B-2016-1216CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1216
10185 PASADENA AVE CUPERTINO, CA 95014-5920 (357 18 002)
(COOK ELECTRIC)
SAN JOSE, CA 95127
OWNER'S NAME: ELLSWORTH VIRGIL E SR TRUSTEE & ET AL
DATE ISSUED: 01/19/2016
OWNER'S PHONE:
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
Class Lic. 4*ec '( G 'J, g- Ll -
License
Contractor ( COOK ELECTRIC ) Date a�I l 4 I 'y;��
X BLDG X ELECT _PLUMB
l
MECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
DUPLEX (UNITS 10185 & 10189), REPLACE 2 (E) 100 AND PANELS,
I hereby affirm under penalty of perjury one of the following two declarations:
SAME LOCATIONS
r. 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.
have and will maintain Worker's Compensation Insurance, as provided for
01
y Section 3700 of the Labor Code, for the performance of the work for which
Sq. Ft Floor Area:
Valuation: $2200.00
this permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and hereby
35718 002
357
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
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with -poin o ce regulations he upertino Municipal
180_ DA �A�7C' CALLED INSPECTION.
Code, Sec " n 9.1 .
Signatur te,,00(1�1itla0ljp
Date:
OWNER-BUIL DER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Code)
Signature of Applicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date:
contractors to construct the project (Scc.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
s. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the
will maintain compliance with the Cupertin unicipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety C , cc ' ns '505,2 33, d 553
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
Owner o authorized agent: `.
be deemed revoked.
Date: J
9 ��
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
! CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
ARCHITECT'S DECLARATION
understands and will comply with all non-point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Code, Section 9.18.
Licensed
Professional
Signature Date
GENERAL PERMIT APPLICATIONM E PP
COMNiUNI TY DEVELOPh/EN T DEPART NENT •BUILDING DIVISION
10300 T ORRE AVENUE • CUPERTINO, CA 9501.4-3255
(408) 777-3228 • FAX (4-,08) 777-3333 • buildincCcDcuDerino.org
CUPERTINO- 2d t
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US =- OF orDLPL El ]JULTI-F�1,G1 Y ?RO QCT Li'a II�L,4SD- E3 ::s PROJECT IN ❑ Y: -:s
IS THE BLDG A.N ❑ ` _S
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BUTTDNIG: ❑COhO,i:-:p'CiA—T URBf-ND\1ZR.-EkCEAP.EA ❑ NO FLOOD ZOMBE ❑ NO
EICIZERHOIJ.E7 ❑ NO
DESCPJPTION OF F. ORK ,
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TOTAL ALU^.TIQ �: ffil
ryer
- s behalf. I have read this
Ey my signa«re below, I certify to each of the follovwinQ: I am the grope_ } o;; ner or aeuorized agen��Is
applicztion and �e izfornation I P_, gravid s- erect. I have read, es den of \TTak and; eurate. I agree to comply;;Vith all applicable local
Ordinances and state laws relat --2 to ' ildin cons ctioa. I - n, .. rep Se :; es of Cope~ no to enter he abov idea i{ed propel y for inspec ion purposes.
Si�aure of ".ppH pt/" --gent: �"Date: �j
STi- Par MEN'TAT— ! N r ORMATION REQU L P.ED
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OFFSCE SS QOM
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1 3,t�JOR z ME_
111JEP-hl'isc,4DP_2011.aoc revised 06121111
CITY OF CUPERTINO
W�W.A FEE ESTIMATOR — BUILDING DIVISION
im,ADDRESS: 10185/10189 PASADENA
FEE
DATE: 01119/2016
REVIEWED BY: MELISSA
APN: 357 18 002
1 BP#:
rT-
*VALUATION: 1$2,200
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
PME Plan Check:
Elec. Plan Check
PENTAMATION
FPERMIT TYPE: 1 REAP
WORK
DUPLEX (UNITS 10185 & 10189), REPLACE 2 (E) 100 AMP PANELS, SAME LOCATIONS
SCOPE
1-111'ech- Perrniil 'w:
VOTE.- This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, sanitary Newer District, lycifool
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept,for adan't info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711113)
FEE
QTY/FEE
MISC ITEMS
Plan (C."fleek f7ee.-
Afi;ch. 'in,.n
rT-
SuppL P(.' .F"
111.1"imb. Piaw, Check
T71
PME Plan Check:
Elec. Plan Check
-0.0
hrs
$0.00
Suppl, Insp.Fee
1-111'ech- Perrniil 'w:
PME Unit Fee:
$96.00
Elec. Permit Fee:
1EPERMIT
C"OnSiTuclion Kyx:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes (F) No
$0.00
Other Elec. Insp.
hrs
1 $48.00
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
lrsp. Fee:
$1.00
VOTE.- This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, sanitary Newer District, lycifool
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept,for adan't info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711113)
FEE
QTY/FEE
MISC ITEMS
Plan (C."fleek f7ee.-
SuppL P(.' .F"
PME Plan Check:
$0.00
Suppl, Insp.Fee
PME Unit Fee:
$96.00
PME Permit Fee:
$48.00
C"OnSiTuclion Kyx:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? 0 Yes (F) No
$0.00
Adwwice-1 Planning
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 ::
$238.50
$0.00 LTE E
Revised: 01/01/2016
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
CUPERTIN0 10300 TORRE AVENUE CUPERTINO, •CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingCfoupertino.org
Address
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
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
CSC 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-SeCtloll-R314 and CBC Sections907:2.11:4-arid-420:6:2: An eleetricalTermit-is~required €or--== -------- --
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 with the terms and cooditins of this statement
Owner (or Owner Agent's) Name:
CfiCQV
... ...... ...................... _..
Si nature.......Date:
Contractor Name:
U
Signature....................:...::........................................ Lic.#...................................... Date: ...................
Smoke and CO form.doe revised 03118114
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
CUPERT1IN10 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
408) 777-3228 • FAX (408) 777-3333 buildingt@cupertino,org )
Owner Name `�'e �t� 'e� Permit No. �' 201 {� - 17-1 V
Address fklma Auau a, , uo-'d in"o (14
Is your real property a registered historical site?
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
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.
— -- ----- SSkipthe-re-sfofthe-for4n-and-sib '�-bo
ott** ra-efr�rm:.-��».
IR No Go to Question 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.
® No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
El 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.
M 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:
El 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).
14 My property is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations orimprovements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
, '----On Err eforeJanuary 1 201'9 `ail fon=complidrrt'plu`rnbiftgfixtm-s-g1raH-be-repiaceA with -water--------
conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
improvements).
El 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 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 fixgs comply with the requirements as indicated in the
table on the followine Daae. ---- A A
Owner or Owner Agent's Signature: Date: (ra
Upon completing and signing this Certificate, Aease return it to the BAil4ng Division in order to final your building permit.
SB407 2015.doc revised 08126115
SMOKE / CARBON MONOXIDE ALARMS
19 OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
Address
(408) 777-3228 • FAX (408) 777-3333 * buildiPlgCa)-cupeitino.om
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
v
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
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: In dwelling units with no commercial power supply, alarm(s) maybe 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
'M1 space: ReferAoo-CRC Section -R314 and CBC Sections-907.2:11:4and 420:6 2k 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.
I have read and`a-qme to comply with the terms and cot7dikns of this statement
Owner (or Owner Agent's) Name:
s �
,(
Si nature._._ ✓Lr':1... .........:....:................:........ Date: ��..: !4
Contractor Name:
Signature........... ............................................. :. 1..... Lic.#...................................... Date: ....................
Smoke and CO form.doc revised 03118114
WATER -CONSERVING :PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE CUPERTINO, CA 95014-3255
�. (408) 777-3228 • FAX (408) 777-3333 + buildingCc_cupertino,ora e
Owner NamePermit No
AddressC! Cl
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.
(g 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. •
El The licensed plumber's certification has been provided to the Building Division.
-- -- Skip -the r -est of the -farm and=sign=bottom-of form: _ —— --
No Go to Question 3. T
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.
�K 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 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).
19 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, 20.19; -all non=compliant plumbing -fixtures shall be-replaped-with=water ,
conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
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- 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).
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 110 1.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's
installation requirements, and that the water -conserving plumbing fixture co ply with the requirements as indicated in the
table on the followingpage.
Owner or Owner Agent's Signature: Date: T— I4—"J(p
Upon completing and signing this Certificate, plkhse return it to the Build' g ivision in order to final your building permit.
SB407 2015.doc revised 08126115