leln c heel Elec. Plan Check 0.0 hrs $0.00
Mech. Pennit Fee: 1AIPERAIIT Elec. Pennit Fee: IEPERMIT
Other Mech. Insp. 0.0 hrs $48.00 Li Other Elec. Insp. 0.0 hrs $48.00
i; h lir,�,. l�.
NOTE. This estimate does not include fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc. . Theseees are based on the preliminari information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-0 3 E1J: 7/7113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Mechanical
Suppl. PC Fee: (E) Reg. Q OT 0.0 hrs $0.00 $143.00 IMFR=<100 I Furnace,Forced-Air
PME Plan Check: $0.00 F__17 # Mechanical
Permit Fee: $0.00 $72.00 IBREMAIR A/C Units(<=10K cfm)
Suppl. Insp. Fee.0 Reg. Q OT 0.0 hrs $0.00 100 amps Electrical
PME Unit Fee: $0.00 $48.00 1BELEC200 Services /
PME Permit Fee: $96.00
'onsiruclion T(ix:
Administrative Fee: (ADMIN $45.00 Q
Work Without Permit? O Yes (E) No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Travel Documentation Fee: ITRA VDOC $48.00 Building or Structure 0
Strong Motion Fee: IBSEISMICR $1.95 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.0
SUBTOTALS: $191.95 $263.00 TOTAL FEE: $454.95
Revised: 07/02/2015
i
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOP10ENT DEPARTNIENT•BUILDING DIVISION
\ 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX(408)777-3333• buildincncuoertino.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 L 131 S RUM F-4'1')-D .pf I AP 99b 41
O��vvNERNAME OWNER ADDRESS-.2 LA 'z`�A c cope-, ►�✓C'
16NaG, �>Aiz4►t o7�AYxM1_)Jl. . _ C CP I
DESCRIPTION OF WORKi Q"Pic _- UGr(W6 L2aocAceM-C� AQQ- ON
WAIIQfCL Uf64v F ✓'? /OV -20-11 Awl/ C 9-40 "C,ATLO✓1/
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. 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
iQsurance coverage for injQries to workers on my property.
2. I understand building permits are not required to be signed by property owners unless they are responsible for
t e 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
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
�,tiame instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
is L5. 1 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.
QL6. 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
Ato serious financial risk.
7. 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.
�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.
OwnerBui:derForm 2010.doc revised 0"/14/10
��L9. 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 Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or wv✓w.cslb.ca.gov for more information about licensed
contractors.
'Oki 0. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
the party legally and financially responsible for proposed construction activity at the site address listed above.
11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will atrtde
,&all applicable laws and requirements that govern Owner-Builders as well as employers.
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 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 may be 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 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 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 owners signature.
Property Owner's Signature: Date:
(NOTE: The follovving Authorization Form is required to be completed by the propertyov✓ner only v✓hen 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 ov✓ners
signature.
Property Owner's Signature: Date:
OwnerBuilderFOrm 2010.dvc revised 041/Id/10
m � u
oc, -0 a
C U N
a' N -4
LL a a c v m
� d a. E E 'C .ti
c`0 v O a 0 .� m
V O Yom, ut- p O
ra CO V1
a O Q w —CL
OL O
� U =
rN
:3
E r p c
a c
t v rn = a
u o N }
o
CL
3 0 Of 7 0o a3,
"O C7 Ln S C C B,
bD 00
Q c o m ? a
m •;I- N In N `1 N Y
aZ3v E a
as v 0 c o o
a
c n n = Y
p � E c u L o v o }Q o=3m ° v ''' C ° 9
z v
a - E w
u _C a C C - 0 64 u N
a a > > m o f u 0 O o
w cu w LA
vCU CL . = -a Q � a3i c E n
y
z c o m 3 3 3 _° Ln
o°o E a
C 0 fn 0 0 m Z 3 O C vii O } YO a ON ..
m v
co o Y C a ° `
N C O O O O C u o v
N >
aL- p , > m
c 0 v
CL
00 CL)
aJ to ` ,� C N O
C O C n O
O f0 .tw r G Y � O
O c 0 E00 u
u u O a
LA
E a
) H
_ ,n m
> `^ E
v a
C
a'. C O
V O = u V fD O
1
C � �
a 0 — O O O S U N o
E E v R $ v
o u o E c N CL U Ln Ln Y E s r ,
a o a
kA
E m m m a o c u N o m
a a a 1 :3 Ln o
E o 0
m +a o
N ? Q -2
c c `^ E Q '-' ✓� ^
L" C O E " ° a O ^ c
c r14
0
Z O N u N O O 41 u 0 vi
Q CO m CD V) m N C Q u
O u
a N
c
a m LA
u O ° C = u
u m - M J E m r_ .O w w
LL cn OQ m u O ` `- _ >
w ^ Z 0 a N O p £ m
Ow C NO " a+ �O a0+ O E O O Z w
m m u v a v u ° u P.' °' E - c
v o z y a o o a E a c > v m a, p m
a` v iv u � `n Z > ::
F a ar CL O C. N c Ln x
+a` o C7 a Ln a w oo m
Q CL Q U 0 0 0 0 0 m v s u
D
D Z yx m � c zz ° sczz
m p D m= ?i
(D mW
rri
D z
�. .» w < = rD
� rD d n v+ p r�D f'D O f1
Qo o' :3 < � z 'D z o 3 y r 7 D
7 z N F n 3 n n n 3 r O Z Z vi + m
c o o m x o 7 rD fD a ° O
DO 3 O _. N C.N N O CC 0,1 V1 T
Ri N _ ^ W W N = O -0 C n n
N s ro (D m T in io min c ^ of
ro' t~i m ° a, Na) 90 O
a0ma 7_
DD a 3 3 O r
o m p Z
N ^ C O O m 7 '� O =•
00 O ^. 3 s " F m rwo °� p v+ N ,fp.. �p 7 p n
rn
< ru m w 7
d D ry ro ID r00o r) a io °: -^-., c '° vii �.
3 0 < x < o �' 3 3 v+
0 3 o ". o N° ' o v 3 d d 0
NJ Cl0 00 a ? S a m D D r9
n — r. 3 3
o o. � Do a o n 3 3
O c 3 > > � ^ c > > o ^
,m„ 0 3 v o 0 3 D 3 to j 3
O
v c H f1
m O .. w iv 7 S O = W ._+
v w rD 7 f9 p 3
0. '^ to 7 N rD y y C °
n m 3 T ^ N 7' •• 3' f9
o
a m m �; oro
° .�► O
7 aCL
= c m D -� m icr
n cu
3 C v m =*. A O F+
rD 7 7 3 m =
< n 2 o0 7 S 7 D
1m N V1 N d f1
N 3 3 m M
_
mm 3 �° ^ 7 m 0 3 o p
N F -0 o 1p C m' 3 Ln
n z z 'p_ c Q rD n c v�o o " On
s M amo v ? < 3 n `ND m
N ..
3 .mow O' d a N Q 7 C 7
� � m � � ? O
< r<D v 3 a n �+ c 3 cu
v� = :3 rD °i v 3 7 W n Un 'D fD
n
o' er a m = Dy 3 °o o iv < 1+ <
0 0 a s o w r1 N 3 o T o
r < o v
C) O rp m a °:ID
'O CD "O
CY) d M -0 p D D O O
NrD (D .+ rD
O n m 0.
m
cp > > j n O ry V
rD Cr) :3 0
J N = O 7 O h
O O N in 7 '� 3 F+
fD
A fV
J a
0000 p
-
° ^ 00 Cl
3 � �
s
m Q
;o o m 3 F+
m f n
o - d ^7 • o o O
opo Q' C fD 3
m < 90
m _
m
x m
m
m
o'c 3 Q m m
o Ln ° n v a c o
G
v m
0 0 < o_ n
1p <. < rD 0) T
F. m y r
Q, 3
n y o
r
J m
O vii rD W T
n O< v a rri x 0 oN m n nNi A Q D 0 v o ~ n
D O x D (D O F 3 _ D m
co rr'- W N m d p v+ A w n1 �+ ^ i\ir < d 3 n 0 (eD
c .. N a O y — 7 3 7 O O ° x 7 (D rD (D C
� X S '� n/ Q s 3 rD eD n p d .�. 3
m v rn _ D � N rD
00 to o — a s s a s 0 CT D V v 0 '< j 7 D
3 Z 'a D A Z c rD — c o- E. (D tc c D T OJ .. T
y O Q° Z 7 cr c 7 7 rD o- 3 °c° O ° •-� 7 n
t!1 y fD Oo .7. rD rD ... 7 N 7 D)
zO
a a '^ c e, v1 (D
-'1 N r7D U.1 = 3 C S 00 0' Inp m D
CL m D7 c „ o < Q 3 3 3 C
jto Q W Do' -� ru m a CA rD (D 3' 0
n D N w 7 or o 7 00 O 3
< m m m 7 m c O < 0r (D
^ W (j m n °' d as a N .� f1 N y. {/1 ,... Z
m -i o_ c O n C f�
7 Dr s ro n N a 7 0 o o c Gl O T
a D Z v CL CL w D
o a0 -0 ° ? c` p 3 p y 00
o y n m < o o Sr n < 3 v+
00 p Do N a rD rD n » <
a o 3 m O �.
0 0 o 3 3 3
r O m _T c vc,
W O y O_ y O' Q1 (D 7 d (D '�
(D 0 1p n 3 O N 3 N N
T O y O rD rD Ola D y o � 0J
CL O C < O_ , n 7 d 3 rr O
0, n a N = a 0 H 3 n (D 3
o 0 o n n' v 3 '' (D 3
cm o y o rD 0' b' O 3
O a 0 7 m 7 rD nrl
3 c 3 0 7 a' 3 `D ^ 3 T
n „
a ° ^ ° 0, a o ^3+ D
o rD o 0 7 0 — u 61 r
o ns 01 N o
y o o, rD 00 0 CL O O =
m 3 0- n n c 3 n 3
ro 3-
m m O_ W T n
O rD 'aO D N n
v C
O < 10 0 7 N
m' a d. < °- Ol
c y a n 3 .�
o - fD
j. N rD o_ s'o c o 3
rD o 00 v1' O ar or C.
s 7
3
D 'D cr ID 00 s v ^ ro v c' ro a AO ? n m 0
00 0
�^. p Q W j 00 j m a O_ �. �" n O D_ 00 7 N D v C
o rD 00 CJl '^. 0 a a w �' N m O = U1 3 (D
o No
rD w 00 1p D f 070 '" I- W � -= O iD rD (1D
(D
w O a m s raD 3
LnID
lin F+ N O v O 3 or f In \1 0) �.
p Q 000 j 0 t on�i .N_a C
CP !D n n ? _. y •+ S
O c H r0 d (p O O
PQ
° 00 m ID O 7 73 =_ V!
d A 7 7 d 0o O_ (CL
D
A j
N � 7
y - a
(p 3
ID O
_ 7 S
�. rD O
v y
m O 7 ID
o m ° c a 7 �.
3 a oa
m w m a
Vw O_ a j a
O a 7 O ID ^.
o-
o r N I N
a
< O -
vrp,
m O CL rD
0 0 O
!D O- a 0 n S 0
a
0 ` 070 = 3 y 3
0
D n a
0 —
rD 7 ° -
77 ^+ n
7 rD ID O
(D m
0 » rD d
m CL
O p vOi
D n N C 0
ti O
rl)a .Z7 O y d N °
O Vt 7 .7e 3 O'
A
l~/1 T ` 7 N CL
rD
:E 7 rD
< _
0 o y n
CL
1 y =
N cu ? U W r
3
F n n O
v m
A l!J N
O cn � T
to
C Z
j. �
� Z b
O m n
J U, d
r� C Gn O
yrUl w .
K �� w V �JjCj
m<m
� ! a+ n as
oa3
0 0 3 CC) O C
�•'0cn y � N
d a 9E !R cc Z D
rt 1 C4 d
V1 S O
w ° vir> Na ZQ14..' ft T i li uZ �C
0
<m
' m
C, . w o z° m
m (D L -�
co: rn
SD
o cc,: G d
cm v O r�tl
a.1 � "O
>• Q S ID
_ O U w
i 0
r DZ
m
1
J 1ii ~ r�
z
WATER-CONSERVING PLUMBING FIXTURES ,
OWNER CERTIFICATE OF COMPLIANCE
1 COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
!i ,
CUPERTINO 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
(408)777-3228• F (408)777-3333• building cu ertino.or
Owner Name D A Y A N i 1 F l C) C� 1=S t}P�94 Permit No. 5-
Address Q 3l m _Pa7,
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
F No 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.
Skip the rest of the form and sign bottom of form.
JX 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. Skip the rest of the form and sign bottom of form.
Into Go to Question 4.
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. Skip the rest of the form and sign bottom of form.
I 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. Check one of the three following statements and sign
bottom of form
5. Please check ONE of the following:
My property is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water-conserving plumbing fixtures throughout the building. On or before January 1,2017,all non-
compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
❑ 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 c0777nercial 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).
I,as the owner or owner's agent 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 plumbing fixtures comply with the requirements as indicated in the
table on the following page.
Owner or Owner Agent's Signature: Date: b Ir—
Upon completing and signing this Certificate,please return it to the Building Division in order to final your bui ding permit.
SB407 2015.doc revised 08126/15
BUILDING PERMIT CANNOT BE FINALED AND COA'IPLETED UNTIL THIS
- :' CERTIFICATE HAS BEEN SIGNED AND RETURNED TO THE BUILDING DIVISION
Non-Compliant Water-Conserving Plumbing Fixture
Plumbing Fixturel (Fixture Complying with Current Code Applicable to New Construction)
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
Gallons/flush 0.5 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 @ 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
may be used to achieve unavailable, aerators or
reduction. other means may be
used to achieve
reduction.
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 08126/15
SMOKE / CARBON MONOXIDE ALARMS F �,.
OWNER CERTIFICATE OF COMPLIANCE j!; E
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION OA/
CUPERTINO 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
(408)777-3228• FAX(408)777-3333• building cDcupertino.or-g
_ �'� '�,�,_�.� � Permit No.
Address 2 3 5 J ,ti►1 � D�a�,�'"1�krsc� # of Alarms Smoke: '7 Carbon Monoxide:
PERMIT CANNOT BE FINALED AND CO'1IPLETED UNTIL TINS CERTIFICATE
1-IAS BEEN SIGNED AND RETURNED TO THE BUILDING DIVISION
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 X X
bedroom(s)
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 agree to co with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
pYAN�.ti , ►moi vI ��.
Sinature.......................1 ::.......:...............................................................Date: .... ...... .......
Contractor Name:
Signature...................................................................Lic.# ......................................Date: ...................
Smoke and CO fonn.doc revised 03/18/14