B-2016-1250 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1250
18660 MEDICUS CT CUPERTINO,CA 95014-3821(375 26 008) (DEMPSTER.
PLUMBING)
SAN JOSE,CA 95110
OWNER'S NAME: BHAISA NINA F TRUSTEE DATE ISSUED:01/25/2016
OWNER'S PHONE:408-207-2651 PHONE NO:408-597-5877
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lie.#M0 g -1-5o% Ie-3�
Contractor(DEMPSTER PLUMBING)Date (/Z z�j X BLDG _ELECT X PLUMB
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:
Replacing(e)water main from meter to service tee.
I hereby affirm under penalty of perjury one of the following two declarations:
1. 1 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.
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. Sq.Ft Floor Area: Valuation:$2200.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN
information is correct. I agree to comply with all city and county Number: Occupancy Type:
37526 008
ordinances and state laws relating to building construction,and hereby 375
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 all non-point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION.
Code,Section 9.18. i
Issued by: 19 � "A-C"'
Signature Date a r�Z S Date:
OWNER-BUILDER 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(Sec.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. 1 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. 1 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
3. 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 Cupertino Municipal Code,Chapter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the-Health&Safety Code,Sections 25505,25533 nd 25534.
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 or authorized agent
be deemed revoked. Date: &((2510'
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is 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 APPLICATION MEP
10 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CUPlERTINO (408)777-3228• FAX(408)777-3333•buildinaColcupertino.org misc
R�'PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS i� [,y �. / 7APN#
OWNER NAME PHONEW Gk�G7 �& E-MAIL
STREET ADDRESS, / CITY,STA
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CONTACT NAME �// i/1 j� Q_ / // PHONE. Zo_/-2E-MAIL
STREET ADDRESS/V ' �/� CITY",,STATE, ZIP FAX
WNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
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COMPANY NAMEem / E-7 d pl U FAX J
STREET ADDRESS CITY.,,STAT�IP// � � PHONE-
ARCHITECT/ENGINEER
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COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OFD or DUPLEX ElMULTI-FAMILYPROJECT IN WILDLAND ElYES PROJECT IN ElYES IS THE BLDG AN ElYES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
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TOTAL VALUATION: -f2 2_6 0- G RECEIVED B
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on theC,,g-_ree
wn s behalf. I have read this
application and the information I have provided is correc. I ave r e Des nption of Work and verify it is accurate. to do with all applicable local
ordinances and state laws relating to build' g co c"on aut ri repr entatives of Cupertino to enter the above-id
r/_ for inspection purposes.
Signature of Applicant/Agent: Date: �I 2 ll�
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE,USE ONLY
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MEPMiscApp_2011.doc revised 06121/11
WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE IANC
COMMUNITY DEVELOPMENT DE-PARTMENT•BUILDING DIVISION
ClJl'"EEtTlhid3 10300 TORRE AVENUE-CUPERTINO,CA14
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)777= 8 FAX{4 $) 77-333A,-buildinvCQ?cupertino.org
Owner-Name AV ' �. Permit Nod
AddressMz
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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.
:'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 rest of the form and sign bottom of form.
IXNo Go to Question 3.
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.
7'10,
1 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.
ETV-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. Ple4se check ONE of the following:
_1 blrM roe is asingle-familyresidential real roe See Civil Code Section 1101.4.
��_...� � y property rtY� property.m'•
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 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 Janizary 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 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 a e. g g „! �►
Owner or Owner Agent's.Signature. f®' Dat ) 0.J I b
Upon completing and signing this Certificate,please return it to the Building Division in order to final.your building permit.
SB407 2015.doc revised 08126115
OKE I CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE FIL f*7'
POLan5
COMMUNITY DEVELOPMENT DEPARTMENT>BUILDING DIVISION 6jjI
CUP T' O 10300 TORRE AVENUE s CUPERTI'NO,CA 95014-3255 16
(408)777-3228 a FAX(408)777-3333•buildin4(a.cupertino.org
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Arar—kiW_S-1116ke:
PERMIT CANNOT RE I INALED AND COMPLETED UNTIL THIS CERTIFICATE
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 INIFORMATION
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 X X
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 da
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 8314 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 cf the above-referenced property,I hereby certify that the alarm(s)referenced above has/have been
installed.accordance with the rnanufacturer's instructions and in compliance with the California Build in,
and Califonua Residential Codes.The alarms have beeil tested and are operational, as of the date signed
below.
1 have read_and,a red to com_1,_with:the ter."ms and conditions.of this statement
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Shzoke andOgfibimt.kc remised 03%1'8114