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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 SP to(6-vs�� 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 .. 9 (�j E -MA i --. dV)f1�vZiJ�22� 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 H 167zoE1& , G IME a� � v<': 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 A y 40 1 L ---5D VE N P:E r/ ltvo ( OA -Me - : ,\1 � A -H POOL F-69 FVICOP-E Det ------------ M A SLE I 11 3 4 I STINS �i N6- � APPROVED I This set 01 piqa is and speciflAbnabe 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. DATE PERMITNO. LAND AR ;U M X M (D M (D -n CL o W M 0 z 0 M 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 �; 22,1 1. � 6 Aft a !y Si nature ........ ........ ............................ D to �",'.. ............. -Contract,- Name: V p LI L, �-Si nature D ........... ............L1e i... ...................rDa�:.................. Smoke and CO form.doc remised 03118114 f 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. j i---'Pagel -: