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160100221i .1 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21155 OROGRANDE PL CONTRACTOR: TRENCHFREE INC PERMIT NO: 16010022 OWNER'S NAME: KUMAGAI SHOJI AND CAROL M iu Ife_e PO BOX U DATE ISSUED: 01/05/2016 OWNER'S PHONE: 4084726102 SAN JOSE, CA 95151 PHONE NO: (408) 726-7926 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL �� / License Cla&st� 6 4�ic."iilI �j(� REPLACE (E) PROPERTY LINE CLEANOUT DUE TO OFF - SET Contracto r &A ��°�( DatetO�f I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions SANITARY 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 Sq. Ft Floor Area: Valuation: $2900 performance of the work for which this permit is issued. dMaye and will maintain Worker's Compensation Insurance, as provided for by APN Number: 36217008.00 Occupancy Type: 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 PERMIT EXPIRES RES IFi 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 180 D D INSPECTIO indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the l /� granting of this permit. Additionally, the applicant understands and will compl{� with all non -point source regulations per the Cupertino Municipal Code, Section RE -ROOFS: 9.18. p' �/ tt Signature _ Dato `� 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: I hereby affirm that I am exempt from the Contractor's License Law for one of the 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 (See.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. I will I 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. I have and will maintain Worker's Compensation Insurance, as provided for by will maintain compliance with the Cupertino Municipal Code, Chapter 9 A2 and the Health & Safety Code, Sect', ns 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner � Date: 5l ( b permit is issued. or authorized ager , 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 CONSTRUCTION LENDING AGENCY 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 pen -nit 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 infonnation is correct. I agree to comply with all city and comity 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, ARCHITECT'S DECLARATION 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 Date GENERAL PERMIT APPLICATION ' (W C0W/iiUNITYDEVELOPPENT DEPARTMENT BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255 (4 08) 777-3228 • FAX (4,08) 777-3333 • buiIdln0(C7OUDe'6no.OrQ /Q O SUP: RT[NU' / M I tPLL'h,�i�G ❑1'ECI_a_J\rICAT ❑ELECTRiCAT ❑A�,ISCELLOUS PROirCT AI) DR` SS �9r L.I1_nk I t Y�'li6isc./�p�_20.1 A??\ Pl/ j6 OwTTRl�?1J�. ��r r �„e hm ' �,J�'`.lJaVr rn r//L��,-A70 e /� ^• J. I Cl SSE CTA1 "- C �lJ I F?✓ tel. V �•AAli ® V CONTACT I LWE q ` "LC.•� MJ Z_L � J ST ET AD KESS/ T TE, Z3 r � �.� -x L �` ✓" `� r I J ❑ MWM ❑ OV+'NER—BL-i-DE-El ❑ Oh � R AGENT CONTRACTOR ❑ COIF?? k CMR AGM:•T ENGID\P, ❑ T _Kc rl C0I\lTP.kCTOR1 a�+� �r-� 1/z LICE?.SE?ti1✓3ER r®j I Last _Ftl 1BUS. LiC COUPk\ry1;. i Ir L 1C C' or I FAX STREET?SDR SS i �y�I✓ g,� � �r ' w( � STATE, ZIP f j G --M 2L ?RClIIMCT Z`NGiKEZlRNA.ME LICENSENU1+43ER . BUS. LIC- COMMNY NAME E -M -11M I FAX STREET.kDDR SS I CITY, STATE, ZIP I PF C117L USE OF E)S� w DUPL.'- ; ElMULTI-FAI+M_Y . ?ROMECT El YS ?RO�=CT LN ❑ � �S Bi."MUNG: ❑ COI+J+�–r C'Q� L?Z AN iyxFACL/?LA ❑ NO FLOOD ZON ❑ NO FZICI?I�HOME? ❑ >i�O DESCPJFTION OF 1%,'ORiC �® xe l 8. ilei Pc f' 4i deAA ® �i_'L epV ZA San i r �J, r n rc W � �� and { o 'Cl`'1 I� �r Aft- n. TOTAL VALUATION'-: s By my siQaztu-e below, I ce-ito each of the following: I z� tr3e prope.y e;;,Der or zn'uorLed zQ con Lhe proper y o;; n ehalf, read Lh'S - ap• hUtion and he nforrztion I have provided is correct. I have read the Desc.ip ion of V+Jol-k L d ven is accurate. I aZ VIM all applicz e oca bl 1 1 crdi�ances and s ate la;; s velar �g to bu ]ding cobs c ioD. I authorize representatives of Cupertino to enter the abqove-ide_t15--d/p'ropel y for iDspec ioa purposes. Sitz pre of—,,uplic�a /.-"_dent: Date: Sli- PLEMENTAL D I--ORI,eTATION REQliLRED FSCE:LSE'.Q7RL1,_.... :` � OV tR TTS COTS T'nI2' ur l ''.: T ].doe revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 19 ADDRESS: 21155 OROGRANDE PL Plumb. Plan Check 10.0 1 hrs $0.00 DATE: 01/05/2016 REVIEWED BY: MELISSA APN: 36217 008 1 BP#: 2��j *VALUATION: 1$2,900 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: Fee., —TP—ENTAMATION 1 RPSS PERMIT P IT TTYPE: YP WORK REPLACE (E) PROPERTY LINE CLEANOUT DUE TO OFFSET SCOPE A,lech. 11/on Che V- Plumb. Plan Check 10.0 1 hrs $0.00 Elec—Plar., Chec,4 I 4euh, Pee-rne i`e'0: Plumb. Permit Fee: IPPERMIT Fvc: 2��j Other Plumb Insp. LL.Oj hrs $48.00 Ll !'haib. Inslo, F-- Fee., VOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School instrict,etc.). inese-tees are Dasea on me preliminary information availavle ana are only an estimate. contact tine vept.loraaan-iii?lo. FEE ITEMS (Fee Resolution 11-053F, �7WI�3 FEE QTY/FEE MISC ITEMS A I ee PNM Plan Check: $0.00 pei?W� PME Unit Fee: $25.00 PME Permit Fee: $48.00 Administrative Fee: 1ADMIN $45.00 Work Without Permit? C) Yes (j) No $0.00 A Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 ,,SUBTOTALS:' $16750 $0.00 TA FEE $167.50 Revised: 10/01/2015 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 PERMIT CANNOT BE:FINALE]D AND'COWLETE,D UNTIL THIS CERTIFICATE TT PIAS BEEN AND ' +',TR1�r TO'rHE BUIILDIItiT DIti'ISI N PURPOSE This affidavit is a self -certification for the installation of all required Stroke 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-fainily 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 T CO ALARM Outside of each separate sleeping area in the iinmediate vicinity of the bedrooms) X X On every level of a dwelling unit including basements X X Within each sleeping roo.rn 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 n.ot 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 comply kvith the terms and conditions of this statement Owner (or Owner Agent's) Name: AflJr1, `'\�1� � Si nature .. ............ ... ........................:. ..... �. ........................... DatJa�..b�'6 Contractor Name: Sinature...................................:............................... Lic.#...................................... Date:................... Smoke and CO forni.doc revised 03118114 1 i. OF -11 OX COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO CA 95014-3255 17'�' • S- i Cb__/1 CUPERTINO I ' I, (408) 777-3228 • FAX (408) 7-7-3333 • ,building (Qcupertino.or9 Owner Name S ► I IA >� GJ ! Permit No l 0 OI o D Address 211 S�J� f��rvavl � _ P_] C��V �t �'� CA % V11 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. At YNo Go to Question 2. 2. Does your real property have a licensed plumber certifying that, 'due to die 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 fore and sign bottom of form. iYI No Go to Question 3. 3. Is water service permanently disconnected for your building? ❑ Yes Civil Code Sections 1101.1 through 1101.5 do not apply. Skip the rest of the form and sign bottom of fond. Y'Ni o 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. ,SjCivil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign bottom of form.. 5. PI ase check ONE of the following: A d 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 mullii/amily 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 coinnzercial real property. See Civil Code Section 1101.5. On and after January 1, 2014, specifiedbuilding 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 1 101.1 through 1.101.8, 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 followinjz page. Owner or Owner Agent's Signature, DaOF i 11 6 , 2D/-6 Upon completing and signing this Certificat please retur t to the Building Division in order to final your building permit. SB407 201 J.doc revised 08126/15