B-2016-1460 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1460
21911 HERMOSA AVE CUPERTINO,CA 95014-2863(357 16 136) (TATS INC)
MISSION HILLS,CA
91346
OWNER'S NAME: FELDMAN J SAMUEL AND JAN L TRUSTEE DATE ISSUED:03/02/2016
OWNER'S PHONE:408-398-0264 PHONE NO:817-691-2782
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 Lia#867625
Contractor(TATS INC)Date 03/02/2016 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 WATER LINE FROM WATER METER TO FOUNDATION
I hereby affirm under penalty of perjury one of the following two declarations: WITH V COPPER
r. 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.
z. 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
I this permit is issued. Sq.Ft Floor Area: Valuation:$5300.00
APPLICANT CERTIFICATION
I 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 357 16 136
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 CALLS INP ION.
Code,Section 44.
Issued by:ALEX VALLELUNGA
Signatur Date 03/02/2016 Date:03/02/2016
OWNER-BUILDER DECLARA ION 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
r. 1,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:03/02/2016
contractors to construct the project(See.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. 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
a. 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 to the air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Mumci al Code,Chapter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Cod=tio55
5533,and 25534.
exemption,I become subject to the Worker's Compensation provisions of the
Labor Code,1 must forthwith comply with such provisions or this permit shall
1 authorized ag
be deemed revoked. Owner or
Date:03/02/2016
APPLICANT CERTIFICATION CONSIR ONNDI G A EN
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 03/02/2016
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
{40 )-777-322$• FAX(408)777-3333 building(c)cuoertino.oramisc
CUPERTINOPLUMBING ❑MECHANICAL [:]ELECTRICAL ❑MISCELLANEOUS �� (ill(lY 1 Y&O
PROJECT ADDRESS ���i � � � APN#
OWNER NAME j 0 per/ 2 i (f
✓` 1 �`�rJ/hl+'V\J PHONE/1cO� 02M E-Mgli. �1
STREET ADDRESS �y a a P �n` � CITY,STATE,ZIP (�/r(,/�'F7�� f� �y` _' FAX
CONTACT NAME fb G/f JC(r�
tlf''IAV b��Li PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ mvi- R-BUILDER ❑OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT E3 ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME - LIrF* r ^^ ^r^
_ LICENSE TYPE BUS.LIC#
q U� C s 6�6 ZS" �3 Z3
COMPANY NAME1 o E-MAIL FAX
STREET ADDRESS �-7 �8 �� CITY,STATE,ZIP / �t � � I PHONE
ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS.LIC# Z L
COMPANY NAME E-MAIL FAX )
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SED or DUPLEX ❑ MULri-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS TBE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑.NO
DESCRIPTION OF WORK
tom' 4V
777
TOTAL VALUATION: a � RECEIVED I3Y„
By my signature bel+ ,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I ave read die Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to b. d b co c" autho ' presentatives of Cupertino to enter the above-i entyied property for inspection purposes.
Signature ofApplicant/Agent: Date: 3,111,1
PPLE EN AL INFORMATION QUIRED
qFFICg USE ONLY
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A7EPMiscApp_�011.doc revised 06121/11
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
+CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228• FAX(408)777-3333• building Wcupertino.org ii/-
`�� a hermit:.o ®I 6
1 Addr-ess —i ' 1� i1 CEJ #ofarms Smoked
. Carbon 1Glonoxde
( ®
PERMIT-CANNOT BE MALED AND COMPLETED UNTIE,THIS`CERTIFICATE
HAS.BEEN IIT { AHD Tial .�D TO THE BUiLDIN+GDIVISIOi`+T..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.
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, CLIC 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 tmits 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 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(o('OwnerA�ent's Name:V j �� �� a�/
F�l .n �...... ....... . G
nature...... ! .. Date +..................
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Smoke and COform.doc revised 03118114
WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT.BUILDING DIVISION
CUi'ERTlNO 10300 TORRE AVENUE CUPERTINO,CA 95014-3255
(408) 77-3228 e FAX(408)777-3333•building(d)cupertino.org OwnerName J PermitNo,. &T) lb
Address
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.
Skip the rest of the form and sign bottom of form.
I ❑ 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.
F,0 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.
0XYes 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:
/l 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).
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 wat r-con ruing plumbing fixtures comply with the requirements as indicated in the
table on the following page.
Owner or Owner Agent's Signatur Daie: f
Upon completing and signing this'lCeltificate,please return it to the Building Division in order to final your buldin ermit.
SB4072015.doc revised 08126115