B-2016-1345 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1345
21536 MONROVIA ST CUPERTINO,CA 95014-4804(356 23 019) (REBOZZI INC)
SAN JOSE,CA 95123
OWNER'S NAME: SHRIVASTANA SAURABH AND SRIVASTAVA PRIYANKA DATE ISSUED:.02/11/2016
OWNER'S PHONE:650-544-6168 PHONE NO:408-229-9689
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class.B Lic.#747473
Contractor(REBOZZI INC)Date 2111/2016 X BLDG _ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9:(commencingMECH X RESIDENTIAL_COMMERCIAL. — —
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
INSTALL(N)3/4 GAS LINE FROM GAS METER TO(N)RANGE-
I hereby affirm under penalty of perjury one of the following two declarations: LENGTH 30'
s. 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
4 performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance,as provided for,
f by Section 3700 of the Labor Code,for the performance of the work for which
I T this permit is issued. Sq.Ft Floor Area: Valuation:$1200.00
if APp7 ICANT CERTIFICATION
certify that 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:
356
ordinances and state laws relating to building construction,and hereby 356 23 019
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-p the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION.
Code Section 9.1.8,
1' P
Issued by:PAUL O'SULLIVAN "
Signature Date 2/1112016 Date:2/11/2016
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
installed without first obtaining an inspection,I agree to remove all new materials for
following two reasons:
inspection.
i. 1,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) Signature of Applicant:
2. I,as owner of the property,am exclusively contracting with licensed Date:2/11/2016
contractors to construct the project(Sec.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three declarations:
i. 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
Health&Safety Code,Section 25532(a)should I store or handle hazardous
this permit is issued.
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 snag meat District I
shall not employ any person in any manner so as to become subject to the will maintain compliance with the Cupe
Mur Code, ha r 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Seed 25505, 533
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:2111/2016
APPLI ANT 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 Lender's Address
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally,the applicant I understand my plans shall be used as public records.
understands and will comply with all non-point source regulations per the
Cupertino Municipal Code,Section 9.18.
Licensed
Professional
Signature Date 2/11/2016
- GENERAL PERMIT APPLICATIONMEP I
' CONfh4UNI TY DEVELOPMIENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228• FAX(4-08)777-3333•buildinVa CUDeliinO.org
CUPERTINO
l_ LUI> BI1NG ❑MECIia.1\?IC.kT— ❑ELECTRIC?s. \❑nhaSCELLAaNapOUS
PROTCT ADDRESS „� I APN' ��� �'►di ��� I
OSHTERNAJIJ_'e, � ,��Ie-- ✓ f�j �' I P�3O. /•f` /-'�/' fi.IJa;II,
STR ET.DDP.ESS / i✓`61tf l 7 I CITY, SATE,ZIP FAX
CONTACT N-4JE 1, P?0 5� la�I EtJaLT
CG.
STREET A.DDR SS CITY,STATE,ZIP ( FAX
OF?.M ❑ O`NEER-BUII.DER ❑OR'I.°r�E.t AGENT XC0I`TI?.4CTOR 71 COIdMACTOR AGI :T ❑ ARCHITECT ❑ENGL SER ❑ DEG]ELOPER ❑ i'cl Sh7
CONTRACTORTA%E: LICE SE UbBER - f` 7, I LICENSE I BUS.LIC
C0IJiPkw. AME fs FAX
STILETA.DDRFSS CITY,STAT Z P I Pn0'E
16� e I '41
ARCIETECTEEN GjK ERNARJE I LICENSEN•UI$BER I BUS.LIC-
C0MPA.h'YNAM I E-I�II I FA.?
STREET ADDRESS I CITY,STATE,ZIP I PHOKt
USE OF ❑SFD or DU-PLF: ❑ 1,6ULTI-F.SEGI.Y I.PRo3-ECT IN wII DLAIM ❑ 1'FS I PROuCT LN ❑ YES I IS THE BLDG ANI ❑ ti_S
Bu-TT.�.U'DG: ❑COj'0'uTCIAL U.RBANIINTERFACEARZA ❑..TO FLOODZO?i3 ❑I:0 ❑ NO
DESCP.IFTIOIQ OF 1FORK
'N4"
c
o -
oll
�d� `9t� RtCFI� D�1 s
TOTAL VALUATION:
By my signatuue below,I certify to each of the following: I aLn` crop S oWner or authorized anent to act on the pro_erty owner's behalf. I have read this
application and the infornation I have provided is correct. I ha ad he D s ion of 5'�ork and verfy it is accurate. I agree to comply with all applicable loca'
ordinances and state laws relatl�g to building copstriction. I at ho ' ere e entad of Cupertino to enter the abo% •i ntifed propel y for inspection purposes.
Sig�att:re of 3 pplicanJ",cent: Date:
r .
_ SUMP PLEDIIENTAL T'FORMATIONT REQUIRED y of ICE I sE�nL 5
n�4
y
x r �
Z u .` g _
-
g
_--
h.1E1?A?isc 4vp_?011.aoc remised 06121111
CITY OF CUPERTINO B906
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 21536 Monrovia St DATE: 02/11/2016 REVIEWED BY: PAUL
APN: 35623019 BP#; *VALUATION: $1,200
�'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition /Repair
PRIMARY
SFD or Duplex PENTAMATION 1RPGAS
USE: PERMIT TYPE:
WORK INSTALL N 3/4" GAS LINE FROM GAS METER TON RANGE- LENGTH 30'
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Piping, Gas <=4 Outlets 1PGASRES 1 # $72
TOTALS:
$72.00
A,o . ?st,<{i C'F;. .. Plumb.Plan Check 0.0 hrs $0.00
.kf<.<.F,.z'r r a.c.t<... Plumb.Permit Fee: 7PP'ERNIIT '?£ t'. a,t
zi he -t- ;:. hup Other Plumb Insp. 0.0 hrs 1 $48.00 . „ ,_..
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 prelimina.. information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 11-05LL&7'1;'13) FEE QTY/FEE MISC ITEMS
°lug £' ,
PME Plan Check: $0.00
PME Unit Fee; $72.00
PME Permit Fee: $48.00
Administrative Feer ]ADMIN $45.00
Work Without Permit? 0 Yes (F) No $0.00
Travel Documentation Fee: iTRAVDOC $48.00 r
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Ite
BldL7 Stets Commission Fee: IBCBSC $1.00
[7BT TALS; $214.50 $0.00 TOTAL ITEE; $214.5
Revised: 1/2016
OWNER CERTIFICATE OF COMPLIANCE
F1 - E
' COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION - —�
CUP RTINO 10300 TORRE AVENUE CUPERTINO,CA 95014-3255 J
(408)777-3228 FAX(408)777-3333•building(cDcupertino.org
� �l�one•
PERMIT
CANNOT
IRE
1p�@TIl`�ALED AND Clyl`�PLET`EDUN'yT•rpI75e.�+,�,TRIS
!��q�CERTIFICATE
LJW �E1.L'.` A �� 9 +!. Vj1./Al. .!./ '4 H
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.
GEN,ERAL 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 SMO°KE ALARM Cot 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 in 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 Mh the,removal of wall and ceiling,finishes or the e is no access by means of attic,basement or crawl.
space.Refer to CRC Section R314 and CBC Sections 9017.2.11.4 and 42.0..6.2_An electrical permit is required for
alarms which must be connected toc the building wiring.
As owner of the above-referenced property,I hereby certify that the alarms)referenced above has/have been
installed In accordance with the manufact,�,rer's instructions and in compliance with the California Building,
and Calftonnza Residential Codes.The alarms have been tested aind are operational,as of the date=signedt
bellow.
b have readpnd a' geat&cam' t L wrfh ths,ter ;s andf condrdiuns of this statemer
--....... ..... . .... 3�aie .
�o�Ga�to�;�larne: �
:
' Y
S' natu [j ?......
Smoke acid CO'fbr-ni doc revised!03/L!8/1i4,
WA"D"ER-CONSERVING PLUMBING FIXTURES
mo OWNER CERTIFICATE OF COMPLIANCE FILE
COMMUNITY DEVEW'AN'EUT DEPARTMENT-BUILDING DIVISION � 3
U I TtbttCT 1V1X TORRE AVENUE e CUPERTINO,CA95014 3255
(408)7 77-3228•FAX�A08)777-3333 o bui6dina�iipertino.ora
Owner Nam SAV�Ai 71 S�KovA s v Permit No,
Address - Z S36 '+`'D f_®\fled �S T CyPC–Ki-/quo/ C& et X6141
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.
E5,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?
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 form and sign bottom of form.
E5-No 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.
L-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.
es 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:
QI–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).
❑ Mypropertyis 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. January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing:f mtures 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.
Owner or Owner Agent's.Signature{' r �' Date: 3 (��'16
Upon completing and signing this Certificate,please return it to the Building Division in order tol final your building.permit. '
SB407 2015.doc revised-'08126115
Flash The following person has successfully completed the FlashShield TM
Certification Tranng Program and is recognized by as a
Qualified installer
RONNIE SMITH ONLINE COURSE'
Name Instructor
REBOZZI CONSTRUCTION 15-MAR 2016
Company Issue Date
Valid for 90 Days from Date of Issue
19621-1864541-239798
Certificate No.
Authorized to purchased and install 1-800-662-0208 / www.gastite.com
FlashShield TM Flexible Gas Piping