B-2016-1418 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1418
7969 SUNDERLAND DR CUPERTINO,CA 95014-4913(36211014) (A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC)
MEMPHIS,TN 38120
OWNER'S NAME: BORTNER ELEANOR D TRUSTEE DATE ISSUED:02/23/2016
OWNER'S PHONE:408-253-0905 PHONE NO:408-982-0405
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO
License Class C-36.C-42&A Lica#765155
Contractor(A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA X BLDG —ELECT X PLUMB
JNA Date 02/23/2016 MECH X RESIDENTILAL_COMMERCLAL
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 JOB DESCRIPTION:
license is in full force and effect. INSTALL(N)2-WAY FOUNDATION CLEANO -
t
I hereby affirm under penalty of perjury one of the following two declarations: �
1. I have and will maintain a certificate of consent to self-insure for Worker's x
Compensation,as provided for by Section 3700 of the Labor Code,for the '?
performance of the work for which this permit is issued.
f ' 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
Sq.Ft F9'o4oreJ: Valuation:$2799.00
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 362 11 014
ordinances and state Jaws 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 PERMIT EXPIRES IF WORK IS NOT STARTED
harmless the City of Cupertino against liabilities,judgments,costs,and WITHIN 180 DAYS OF PERMIT ISSUANCE OR
expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will 180 DAYS FROM LAST INSPECTION.
comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18.
Issue
Da e: 23/2
Signature' y Date 02/23/2016
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of the installed without first obtaining an inspection,I agree to remove all new materials for
following two reasons: inspection.
1. 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 Signature of Applicant:
for sale(Sec.7044,Business&Professions Code) Date:02/23/2016
2. I,as owner of the property,am exclusively contracting with licensed
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:
2. I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will
2. I have and will maintain Worker's Compensation Insurance,as provided for maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
by Section 3700 of the Labor Code,for the performance of the work for which Health&Safety Code,Section 25532(a)should I store or handle hazardous
this permit is issued. material. Additionally,should I use equipment or devices which emit hazardous
3. 1 certify that in the performance of the work for which this permit is issued,I 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
the Health&Safety Code,Sections 25505,25533,and 25534.
Worker's Compensation laws of California. If,after making this certificate of ,
exemption,I become subject to the Worker's Compensation provisions of the
Owner or authorized agent:
Labor Code,I must forthwith comply with such provisions or this permit shall Date:02/23/2016 /�
be deemed revoked. CONSTRUCTION - NDINA ENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance
I certify that I have read this application and state that the above information is of work's for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws Lender's Name
relating to building construction,and hereby authorize representatives of this city
to enter upon the above mentioned property for inspection purposes. (Vile)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
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228• FAX(408)777-3333•buildindCc)-cupertino.org MISC
CUPERTINO Z016 Y/
PLUMBING [:1 MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS APN# -3 W/ Z
OWNERNAME P O E-MAIL
STREET ADDRESS CITY,STATE,ZIP Q ' FAX
L"
CONTACT NAME f/ �B�� PHOI� — E-MAIL
STREET ADDRESS23o CITY,STATE,ZIP 'T0Q' Vl 9 FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACTOR 1:1CON*TRACTORAGENT 22��❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENISE NUMBER. 1 S� LICENSE TYPE BUS.LIC# ,l
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COMPANY NAME , E-MAIL FAX
G� cry e�
STREET ADDRES r- Csv c-' iJ^ CITY,STATE,ZIP
W 1 PHO 6 U`l V
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROTECT IN ❑YES IS THE BLDG AN El-,,Es
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK A r
VDC) � c
TOTAL VALUATION: Q-7-L'OL Ci
By my signature below,I certify to each of the following: I am the property owner or authorized age onthe propertyowner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work andOFtEfy it is accurate. I agree to comply with all applicable local
ordinances and state laws relatilfg to building tion. I authorize re resentatives of Cupertino to enter the above-identified p o/perty for inspection purposes.
Signature of Applicant/Agent: "' Date:T�l l
SUPPLEMENTAL INFORMATION REQUIRED o
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MEPMiscApp_2011.doc revised 06121/11
WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO- (408)777-3228• FAX(408)777-3333' building okupertino.org M
Owner Name Permit No. 626 r
'77Address 9D2qjl
Please refer to the attached California Civil Code Sections 1101.1 1101.8 which are part of this'Certification form.
1_ 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.
Skip the rest of the form and sign bottom of form.
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.
No Go;to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
0 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..
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 improvements)..
UWe,the owner(s)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 page. 1
Owner's (or.Owner Agent's) Signature: c� h � Date: ✓ / b
SB4072015.doc revised 08125115
F
SMOKE / CARBON MONOXIDE ALARMS t a-
OWNER CERTIFICATE OF COMPLIANCE f , 2Q16
h�
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDINpIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO BY
(408)777-3228 FAX(408)777-3333•buildingcu ertinon` �___�
"`&Permit No. 6,20 0 6' j` l
Address " `7 SUMD6elAAM MV #of Alarms Smoke Carbon Monoxide:
PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE
} HAS BEEN SIGNED AND RETURNED TO THE BUILDING DIVISION
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
..___compjiancerwith 2013 CRC Section 8314,2013 CBC_Sect ons.420.6_and 907:2.11:2 where-no_interior-access-fox _-
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 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.
existingdwelling 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 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 agree to comply with the terms and conditions of this statement
Owner(Owner Agent)NXr)wej�_
l �t��r Si nature.... :"......... ...... ... a .h..................:..Date: d• /
Contractor Name:
leEge- .t c:. 12007—&'e- Signature......
Smoke and CO form.doe revised 03/14114