15110196-OLCITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20300 PINNTAGE PKWY
CONTRACTOR: BELLOWS PLUMBING,
PERMIT NO: 15110196
HEATING, & SEWER
OWNER'S NAME: KWAN TOM T AND AMY Y TRUSTEE
2652 RESEARCH PARK DR
DATE ISSUED: 11/30/2015
OWNER'S PHONE: 4088813113
SOQUEL, CA 95073
PHONE NO: (831) 477 -7150
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REPLACE WATER HEATER IN SAME LOCATION
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
Sq. Ft Floor Area: 0
Valuation: $1000
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
-
APN Number: 36947017.00
Occupancy Type:
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. 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 EXPIRES IF WORK IS NOT STARTED
permit is issued.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION
180 DAYS FROM LAST CALLED INSPECTION.
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
Issued by: Date:
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
RE- ROOFS:
granting of this permit. Additionally, the applicant understands and will comply with
All roofs shall be inspected prior to any roofing material being installed. If a roof is
all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
installed without first obtaining an inspection, I agree to remove all new materials for
Signature Date
inspection.
Signature of Applicant: Date:
❑ OWNER- BUILDER DECLARATION
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. I, as owner of the property, or my employees with wages as their sole
HAZARDOUS MATERIALS DISCLOSURE
compensation, will do the work, and the structure is not intended or offered for
I have read the hazardous materials requirements under Chapter 6.95 of the
sale (Sec.7044, Business & Professions Code)
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
2. I, as owner of the property, am exclusively contracting with licensed contractors to
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
construct the project (Sec.7044, Business & Professions Code).
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
I hereby affirm under penalty of perjury one of the following three declarations:
contaminants as defined by the Bay Area Air Quality Management District I will
1. I have and will maintain a Certificate of Consent to self - insure for Worker's
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Compensation, as provided for by Section 3700 of the Labor Code, for the
Health & Safety Code, Sections 25505, 25533, and 25534.
performance of the work for which this permit is issued.
Owner or authorized agent:
2. I have and will maintain Worker's Compensation Insurance, as provided for by
Date:
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
CONSTRUCTION LENDING AGENCY
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
I hereby affirm that there is a construction lending agency for the performance of work's
Compensation laws of California. If, after making this certificate of exemption, I
for which this permit is issued (Sec. 3097, Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code, I
Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
Lender's Address
revoked.
ARCHITECT'S DECLARATION
APPLICANT CERTIFICATION
I understand my plans shall be used as public records.
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
Licensed Professional
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
WATER - CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
C U f E 11TI N O 10300 TOR RE AVENUE - CUPERTINO, CA 95014 -3255
(498),777-3228 • FAX (408) 777 -3333 buildings- cupertino.orci
Owner Name y�a� Permit No
Address :)-P sL�� n �n . ��r /_' , a a ,,. r 4
1. Is your real property a registered historical site?
0 Yes Civil Code Sections 1101.1 through 110I.8 do not apply. Skip the rest of the form and sign bottom of form
[ErNo 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?
0 Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
0 The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
Po No Go to Question 3.
3. Is water service permanently disconnected for your building?
0 Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
EP-'Ro Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
0 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
0?'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..
Please check ONE of the following:
0 Myproperty 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).
IV 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).
0 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- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures,
On or before January 1, 2019, all plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements).
1, 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 followine nave.
Owner or Owner Agent's Signature: l�U� Date: f /7 -.S— I
Upon completing and signing this Certificate, please ret6ru it to the Building Division in order to final your building permit.
SB407 201 S.doc revised 08126115
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