B-2016-1343 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1343
10594 FELTON WAY CUPERTINO,CA 95014-4313(359 18 023) (BLUE HAVEN
BUILDERS)
CAMPBELL,CA 95008
OWNER'S NAME: VITOLS LYNNE C DATE ISSUED:02/10/2016
OWNER'S PHONE:408-832-8701 PHONE NO:408-205-5806
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#943069
Contractor(BLUE HAVEN BUILDERS)Date 02/10/2016 X BLDG _ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing _MECH 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:
REPLACE BATHTUB WITH ARCRYLIC SHOWER PAN OF SAME
I hereby affirm under penalty of perjury one of the following two declarations: FOOTPRINT IN SAME LOCATION. REPLACE SHOWER VALVE.
1. I have and will maintain a certificate of consent to self-insure for Worker's INSTALL 3 PIECE SHOWER WALL SET.
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
'r 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 is issued, Sq.Ft Floor Area: Valuation:$2500.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
information is correct.I agree to comply with all city and county APN Number: Occupancy Type:
ordinances and state laws relating to building construction,and hereby 359 18 023
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. / � ez� 't"
n Issued by:JA-2-f
".Signature Date 02/10/2016 Date:02/10/2016
OWNER—BUILDER DECLARATI N 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:
z. I,as owner of the property,am exclusively contracting with licensed Date:02/10/2016
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. 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
shall not employ any person.in any manner so as to become subject tthe air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Munici al ode,Chapter 9.12 and
Worker's Compensation laws of California, If,after making this certificate of the Health&Safety Code,Sectio 5505, 5 33,and 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, c, Date:02/10/2016
APPLICANT CERTIFICATION N TRUCTION NDING 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 1 understand my plans shall be used as public records.
Cupertino Municipal Code,Section 9.18.
Licensed
Professional
Signature Date 02/10/2016
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 1�
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 -
f
(408) 777-3228• FAX(408)777-3333 building
(a)-cupert!no.org
CUPERTINO
NEW CONSTRUCTION ❑ ADDITION15kLTERATION/Tl ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROSECT ADDRESS APN55
If m[ °
ONVNERNAME PHONE E-MAIL
AlAle
STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NA E E-MAIL
��� �PHONE- e
STREET ADDRESS CITY,STATE, ZIP FAX
❑OSVNER ❑ OWNER-BUILDER ❑ OWNER AGENT :CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME B��9 S LICENSE NUMBER LICENSE TYPE BUS.LIC
COMPANY NAME ` E-MAIL FAX J
v- e2 e—LV
STREETADDPESS CITY,STATEL ZIP ® PHO IE
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK ` 1
€ a e-e, /L ( fIlk, ae k-1 S-9
I ll °e
STING USE- -PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA -
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DEC&`PORCH AREA I GARAGE AREA: DETACH
❑ATTACH
r DWELLING UNITS: IS ASECOND UNIT ❑YES SECOND STORY [-]YES
-
BEINGADDED? ONO ADDITION? ANO
PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES yRECEIVED S1w TOTAL VALUATION:
PLANNINGAPPL# ❑NO PLAT�NINGAPPROVAL LETTER EICHLERHO. E'. ❑'0 � ��> ��u I:� �gs 1"
By my signature below,I certify to each of the following: I am the pI o erty oINvner or authorized agent to act on the property owner's behalf. I have read this
application and the information I�have�� c,t�c
tI hav eae Description of\�TDrk andverify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatingon. I a or representatives of Cupertino to enter the above-ide ioiied roperty for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INTFORD ATION REQUIRED y, �PI a cxECI.r1 rE,, ,,P xolrrll�c slzr y '` F
New SFD or Multifamily dwellings: Apply for demolition permit for �z
O�ER THE COII\TER BUILDI LG PLA\REQ IE\4
existing building(s). Demolition permit Is required prior to Issuance of bullding xix
r
permit for new building. l EaItEss2PA SIG Y�I`itE�?E�
� '. aI v3 „�,rar ��,,,�a �
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STAl�D�RD 1] PUBLIC-�oRis
b 3 a
form if any Hazardous Materials are being used as part of this project. LARCERE VEr
_Copy of Planning Approval Letter or Meeting with Planning prior to u
74L4JOR SA\ITR DISTRICT
submittal of Building Permit application. T
+ flrE\iIItO\A4ENTAi HEALTH
BldgApp_2011.doc revised 06/21/11
OMMO' URBO NI NOXIDE ARA M
OF COMPLIANCE F1
COMMUNITY DEVELOPMENT DEPARTMENT►BUILDING DIVISION
CUPERTIN`O 10300 TORRE AVENUE►CUPERTINO,CA 95014-3255
(408)777-3228®FAX(408)777-3333► buildinat7a.eupertino.or4
PF.R__WT CANNOT BE I±INAI,ED AND COMpLETEI)UNTIL THIS CERTIFICATE
OR ril G I)TV 81 r
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 h-L the following locations:
AREA SMOKE AAILARM 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 slee2ing 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 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 buildhLg 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 instm-dions an d i i2n comphlance with the.California Building.
annd Callifoinx is Residenbal Codes..The aurins have been tested and are operafiional as of fife date signed
below.
havar read_and a weer toterr 1 with,ifre,free r s and!ao d1fr.QnS of,tits statement
oatilte... .
_ .. ......... ..._..... ......... _,...... Date.= . . .,....
Contraci�rName:;
S:iggafuret._ _..LI, # GP Dail€l
306�
Sna.oke andiCOfoimz.doc revised.!037181T4.
WATER-CONSERVING PLUMBING FIXTURES Ron
NEN CERTIFICATE OF COMPUANCE Lt
Ct3A+4Md1M1TY t7ELOPMENT DEf'ARTMENT-'BULOING DIVISION fb53
1
CUPERTINO 10300 TORRE AVENt1E-CUPERTINO,CA,95014-3255 d
/` (408)777 3 8 'F (408)777-3333 p buiEd7tUg quaertino.o[g
Owner Name /Mlle b t c5 S Permit No,_ 4g 3
Address l p-S-g e/
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.
The licensed plumber's certification has been provided to the Building Division.
Ship the rest of the form and sign bottom of form.
No Go to Question 3.
3. Is "`water service permanently disconnected for your building?
gYes 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?
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.
E ! (,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. 'Dl-ase cheek 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),.
❑ 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 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 improveinents).
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 plummg fix res comply with the requirements as indicated in the
table on the following p age.
Owner or Owner Agent's,Signature;''_.J Dates i
Upon completing and signing this Certifieat ,please return it to the Building Division in order to final your build :g pe it.
SB407 2015.doc revised 08/26/15