B-2016-1546 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1546
10162 ALPINE DR CUPERTINO,CA 95014-0942(326 15 023) CHAMPION
PLUMBING PRO'INC
SAN JOSE,CA 951.12
OWNER'S NAME: ROOK ANN LAND JOHN M TRUSTEE DATE ISSUED:03/16/2016
OWNER'S PHONE:408-253-8533 PHONE NO:(408)437-1507
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#767547
Contractor CHAMPION PLUMBING PRO INC Date 12/31/2017 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 MAIN TO HOUSE
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
Compensation,as provided for by Section 3700 of the Labor Code,for the
�performa e-of the work for which this per nut is issued,
e 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:$2800.00
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 ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 326 15 023
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 expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against.said City in cons quence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understa ds and will comply with all non-point
source regulatio s er0t, upe o Municipal Code,Section 9,18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature 1 Date 3/16/16 Issued by:ABBY AYENDE
Date:3/16/16
OWNER-BUILDER DECLARATION '
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for I inspeption.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: _
contractors to construct the project(Sec.7044,Business&Professions Code). 'Date:3/16/16
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
s. 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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will"maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. i will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
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 Cuper'no Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Se"io 5505,255!X3 ,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. �i
.Owner or authorized agent: e
APPLICANT CERTIFICATION -Date: /3 16/16 e
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.1 agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
I Code,Section 9.18, 1 understand my plans shall be used as public records.
Licensed
Signature Date 3/16/16 Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 MISA06,
CUPERTUN0; (408)777-3228• FAX(408)777-3333•building(d)cupertino.ong
PLUMBING WCHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS
4� APN
ora
PHONE .,. c9 �.r.� E-MAIL
STREET ADDRESS �i CITY,STATE,ZIP
Q � FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FA3i
❑ OWNER ❑ O"AWER-BUILDER ❑ MWERAGENT CONTRACTOR ❑CONT.RACTORAGENT ❑ ARcHrrFCT ❑ENraiNTEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NA L10EJ�TSE NUMBE� LICENSE TYPE BUS.LIC
COMPANY NAME E
ozzo
STREET ADDRESS CITY,S E,ZI
ARCHITECT/ENGNEER NAME LICENSE NUMBER V BUS.LIC 4
COMPANY I TTAME E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF FD or DUPLEX MULTI-FAMILY PROJECT IN IVILDLAN'D ❑ YES PROJECT IN ❑'ITS IS THE BLDG AN ❑YES
BUILDL11e'G: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE NO EICHLER HOME? NO
DESCRIPTION OF WORK
6
TOTAL VALUATION: -v RECEIVED BY a i +
V�J r
By my signature belov,I ce�rhfy ch o ffi following; I ai e property owner or authorized agent to act on the property own is beh lf. I have read this
application and the information I have vide is correct. I e read the Description of R7ork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bf-d' g onstraction. uthoiize representatives of Cupertino to enter the above-identi d prop7ty for inspection purposes.
Signature of Applicant/Ageut: t Date:
SUP LEMtNTAL INFORMATION REQUIRED
''CEUSE
;? �r _, dl ER'-'TPIE COUI\TER
IPM
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❑ EAPRESS�x� <,_,,,:
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STANDARD �`, '
s3ARGEF
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A'IAJOR
AIIEPAIIiseAppjOl Tdoe remised 06121/11
F1
WOKE/C,ARSO `1,0NO D ALARM
OWN
l t , OF COMP LIANCE
tlltliltlNITY r)EVE ONENT-PkPARTKENTiBUILDING IDIVIS IO
l) 1 10200 TORRE AVENUE--G13i'1"qTINO,CA gi5of4.3266
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This affidavit is a self-cerlifieaUM for the required Smoke and Carbon Monoxide Alarms for
Cornpliatee With 2013 CIBC Section R314,2013 CSCSectiorts 420.6 aild 907.2.11,2 whorc no anterior access for
inspectiUxts aae rediµired.
G NERAIINIFOR 1A.'I'TOt+i.
BxistiRgsingle.family and 1-riullz family d%rellings shall lre.provided iitlr Statol Alarms and Caxlrttxt
Monoxide alCirnts. When the valuation of additions,al#e�4ariraxts;err repairs to istiul;dwelling rrxtits exceeds
a100II.rlo,CRC Section 8131=1 arid CBC:Sections 9072.11,5-tx�d 42El f require that Sm6k Alarms and/or Carbon
Monoxide Alar be instal led int the.foljo3 vittg locations
AREA ...__ sitxi AIz CO
Outside of each separatesiKping a're l in llae ix>ktaraedi ate i icaJ� "t1 f tits
I>edrtram{sl
On ever leNel Df a dlvell!ng uxtitirtelri�tira ivasi�rrtertts T
HxineadtsleoPh? rgctux X
Carbeaxt Monoxide alarnxs are not regvired,111.dwellings 1�1*dch do riot for,talar fuel-burni3tg xppl lxanc4s and That
<loncx#have ttt attached,garage,.,Carbonrnonoxdcalarmscombined.ivith-,sn-toke.alarmsshallcaniptyv+rith
Gll oetir�rr ?0; and shalt be aha_proved bar the.Office of the State-Fire mazsha1.
i'otvea SupialEf In cltvellttta uni#s tt i#l,.no csatx mereral Pcv*r supply,alarsn(s)may be solely battery eaperat�c,
Ira exiting dwelling units,alarms<'are perm-fitted to be soleal batterar operated'Where repairs os rl#eraFions do
not result itt the removal of Wall anti ceilang fiaghr,s or,there is no access lel means of attl�l�asc�raaeza#.or crawlapace,Refer to CRC Section 1634 and CIBC Section 007 2.x71,4 sand 4,20.6.2..A n electrical laeinlit is required for
al"in'Which:ttLust be connerted to the buJi dins Ivitxnt;
As*wnerof the alacrvetra ferencecl}xr4partlr I Itor bl�cerft(}
that the alarm srefeixtstaileit aec rW5oed above xrs/#avt burrol [ � tstruetij .
rind it,earn�al%�tner tr itlk the Cal fotnia l3uilrl ng
anti C ItEcsrraia I�oslc7ertteat Coders. the a(at rtq have;been tested anti Etre operational,as of the dajL stated
belov,=,
t have;mad vii a,rse Icr omg! k�ira fh torrxas aiad cflflrl!#lbns ef}fri5 latenxarat
anc�ror-�atlef�,r rzl'�fiFaxr�; �;
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