15090170I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 405 1 CONTRACTOR: VALLEY GREEN DRIVE PERMIT NO: 15090170
OWNER'S NAME: .�V fDp 'V(t 11,,
OWNER'S PHONE: 4082530200
Y� I P.O. BOX 1368
CUPERTINO, CA 95014
DATE ISSUED: 09/25/2015
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION I JOB DESCRIPTION: RESIDENTIAL ElCOMMERCIAL [I
UNIT 405 - INSTALL NEW 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. 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.
2. 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
permit is issued.
APPLICANT CERTIFICATION
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
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.
Signature.
Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. 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)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
t. 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.
2. 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
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
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 forthwith comply with such provisions or this permit shall be deemed
revoked.
APPLICANT CERTIFICATION
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
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.
Date
Sq. Ft Floor Area: I Valuation: $500
APN Number: 32609040.405 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 R LED INSPECTION.
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
or aluttnnorizea nt:
dMo Date: ' Z s-- I S
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
GENERAL :PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIV MEP
10300 TORRE AVENUE - CUPERTINO. CA 95014-3255 DIVISION
CUP15RT IN0 (408) 777-3228' FAX (408) 777-3333 - buildincupertino om
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OWNER '❑ OWNER -BUILDER
❑OWNERACENT ❑CONTRACTOR ❑CONTRACTOR
CONIRACTORNAME
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❑ ARCHITECT
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USE OF ❑ SFD or DUPLEX
❑ MUL2t-FATS Y
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aUILDINCr. ❑ COMMERCIAL
PROlEC1 IIi WB DLANO
URBAN WMFACE AREA
PROJECT IN
❑YES
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DL•SCRIPnONOFWORK
❑ NO
FLOOD ZONE
❑ NO
CHLERHOMET
❑ NO -
TOTAL VALUATION_ ® _ - - ;;:.,:�h _ -..• '
13y my signature below, I certify to each of the following: Jam the
property owner or a = {: —• :4�,.
application and the information I have provided is correct I have read the Description of Work and verify it t o o V
ordinances and state Taws relating to bui 'ng const ction I auth ri representatives of Cupertino to enter £ I have read this
comply with all applicable local
Signature of ApplicanUAgent: nti&cd property for inspection purposes.
Date:
ST_rKMr1V'KAA n, ..........._
MEPd-fisc,4pp 20JLdocrevised06/21/11
CITY OF CUPERTINO
9W FEE ESTIMATOR — BUILDING DIVISION
19'
ADDRESS: 20800 VALLEY GREEN DR
DATE: 09/25/2015
REVIEWED BY: MELISSA
UNITS
APN: 326 09 040
BP#:
*VALUATION: $500
'PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Multi -Family Dwelling
USE:
Buildino is
1 >3 Stories 0 Yes Q No
PENTAMATION 1 RMAP1
PERMIT TYPE:
WORK
UNIT 405 - INSTALL NEW WASHER/DRYER HOOK UPS
SCOPE
Silly)/. Insp Fee
APPLIANCE / EQUIP TYPE
FEE ID
hunb. Plan Chee%
QTY
UNITS
BP FEES
Efec. Permit ree
Other Appliance/Equip
1BAPPLOT
=cher Elec. Insp.El
2
#
$144
Permit Fee:
Silly)/. Insp Fee
PME Unit Fee:
$144.00
PME Permit Fee:
$48.00
Construction Tax:
r__
Administrative Fee: IADMIN
$45.00
Work Without Permit? Yes 0 No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$144.00
Strong; Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. i; 1%13)
Mech. Plan Check0.0 hrs $0.00
hunb. Plan Chee%
lee. Plan Check
Mech. Permit Fee: IMPERMIT
Plumb. Permit Pee:
Efec. Permit ree
Other Mech. Insp. 0.0 hrs $48.00
(Vier Plumb Insp.
=cher Elec. Insp.El
PME Plan Check:
$0.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. i; 1%13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Sutrpl. PC Fee
PME Plan Check:
$0.00
Permit Fee:
Silly)/. Insp Fee
PME Unit Fee:
$144.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: IADMIN
$45.00
Work Without Permit? Yes 0 No
$0.00
Y
P hrnning 'ees:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong; Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
1
Bldg Stds Commission Fee: IBCBSC
$1.001
SUBTOTALS:
$286.50
$0.00 TOTAL FEE:
$286.50
Revised: 07/02/2015
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
21 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
CU P E RTI N O (408) 777-3228 - FAX (408) 777-3333 - building(d>rt g-ertinn n.`
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
specified at: peRy
improvements speci
SITE ADDRESS
APN
OWNER NAME "_'�`—x�-/•%% �_1___=7 G D G/%�'�%%J BP#
OWNER ADDR
DESCRIPTION OF WORK• /,/,,,777 / =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.)
15�1 1. I understand a frequent practice of unlicensed persons is to have the
Builder' building permit that erroneously implies that the roe property owner obtain an "Owner -
personally. I, as an Owner -Builder, may be held liable and subject o serious rfinan cal r skrforany injuries suhr own labor stained 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 m aware of the limits of my
insurance coverage for injuries to workers on my property.
56./ 2. 1 understand building permits are not required to be signed b property
the construction and are not hiring a licensed Contractor to assume hresponsibility. unless they are responsible for
j_�/_3. 1 understand as an "Owner-Buifder' I am the responsible party of record on the permit. I understand that i ma
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her y
name instead of my own.
iIL4. 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 -LI -5, f 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.
'5�/6. 1 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.
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-
0""?erBirilderForrrn_2010.doc remised 04114110
j-LZ—J. I understand I may obtain more information regarding my obligations as an "employer- fr
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments
from the Internal
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSCR) at 1 -800 -321 -CSCR (2752) or www.csib.ca.gov for more information about licensed
contractors.
10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name,
am the party legally and financially responsible for proposed construction activity at the site address listed above, that I
l,/ 11. 1 agree that, as the party legally and financially responsible for this proposed construction activit i
by all applicable laws and requirements that govern Owner -Builders as well as employers. y will abide
v' 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes. to an of the
information 1 have provided on this form. Licensed contractors are regulated by laws designed to pry 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. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A 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 veri2 the propelZ owner's si nature.
Property Owner's Signature: I'd 111
Date: C`- 2
---------------e foll---------------------------------------------------------------------------------------------------------------------
(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).
AUTHOR17ATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excludino the Notice to Property Owner, the execution of which i understand is my personal responsibility, 1 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:
Address of Authorized Agent:
Tel No
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 cerLify 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:
011a:erBl' ldeiForrn_2010.doc revised 04/14/10
CUPERTINO
Owner Name
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a-cupertino.ora
-- L� S Permit No
Address ZC/ Y,9 0 VNI,16Z /J_%t' �!�' d� �- ` Li C� ri L/lir, 7�:r, /'.X%
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 110 1. 1 through 110 1. 8 do no apply. Skip the rest of the form and sign bottom of form.
XNo 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.
kNo Go to Question 3. '
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not ap Y. Skip the rest of the form and sign bottom of form.
No 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.
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 apply7,�_ eck one of the three following statements and sign
bottom of form.. C:5 i4 �
C
5.*,ease 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 Yundergoes alteration
improvements).
❑ My property 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- compli
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 naue.
I Owner or Owner Agent's Signature: —�, �� /� 6zs Date: /% ---; - / t
Upon completing and signing this Certificate, please return it to th uilding Division in order to final vour buildinu nPrmit
SB40 7 2015. doc revised 08/26/15
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 • buildingCa cupertino.org
Permit lto.
Address ZO �^D (/ / 1�� e 2L� , �- L/� `/ # of Ala>rnis Smoke: Carbon Mano�:ide: �
PERMIT CANNOT BE FINALED A!ND COMPLETED UNTIL, TFIIS CERTIFICATE
HAS BEEN SIGFE NND RETURIilI D 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 8314 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: Iii 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 permi is re uired for
alarms which must be connected to the building wiring.Law
n �
As owner of the above -referenced property, I hereby certify that the alarm(s) referenced abWse e
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 and conditions of this statement
-
OvmEr (or Ov%ner Agent' ) Name:
_
...........
CX
w
Signature ... ( .. .................................................. Date:.
Contractor Name:
F
Signature. .................Lic.# Date
Smoke and CO fornr.doc revised 03118114