15100133CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7955 SUNDERLAND DR CONTRACTOR: KIRTLAND HENRY H PERMIT NO: 15100133
AND ERIKA H TRUSTE
OWNER'S NAME: KIRTLAND HENRY H AND ERIKA H TRUSTE
7955 SUNDERLAND DR I DATE ISSUED: 10/16/2015
OWNER'S PHONE: 4082571372 CUPERTINO, CA 95014 1PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
INSTALL (N) SUMP PUMP IN CRAWL SPACE
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:
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.
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:
i. 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. 1, 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:
1. 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. 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.
3. 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.
Signature W::qA� /\,—j Date 10Z 10 f
Sq. Ft Floor Area: I Valuation: $4000
APN Number: 36211012.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
W t Ct (- c4v� • f 0/16J 9OL7 .
Issued by: Date:
RE -ROOFS:
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.
lar oorized agent: _
►1 Date:
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
GENERAL PERMIT APPLICATfON 15I00I33
COMMUNITY DEVELOPMi�ENT DEPARTMENT • BUILDING DIVISION
10300 T ORRE AVENUE - CUPERTINO, CA 05014-3258
(408) 777-3228 - FAX (408) 777-3333 - build! no(d)cuoeriino.org
PLUh3ING LJ II ECF A LAICAL
ELECTRICA-L ❑A�ISCELLANEOUS
y4i
PROD-LC'I .ADDP.ESS -� � � � � t, � � �CZL � IS D � � •
, AP?\
O WTrR KAJ , ,_
I- F -mV --4 i4r� ' LA-M�
PHON
4a� asp
-)37Z
E-l✓L4.IL
pari k OLkis
Qv .
STREET ADDRESSq J L) %i D' t is N0 t
jITY, C , i c� � tl I
FAX
CONITACT N.ANE
PHO1
I E-I.ZAII
STREET MDRESS
I CITY, STATE, ZIP
I
FAX
❑ Ov'.= OFN�AGEN'T ❑ CON71PACTOR ❑ CON-IRACTORAGE-WT ❑ ARC-:= CT ❑ ENG1?�'�a
❑ DE ELOPEa
❑ T-zNAN-T
CONTRACTOR N-a1%r
I LICENSE NU>\fBER
I LICENSE TYPE
I BUS. LIC r
CON.PANY NAS
I E-IJAIL
I FAX
STREET ADDRESS
CITY, STATE, ZIP
( PHO\'.E
ARCHITECTrNGDNEER NAh:E
I LICENSE NUMBER
I BUS. LIC n
C0I✓2A-W FAME
E-MAIL
( FAX
STREET ADDRESS
CITY, STATE, ZIP
HOTr,
F
USE OF ❑ SFD or DUPLEX ❑ 1✓.ULTI-F-AJ,=Y I PROJECT IN WIT I)L N"D ❑ YES
BUII-DL G: ❑ CO1 I CLAI URBP?.' L>`TERFACE AREA ❑ NO
PROTECT LN ❑ Yr --s
FLOOD ZO?�-- ❑ NO
IS TAE BLDG AN
EICHLER HONE?
❑ YES
❑ NO
DI✓SCP.IPTION OF WORK
TOTALVALUATIO'\: �j� RJ✓CEIVrDB]' t _`
By my signature below, I certify to each of the following: Ian the properly 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 Nvith all applicable local
ordinances and state laws relating t b ildin cons ct10n. I authorize representatives of Cupertino to enter the above -identified propel -tLy for inspection purposes.
w
Signature of Applicant/Agent:\ Date: 1 S 1
SUPPLE? ENTAL DINT'ORMATION REQUIRED
AEP -A1 scApp_2011. doc revised 06/21/11
CITY OF CUPERTINO )J�"ICO)33
FEE ESTIMATOR -BUILDING DIVISION
IlaADDRESS:
7955 Sunderland Dr. DATE: 10/16/2015
APN: 36211012 BP#:
REVIEWED BY: PAUL
*VALUATION: 1$4,000
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: SFD or Duplex
Ek,(. Permit Fee:
PENTAMATION
PERMIT TYPE: 1 RPP
WORK
Install N Sump Pump in Crawl Space
SCOPE
#
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Ek,(. Permit Fee:
Septic Tank
1 PPRESEWG
Jiher flee. In p.
1
#
$143
PME Unit Fee:
$143.00
PME Permit Fee:
$48.00
COnstruc.'tioi? 1'4!:x '
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$143.00
Strong Motion Fee: 1BSEISMICR
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 vreliminary information available and are onlv an estimate. Contact the Dent fnr addn'1 info_
FEE ITEMS (Fee Resolution 11-053 U 7f /1/13,
llec It I' (m Check
Plumb. Plan Check 0.0 1 hrs $0.00
MISC ITEMS
i tcc°h. Permii k cue:
Plumb. Permit Fee: I PPERMIT
Ek,(. Permit Fee:
Other .He ch..Insp.
Other Plumb Insp. 0.0 hrs $48.00
Jiher flee. In p.
Vech. Insp
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 vreliminary information available and are onlv an estimate. Contact the Dent fnr addn'1 info_
FEE ITEMS (Fee Resolution 11-053 U 7f /1/13,
FEE
QTY/FEE
MISC ITEMS
i- lain C heck 1, ee.,
'A
F71
PME Plan Check:
$0.00
PME Unit Fee:
$143.00
PME Permit Fee:
$48.00
COnstruc.'tioi? 1'4!:x '
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes No
$0.00
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: 1BSEISMICR
$0.52
i Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$285.52
$0.00 TOTAL FEE:
$285.52
Revised: 10/01/2015
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildingalcunertino,org
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:
SITEDDRESS s APN .
.4
OWNER NAME
.E OVJN ADDRESS -
i L 7R:_S
1LND
DESCRIPTION OF WORK:
a L A r-.�4� 0Q.
BP#IM00l33
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.)
W�_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
insurance coverage for injuries to workers on my property.
14-2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
tk 3.1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
W— 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.
t�9� 5. 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.
14 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.
1,K 7. 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
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.
GwnerBuilderForm 2010. doc revised 04/14/10
W-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,
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.cslb.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, and understand that
am the 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.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information l 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 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 drivel'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 natu e.
Property Owner's Signature: Date: i0 CC )t'`
----------------------------------------------------------------------------------------------------------------------------------------------
(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:
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 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
w;SMOKE / CARBON MONOXIDE ALARMS
VOWNER CERTIFICATE OF COMPLIANCE
kyr:,qsa., COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE•,CUPERTINO,CA 95014-3255
(408)777-3228 FAX(408)777-3333• buildinc�na.cupertino.orq
PERMIT CANNOT BE FINALED UNTIL�THIS CERTIFICATE HAS BEEN
COMPLETED,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 X X
the 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 specified below have been tested and are operational, as of the
date signed below. '
' aar 1 S St-? i'.! 'r RI,-A o '� I . ? CUP N1° Permit No.161 O01 33
Specify Number of Alarms: #Smoke Alanns: L #Carbon Monoxide Detectors: I I
I havee� d and agree to comply with the terms and conditions of this statement
otirrolOritl) ignireept3-11-L6J1t-
tftii in
Contractor Name:
Signature Lic.# Date:
Smoke and CO fonn.doc revised 09/27/16