D-2016-0365mi
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: D-2016-0365
18840 TILSON AVE CUPERTINO, CA 95014-3653 (375 16 047)
OWNER/BUILDER
6733 CLIFFORD DR
OWNER'S NAME: SAHNI SANJEEV AND CHAWLA SEEMA TRUSTEE
DATE ISSUED: 03/11/2016
OWNER'S PHONE: 408-242-2154
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OWNER/BUILDER Date 03/11/2016
—BLDG _ELECT 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:
I hereby affirm under penalty of perjury one of the following two declarations:
REMOVE (E) SWIMMING POOL & FILL FOR FUTURE
CONSTRUCTION (90 % CERTIFIED COMPACTION)
r. 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
performance of the work for which this permit is issued.
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: $800.00
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
ordinances and state laws relating to building construction, and hereby
375 16 047
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 inconsequence of the
granting of this permit. Additionally, the applicant understands and. will
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
"comply with all non -point source regulations per the Cupertino Municipal
180 DAYS FROM LAST C INSPECTION.
Code, Section 9.18.
Issued by: MELI
Signature Date 03/11/2016
Date: 03/11/2016
RE -ROOFS:
OWNER -BUILDER DECLARATION
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
followitwo reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
ras 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: 03/11/2016
contractors to construct the project (Sec.7044, Business & Professions Code).
rm under pill enalty of perjury one of the following three declarations:
I hereb�7have
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
iand wmaintain 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. 1 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
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 to the
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, 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_ V v
be deemed revoked.
Date: 03/11/2016
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 understandmy plans shall be used as public records.
Cupertino Municipal Code, Section 9.18.
Licensed
Si maturer&MPtPPA/,6AJNZDate03/11/2016
Professional
LWA
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT •-BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 buildiniaCa?ct3p�riirlo.org
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PROJECT ADDRESS +� ��
OWNERNAME A-YV��Ci r gAfl PHONEI 215 E-MAIL
STREET ADDRESS6 7 33 r PF -v � � � CITY, STATE, A,oZIP � E_g�) � V (gA cA qs- , X
CONTACT NAME r PHONE
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STREET ADDRESS,
CA 'j.� I FAX
®�R ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPS-("' 13 TENANT
CONTRACTOR NAME lLICENSE NUMBER 7 LICENSE TYPE BUS. LIC #
COMPANY NAME E-MAIL FAX
STREET ADDRESS - _ CITY, STATE,. ZIP PHONE -
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS. LIC#
COMPANY NAME f� r E-MAIL FAX
STREET ADDRESS V CITY, STATE, ZIP - - PHONE -
DESCRIPTION OF WORK --
USE OF QAFD or Duplex ❑ Multi -Family TYPE MATERIAL TYPE (CODE) j AREA. (SQ. FT.) ,VALUATION ($)
STRUCTURE: ❑ Commercial POOL
`� S fit.., ,j9 Ei�'p ��.iCgf' I �-1.-- � � � `
POOL/SPA MATERIAL TYPE CODES: SP �' 0A k.° W i 1p VW)
V - VINYL -LINED /
F - FIBERGLASS E
G - GUNITE a C/
P - PREFABRICATED RECEiVEB BYa -�
'TOT IJ7A`�'I
By my signature below, 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 have read the Description of Work and verify it is accurate. I agree to comply with^all applicable local
ordinances and state laws relating to burg construction. I auth ze r presentatives of Cupertino to enter the above -identified ro rry for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
_ Commercial or Multi -Family Buildings with Public Swimming Pools:
Department of Environmental Health approval required.
SwimPoolApp_2011.doc revised 03/16/11
CUPERTINO
Oft NER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • buildina(8cuoertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
ITE ADDRES'e `
OWNER NAME � 0.. FR AD
DESCRIPTION OF WORK:
� L LE M t)Ar L—,? - V .C.i i
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We are providing you with an Ownet-Builder AckhoMedgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
UVVNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
41_�I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Kilder' building permit that erroneously implies that the properly owner is providing his or her own labor and material
personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
ins. urance coverage for injuries to workers on my property.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
arae instead of my own.
k---4. I understand Contractors are required b law to be lice
q y licensed and bonded In California and to fist their license
numbers on permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04114110
n 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
<<< Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, "
and the California Division of industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or wvrw.cslb.ca.gov for more information about licensed
contractors.
am aware of and consent to an Owner -Builder building permit applied for in my name and understand
am the party legally and financially responsible for proposed construction activity at the site address listed above. that I
1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers.
^2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information l"have"provided on this form. Licensed contractors are regulated by_.faws designed to protect.the..public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a. result of a complaint -Your only remedy against unlicensed
Contractors msy"be in civil court. If is also important for you -to understand that if an unlicensed Contractor or
employee of that individual or firm is injured .while working on your property, you may* be held liable for damages. If "
you obtain a permit. as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name:
Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's sianatura. A
Property Owner's Signature:
---- ------ ------ - ----------- ------------------------------ ----------------------------------------------------------------------
(NOTE: The following Au--thorization Form is required to be completed by the property owneronly when designating an
agent of the property owner to apply for a construction permit for the Owner-Suilder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which 1 understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and cer tfy its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature:
Date:
OwnerBuilderForm_2010. doc revised 04114110
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MUSTkept Vta—t t -b a
job site duririiconstruction. It is unlawfuFt—omake any
changes or alterations on same, or to deviate
therefrom, without approval from the Building Official.
The stamping
. , of this plan and specifications SHALL NOT
be held to pees n
approval of the violation
of o 1310 c �. , ^ity Ordinance or State Law.
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OFFICE COPY
C'UPERTINO
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(d)-cupertino.org
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
bedroom(s)
X
X
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 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.
have read and agree to comply with the terms and conditions of this statement
-Owner (oi OwnerA�gjent's) Name::
a �;
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Si nature ........ ........ ............................ D to �",'.. .............
-Contract,- Name:
V p LI L, �-Si
nature D ........... ............L1e i... ...................rDa�:..................
Smoke and CO form.doc remised 03118114
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wyt.i9ss
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-32.2$ • F 408) 7 7-3333 buildina(a_cupertino.or4 t
Owner Namei� `► V Permit Noll
Address ? L1 0 1 P '.
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.
g 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?
El 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?
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
1
No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
171 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.
f Yes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8apply. Check one of the three following statements and sign
bottom of form..
5. Please check ONE of the following:
EA 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 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).
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 page. a , < _
Owner or Owner Agent's Signature; A) DateY I Z z OXY
completing and signing this Certificate, please return it to the Building Division in order to final your building permit.
SB4072015.doc revised 08126115
American Soil Testing, Inc. — 0[ 0 f O
Soil, Foundation and Environmental Engineers T
2734 S. Bascom Avenue, San Tose, CA 95124
408-559-6400 - Fax 408-559-6688 www.americansoiltestin-inc.com
File No. 16-4001-P
April 19 2016:
Mr. Sanjeev Sahni
6733 Clifford Drive
Cupertino, CA 95014
Subject:
Gentlemen
Single family residence
18840 Tilson Avenue, APN:375-16-047
Cupertino, California.
Field density testing during backfilling
operations for abandoned swimming pool
Per your request, our firm has provided field density testing services during
backfilling operations for the above abandoned swimming pool.
We performed eleven(11), field density tests during backfilling operations in
accordance with ASTM Test procedure D2922-81 (Nuclear Method) at random
locations, different elevations and in finished grade. All pool's concrete rubbles
were removed from the pool cavity prior backfilling operations.
Summarized in Table I are the results of the field density tests performed by our
firm to date. To obtain the optimum moisture and maximum dry density for the
imported material we performed one -laboratory compaction tests in accordance
with ASTM D1557-12 procedure (Modified Proctor Compaction test).
h
File No. 15-3928-S
American Soil Testing, Inc.
We are pleased to have been of service to you in this matter. Should you have any
question or require additional information, please feel free to call our office at
your convenience.
Very truly yours,
American Soil Testing, Inc.
Ben Rahimi, MSCE, EP
Senior Project Engineer
Andrew A. Ghofrani, P.E.
R.C.E. # 38159
Expire: 3-31-17
California Code of Regulations, Title 16, Division 5,ff
,400.476
Article 1. General Provisions 411. Seal and Signature. (Partial) (e)
The Seal shall be capable of leaving an electronically -generated representation
on the documents. The signature may be applied to the documents electronically.
Please contact American Soil Testing if Authenticity is questionable: 408-559-6400
2
1314C PitQt
w
ICU FIL
4��..
California Code of Regulations, Title 16, Division 5,ff
,400.476
Article 1. General Provisions 411. Seal and Signature. (Partial) (e)
The Seal shall be capable of leaving an electronically -generated representation
on the documents. The signature may be applied to the documents electronically.
Please contact American Soil Testing if Authenticity is questionable: 408-559-6400
2
File No. 15-3928-S American Soil Testing, Inc.
TABLE
SUMMARY OF FIELD DENSITY TEST RESULT
ISoil Type &;
Test w Date of
Location # Water 'Moisture '0 ptimum? Dry Max ;Relative
Recomm
No. Test
w or :Content> Field Moisture =Density; Dry i Comp
Relative
` Remark
{ 8evation Field Lab { Field =Density,-
Comp.
d
Lab d
# 2016
Feet pcf (%) (%o) p� p� (%)
(% )
f
Native
1 4/5/2016
PC -NG-7' 12.80 12.18% f 14.50% 105.10 114.00 . 92.19%
900/0
Native
2 4/5/2016
A.415
PC-NG-41 14 25 13.67%o .25
14.50% 104114.00 * 91.45% `
_ ti a_ _. .. _r
90 %0
Imported
3 4/6/2016
PC-4' 1, 10 13 59% 13 00% 111 15 118 00 r 94 19%
900/0
Soil
M
_
Imported
4 4/6/2016
.,
PC-3.5' 16.25 15.01% 13.00% 108.25 118.00 91.741/0 ^
90%
Soil
{
a 4 e
r
Importe d
S 4/6/2016
k PC-3.5' 15 60 14.54% 13.00% 107.30:118 00 ; 90 93%
_
90%
i Soil
Imported
6 4/7/2016
PC-3' 17.20 .' 15.99% ' 13.00% 3 107.60 ;' 118.00 9119%,
90°/u
Soil
r _.r.......... ,
Imported _ s.
7 4/7/2016
' PC-3' 16.70 s 15.59% 13.000/. i 107.10 118.00 1 90.76% '_
_.
90%
Soil
.gym
-
Im ported
8 4/7/2016
y PC-2.51 15.90 14.900A 13.00% 106.70 1 118.00 " 90.420/.
900/0
Soil
Imported
9 i 4/7/2016 aN...-
PC-2.5'- 16.30 14.57% ,' 13.00% 111.90 ,} 118.00 94.83%
_..
90%
m_.
Soil
Imported
10 4/7/2016
PC-FG-1.5'- 17.90 16.45% 13.00% 108.80 ..` 118.00 92.20%
90%
Soil
r
Imported
11 4/7/2016
> PC-FG-1.5' 15.60 14.270/6 13.00% it 109 30 118.00 92.630/.':
900/0
Soil
�
3
a
,
5 �
5
s
PC -Pool Cavity
NG -Natural Ground FG =Finished Grade
�. . _ _=F ,
t
g ' Native = Light brown Silty Clay with fine gravel
f
Imported Soil brown Gravley Silty Clay.
VLight
s
3
Project:
18840 TilsonAvenue, Cupertino, California.
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