15120159CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS.: 21355 RUMFORD DR
CONTRACTOR: YANG AYFANG E AND
PERMIT NO: 15120159
'
DIANA S TRUSTEE
OWNER'S NAME: YANG AYFANG E AND DIANA S TRUSTEE
21355 RUMFORD DR
DATE ISSUED: 12/17/2015
OWNER'S PHONE: 4082553645
CUPERTINO, CA 95014-1335
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
ADD 243 S.F. TO CREATE (N) DINING ROOM
License Class Lia #
Contractor Date
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 license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
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
Sq. Ft Floor Area:
Valuation: $30000
performance of the work for which this permit is issued.
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.
APN Number: 32641047.00
Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
WITHIN ISD DAYS PERi3T SUANCE OR
j5
�T
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAY " CALLED INS ECTION. "
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
Date:
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
RE-ROOFS:
All roofs shall be inspec prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Of OWNER-BUILDER DECLARATION
I hereby affirm that I am :exempt from.. the Contractor's License Law for one of
Signature of Applicant: Date:
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, 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 for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code;"Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cu ertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 2 05, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
f
�'
Owner or authorized agent: � . Date: `
permit is issued.
/ /"
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's -
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097; Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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 ordinances and state laws 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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
-
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with ail non-point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature DateLLJ
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: 15120159
21355 RUMFORD DR CUPERTINO CA 95014 (326 41 047)
QUALITY GENERAL
CONSTRUCTION CO
INC
SAN FRANCISCO, CA
94112
OWNER'S NAME: YANG AYFANG E AND DIANA S TRUSTEE
DATE ISSUED: 12/17/2015
OWNER'S PHONE:
PHONE NO: (415) 336-5657
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic. #990912
Contractor QUALITY GENERAL CONSTRUCTION CO INC Date 02/28/2018
—BLDG _ELECT _PLUMB
MECH RESIDENTIAL _ COMMERCIAL
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
license is in full force and effect.
JOB DESCRIPTION:
ADD 243 S.F. TO CREATE (1) DINING ROOM
I hereby affirm under penalty of perjury one of the following two declarations:
1. { have and will maintain a certificate of consent to self -insure for Worker's
ompensation, as provided for by Section 3700 of the Labor Code, for the
rformance of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance, as provided for by
Labor Code, for the of the work for which this
ection 3700.f the performance
permit is issued.
Sq. Ft Floor Area:
Valuation: $30000.00
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
326
326 41 047
and state laws 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 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 consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulations r the Cu ino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
i,
/jam%6
Signature Date a l �/
Issued by: Phuong Devries
f
Date:
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
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
inspection.
sale (Sec.7044, Business & Professions Code)
z. 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:
I hereby affirm under penalty of perjury one of the following three 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
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.
3. I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the
Worker's Compensation laws of California. If, after making this certificate of
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
be deemed revoked.
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 ordinances and state laws
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 harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Signature Date
COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupert' o Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sectio s 2 05, 25533, and 25534.
Owner or auth7n-r745:Date: s 1� / �UCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
understand my plans shall be used as public records.
I Licensed
-- CONSTRUCTION PERMIT APPLICATICQN
COMIMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300TORRE AVENUE • CUPERTINO, CA 95014-3255 -9B
CUPERTINO, (408) 777-3228 • FAX (408) 777-3333 • buildino aOcupertina.orq
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DESCRP T IOI<' OF Woo K
AT P A WXtu`i�21 IZa�
EJOSTLNGUSEI FROPOSED USE CONSTR TYT3 ' STORIES
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USE I TYPE OCC.
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By my signature below, I certify to each of the follo- ing: I am the property mkmer or authorized agent to act on the property owmer's behalf. I has e req this
application and the information I have provided is co„ ect. I have read the Description of Work and verify it is actuate. I agree to -comply with all applicable local
ordinances and state laves relating to buildin 0 st, ctio I authorise representatives'of Cupertino to enter the above- nenjjtiaa"ed property for inspection purposes.
Signature of Applicmt/Agent: _ Date: ff X1171/-e—
SUPPLEl,?TTL IiI3 ORMATION REQUIRED_IF
-PI�CEO CK1YEs .1
_:- -
==OLTLNGSL)a
_ New SFD or Multifamily d-vvellings: Apply for demolition perm it for
existing building s). Demolition is required to issuance buildi'a
_ _rm`
BITIILDL�GTL�R 12E�Zr tY
OAR TECOL�TER r
permit V 1 prior of
permit for -new building.
I--Jj E n
LD pI �.�,zh PL zEF§
_ Cornir_ercial Bldg: Provide a con-pletcd Hazardous Materials Disclosure
for -m if any Hazardous h/Laterials are being used Dart of this project.
Copy of Planning Approval Letter or Neetlpg with Plannislg prior to
�
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submittal of Building Peirrmt application.
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BidgAP.p_2011.doc revised 06121/II
ii
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21355 RUMFORD DR DATE: 12117/2015 REVIEWED BY: MELISSA
APN: 326 41 047 BP#: *VALUATION: [$30,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY
USE. SFD or Duplex 2nd Unit? 0 Yes No PENTAMATION 1R3SFDADD
OTC? 0 Yes @No PERMIT TYPE:
WORK [ADD 243 S.F. TO CREATE (N) DINING ROOM
SCOPE]
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR.
7--
R-3 (Custom) 11-Bj11-B,IV,V-B 243 $1,091.00 IADDPLCK $1,05-7-0_0 IADDINSP
A
TOTALS: 243 $1,091.00
$1,057.00F
NUI E: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These tees are haled an the nrPliminary infnrmafinn availahle and are nn1v an estimate_ Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff'717113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$1,091.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl.. PC Fee: (F) Reg. 0 OT I
_00
I hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,057.00
Suppl. Insp. Feer Reg.
0 OT"00
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit FTee:
$0.00
Con 'rueflon. 41x:
0
G
Work Without Permit? 0 Yes No
$0.00
Advanced Planning Fee:
IPLLONGR
$34.02
Select a Non -Residential
Building or Structure
E)
0
Strong Motion Fee:
IBSEISMICR
$3.90
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$2.00
.. ....... .
$2,187.921
$0.00 t C3TAL EES.
$2,187.92
Revised: 10/01/2015
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS:
PERMIT #
OWNER'S NAME:PHONE
#
GENERAL CONTRACTOR:
BUSINESS LICENSE #
ADDRESS:
CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBC TRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: 9A/'_�a Z
Signature liate
Please check applicable subcontractors and complete the following information:
V
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
Date
it
CALGREEN RESIDENTIAL CHECKLIST - MANDATORY
ITEMS t
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
CUPERTINO ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingQcupertino.org �
PURPOSE:
The 2013 CalGreen Code applies to additions or alterations of existing residential buildin s where the addition
or alteration increases the building's conditioned area, volume, or size and also applies to all new low-rise
residential buildings, high-rise residential buildings, or both. Existing site and landscaping improvements that
are not otherwise disturbed are not subject to the requirements of CALGreen.
Project Name
Project Address
Project Description:
Instructions:
XkV GI I1 49 P1 T! a -2.j
2 3 ,S -I^ lQ a D DY 4,a
a�,W &DJC/ Ti --,-J 6-;-r '> iA j
1. The Owner or the Owner's agent shall employ a licensed professional experienced with the California
Green Building Standards Codes to verify and assure that all required work described herein is properly
planned and implemented in the project.
2. The licensed professional, in collaboration with the owner and the design professional shall initial Column
2 of this checklist, sign and date Section 1 - Design Verification at the end of this checklist and have the
checklist printed on the approved plans for the project.
3. Prior to final inspection by the Building Department, the licensed professional shall complete Column 3
and sign and date Section 2 - Implementation Verification at the end of this checklist and submit the
completed form to the Building Inspector.
%jrriut: (;()py
Page I of 5 CalGreen 2014.doc revised 11/04/14
Column 2
Column 3
MANDATORY FEATURE OR MEASURE
Project
Verification
Requirements
A4.1 PLANNING AND DESIGN
Planning and Design,- Site Development
4.106.2 Storm water drainage and retention during construction. A plan is
developed and implemented to manage storm water drainage during
construction.
4.106.3 Grading and paving. The site shall be planned and developed to
keep surface water away from buildings. Construction plans shall indicate how
L
❑
site grading or a drainage system will manage all surface f
%jrriut: (;()py
Page I of 5 CalGreen 2014.doc revised 11/04/14
General
4.201.1 Low-rise residential buildings shall meet or exceed the minimum
El
standard design required by the California Energy Standards.
A4.3 WATER EFFICIENCY AND CONSERVATION
Indoor Water Use
4.303.1 Water conserving plumbing fixtures and fittings. Plumbing fixtures
(water closets and urinals) and fittings (faucets and showerheads) shall comply
with the following:
❑ 4.303.1.3.2 Water Closets. The effective flush volume of all water closets
shall not exceed 1.28 gallons per flush. Tank -type water closets shall be
certified to the performance criteria of the U.S. EPA WaterSense
Specifications for Tank -type Toilets.
❑ 4.303.1.3.2 Urinals. The effective flush volume of urinals shall not
exceed 0.5 gallons per flush.
❑ 4.303.1.3.1 Single Showerheads. Showerheads shall have a maximum
flow rate of not more than 2.0 gallons per minute at 80 psi. Showerheads
shall be certified to the performance criteria of the U.S. EPA WaterSense
Specification for showerheads.
❑ 4.303.1.3.2 Multiple Showerheads serving one shower. When a
shower is served by more than one showerhead, the combined flow rate of
all showerheads and/or other shower outlets controlled by a single valve
shall not exceed 2.0 gallons per minute at 80 psi, or the shower shall be
designed to allow only one shower outlet to be in operation at a time.
❑ 4.303.1.4.1 Residential lavatory faucets. The maximum flow rate of
residential lavatory faucets shall not exceed 1.5 gallons per minute at 60
psi. The minimum flow rate of residential lavatory faucets shall not be less
than 0.8 gallons per minute at 20 psi.
❑ 4.303.1.3.2 Lavatory faucets in common and public use areas. The
maximum flow rate of lavatory faucets installed in common and public use
areas (outside of dwellings or sleeping units) in residential buildings shall
not exceed 0.5 gallons per minute at 60 psi.
❑ 4.303.1.4.3 Metering faucets. Metering faucets when installed in
residential buildings shall not deliver more than 0.25 gallons per cycle.
❑ 4.303.1.4.4 Kitchen Faucets. The maximum flow rate of kitchen faucets
shall not exceed 1.8 gallons per minute at 60 psi. Kitchen faucets may
temporarily increase the flow above the maximum rate, but not to exceed
2.2 gallons per minute at 60 psi, and must default to a maximum flow rate
of 1.8 gallons per minute at 60 psi.
4.303.2 Standards for plumbing fixtures and fittings. Plumbing fixtures
and fittings shall be installed in accordance with the California Plumbing Code,
El
and shall meet the applicable standards referenced in Table 1401.1 of the
California Plumbing Code.
Page 2 of 5 CalGreen 2014.doc revised 11/04/14
Outdoor Water Use
4.304.1 Irrigation controllers. Automatic irrigation systems installed at the
time of final inspection shall be weather -based.
❑ 4.304.1.1 Controllers shall be weather- or soil moisture -based controllers
that automatically adjust irrigation in response to changes in plants' needs
as weather conditions change.
❑
❑
❑ 4.304.1.2 Weather -based controllers without integral rain sensors or
communication systems that account for local rainfall shall have a separate
wired or wireless rain sensor which connects or communicated with the
controller(s). Soil moisture -based controllers are not required to have rain
sensor input.
MATERIALRESOURCE
Enhanced Durability and Reduced Maintenance
4.406.1 Rodent proofing. Annular spaces around pipes, electric cables,
conduits, or other openings in plates at exterior walls shall be protected
against the passage of rodents by closing such openings with cement mortar,
concrete masonry or similar method acceptable to the enforcing agency.
Construction Waste Reduction, Disposal and Recycling
4.408.2 Construction waste management plan. Where a local jurisdiction
does not have a construction and demolition waste management ordinance, a
construction waste management plan shall be submitted for approval to the
enforcing agency.
Building Maintenance and Operation
4.410.1 Operation and maintenance manual. At the time of final inspection,
an operation and maintenance manual shall be provided to the building ✓�vv ❑
occupant or owner.
A4.5 ENVIRONMENTAL
Fireplaces
4.503.1 General. Install only a direct -vent sealed -combustion gas or sealed
wood -burning fireplace, or a sealed woodstove.
Pollutant Control
4.504.1 Covering of duct openings and protection of mechanical
equipment during construction. Duct openings and other related air
distribution component openings shall be covered during construction.
4.504.2.1 Adhesives, sealants and caulks. Adhesives, sealants and caulks
��
❑
shall be compliant with VOC and other toxic compound limits.
4.504.2.2 Paints and coatings. Paints, stains and other coatings shall be
LLJJ
compliant with VOC limits.
4.504.2.3 Aerosol paints and coatings. Aerosol paints and other coatings
shall be compliant with product weighted MIR Limits for ROC and other toxic
compounds.
Page 3 of 5 CalGreen 2014.doc revised 11/04114
4.504.2.4 Verification. Documentation shall be provided to verify that
❑
❑
compliant VOC limit finish materials have been used.
4.504.3 Carpet Systems. Carpet and carpet systems shall be compliant with
❑
❑
VOC limits.
4.504.4 Resilient flooring systems. Eighty (80) percent of floor area
receiving resilient flooring shall comply with the VOC-emission limits defined in
the Collaborative for High Performance Schools (CHPS) Low -emitting
❑
❑
Materials List or be certified under the Resilient Floor Covering Institute (RCFI)
FloorScore program.
4.504.5 Composite wood products. Particleboard, medium density
fiberboard (MDF), and hardwood plywood used in interior finish systems shall
❑
❑
comply with low formaldehyde emission standards.
Interior Moisture Control
4.505.2 Concrete slab foundation. Required vapor retarders and capillary
❑
❑
breaks are also required to comply with CalGreen Section 4.505.2.1.
4.505.3 Moisture content of building materials. Moisture content of building
�G�
❑
materials used in wall and floor framing is checked before enclosure.
Indoor Air Quality and Exhaust
4.506.1 Bathroom exhaust fans. Exhaust fans which terminate outside the
❑
❑
building are provided in every bathroom.
Environmental Comfort
4.507.2. Duct systems are sized and designed and equipment is selected
using the following methods:
1. Establish heat loss and heat gain values according to ACCA Manual J or
. equivalent. ❑
❑
2. Size duct systems according to ACCA 29-D (Manual D) or equivalent.
3. Select heating and cooling equipment according to ACCA 36-S (Manual S)
or equivalent.
INSTALLER AND SPECIAL INSPECTOR QUALIFICATIONS
Qualifications
702.1 Installer training. HVAC system installers are trained and certified in
❑
❑
the proper installation of HVAC systems.
702.2 Special inspection. The Licensed Professional responsible to verify
CALGreen compliance is qualified and able to demonstrate competence in the
❑
❑
discipline they inspect and verify.
Verifications
703.1 Documentation. Verification of compliance with CALGreen may
include construction documents, plans, specifications, builder or installer
certification, inspection reports, or other methods acceptable to the enforcing
❑
❑
agency which show substantial conformance. Implementation verification shall
be submitted to the Building Department after implementation of all required
measures and prior to final inspection approval.
Page 4 of 5 CalGreen 2014.doc revised 11/04/14
CALGREEN SIGNATURE DECLARATIONS
Project Name: ^611 /�D��`�
Project Address: 2.j 3 Ste- flu4lr-�-D 2-6
Project Description: fi/7ti� /&V P 7 e::p P11J1k4 /Z" -m
SECTION 1 - DESIGN VERIFICATION
Complete all lines of Section 1 — "Design Verification" and submit the completed checklist (Columns 1 and 2) with the
plans and building permit application to the Building Department.
The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and
certify that the items checked above are hereby incorporated into the project plans and will be implemented into the
project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as
adopted by the City of Cupertoo.
Owner's Signature
�f
i
Owner's Name (Please Print)
Design Professional's Signature
-f-���J 7`7,
Design Prof�es�si/onnal's Name (Please Print)
/
Signature of,License Professional responsible for CalGreen compliance
�G -J
Name of License Professional responsible for CalGreen compliance (Please Print)
�z_(Cw ,� � (2 /, 66-v-
Email Address for License Professional responsible for CalGreen compliance
SECTION 2 - IMPLEMENTATION VERIFICATION
Date
Date
Date
Phone
Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section
2 to the Building Department prior to Building Department final inspection.
I have inspected the work and have received sufficient documentation to verify and certify that the project identified
above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of
the 2013 California Green Building Standards Code as adopted by the City of Cupertino.
Signature of License Professional responsible for CalGreen compliance Date
Name of License Professional responsible for CalGreen compliance (Please Print) Phone
Address for License Professional responsible for CalGreen compliance
Page 5 of 5 CalGreen 2014.doc revised 11/04/14
STATE OF CALIFORNIA
Prescriptive Residential Additions 300 Ft2 or Less, or Additions That Do Not Reauire HERS Field Verifir-atinn
I+fi111;
CEC-CFIR-ADD-02-E Revised 10/15 _ CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF1R ADD 02 E
Prescriptive Residential Additions 300 Ft or Less, or Additions That Do Not Require HERS Field Verification (Page 1 0 9)
Project Name: / Date Prepared:
This compliance document is only applicable to additions 300 ft or less, or additions that do not require HERS field verification for compliance. When HERS verification is required, a CF1R-ADD-01
shall first be registered with a HERS Provider Data Registry.
Alterations to Space Conditioning Systems that are exempt from HERS verification requirements may use the CFIR-ADD-02 and CF2R- ADD -02 Compliance Documents. Possible exemptions from duct
leakage testing include: less than 40 ft of ducts were added or replaced; or the existing duct system was insulated with asbestos; or the existing duct system was previously tested and passed by a
HERS Rater. If space conditioning systems are altered and are not exempt from HERS verification, then a CFIR-ADD-01 must be completed and registered with a HERS Provider Data Registry.
Additions or alterations that utilize close Cell Spray Polyurethane Foam (ccSPF) with a density of 1.5 to less than 2.5 pounds per cubic foot having on R -value other than 5.8 per inch, or Open Cell
Spray Polyurethane Foam (ocSPF) with a density of 0.4 to less than 1.5 pounds per cubic foot having an R -value of 3.6 per inch, shall complete and register a CF1 R ADD -01 with a HERS Provider Data
Registry.
If more than one person has responsibility for installation of the items on this certificate, each person shall prepare and sign a certificate applicable to the portion of construction for which they are
responsible. Alternatively, the person with chief responsibilityfor construction shall prepare and sign this certificate for the entire construction. All applicable Mandatory Measures shall be met.
Temporary labels shall not be removed before verification by the buildina inspector.
A. General Information
01
Project Name:
� T�d�
02
Date Prepared:
�l J-
03
Project Location:
2 ( — Kul\1 IPY,
J
04
Building Front Orientation (deg):
05
CA City:
"t//J-0
06
Number of Dwelling Units with Additions:
07
Zip Code:
08
Fuel Type:
09
Climate Zone:
10
Total Conditioned Floor Area (ft') (Addition):
11
Building Type:
l �(� L�-��-t 1
12
Slab Area (ftz):
r13
Project Scope:
c D T 2-v 5
0 A
CC)"'f
FFICE
LA rsuuamg tnergy ttticiency Standards - 2013 Residential Compliance October 2015
STATE OF CALIFORNIA
Prescriptive Residential Additions 300 Ft2 or Less, or Additions That Do Not Require HERS Field Verification
CEC-CFIR-ADD-02-E Revised 10/15 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE
Prescriptive Residential Additions 300 Ft CFIR-ADD-02-E
or Less, or Additions That Do Not Require HERS Field Verification (Page 2 0 9)
P,, J-1 Name:
Jgkp Date Prepared: It-
-
01
02
03
04
05
06 1 07 08 09 10 11
Tag/ID
Assembly Type
IZ4�16Vu
Frame Type
W—" -D
Frame
Depth
(inches)
ZX �
Frame
Spacing
(inches)
Proposed
Required
Comments
Cavity
R -value
1Q 30
Continuous
Insulation
R -value
—
LI -Factor
0, o � 1
Appendix JA4
Reference
U -Factor
Table
4; 2- ,1
Cell
A 20
o , ,y3 I
�WA-u-
L- SP
vi -M71)
WlNP
ZX
o.077
g tnergy ttticiency Standards - 2013 Residential Compliance October 2015
STATE OF CALIFORNIA
Prescriptive Residential Additions 300 Ft2 or Less, or Additions That Do Not Require HERS Field Verification
CEC-CFIR-ADD-02-E (Revised 10/15) CALIFORNIA
CERTIFICATE OF COMPLIANCE
Prescriptive Resid
/�ential Additions 300 Ft or Less, or Additions That Do Not Require HERS Field Verification
Project Narm: �/v/v�/ D I`i(
l,y� t 6-,-J Date Prepared.
COMMISSION 4z
CFIR-ADD-02-E
(Page 3 of 9)
C. Opaque
Surface Details
— Non -framed (Section
150.1(c)1)
01
02
03
04
05 06 07 08 09
10
11
Tag/ID
Assembly Type
N
Assembly Materials
Thickness
(inches)
Proposed
Required
U -Factor from
Package A
Comments
Core
Insulation
R -value
Continuous
Insulation
R -value
U -Factor
AppendixJA4
Reference
Table
Cell
R -value
U -factor
tMass
Imo, f'T
D. Opaque Surface Details — Mass Walls (Section 150.1(c)1)
01
02
03
07 09
10
Tag/ID
Above
Grade
Type
704=Strip
Thickness
(inches)
Thickness
(inches)
Proposed
Req
Exterior Insulation
Appendix JA4
Reference
Interior InsulationWalls
R -value
U -factor
R -value
U -factor
Table
Cell
R -value
U -factor
tMass
Imo, f'T
CA Building Energy Efficiency Standards - 2013 Residential Compliance
11
fired
Exterior Insulation
R -value T U -factor
October 2015
STATE OF CALIFORNIA
Prescriptive Residential Additions 300 Ft2 or Less, or Additions That Do Not Require HERS Field Verification
CEC-CFIR-ADD-02-E (Revised 10/15) CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE
2-E
Prescriptive Residential Additions 300 Ft or Less, or Additions That Do Not Require HERS Field Verification (Page 4 CF1R-ADD-00 -E
Pmi-t Name:
Date Prepared:
F. Radiant Barrier (Section 150.1(c)2)
01
Radiant Barrier installed below the roof deck and on all gable end walls
\y1�_5 ,
02
Comments
A radiant barrier is required (for Climate Zones 2-15)
• Radiant barriers shall meet specific eligibility and installation criteria to receive energy credit for compliance with the Building Energy Efficiency Standards for low-rise residential
buildings. Refer to RA4.2.1
• The emittance of the radiant barrier shall be less than or equal to 0.05 as tested in accordance with ASTM C1371 or ASTM E408.
• For Prescriptive Compliance the attic shall be ventilated to provide a minimum free ventilation area of not less than one square foot of vent area for each 300 ft2 of attic floor area with
no less than 30 percent upper vents. Ridge vents or gable end vents are recommended to achieve the best performance. The material should be cut to allow for full airflow to the venting.
CA Building Energy Efficiency Standards - 2013 Residential Compliance October 2015
STATE OF CALIFORNIA
'Prescriptive Residential Additions 300 Ft2 or Less, or Additions That Do Not Require HFRS FiPiri Vnrifirra+inn n
CIEC-CF1R-ADD-02-E (Revised 10/15) CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF1R-ADD-02-E
Prescriptive Residential Additions 300 Ft or Less, or Additions That Do Not Require HERS Field Verification (Page 5 of 9)
Project Na—
Date Prepared i Z 2—
G. Roofing Products (Cool Rooq (Section 150.1(c)ll)
01
02
03
04
05
06 07 08 09
10 11 12
Mass Roof
2SIb/ft2 or
Greater
Roof Pitch
Method of
Compliance
Product
Type
CRRC Product ID
Number
Proposed
Required
Initial Solar
Reflectance
Aged Solar
Reflectance
Thermal
Emittance
SRI
(Optional)
Aged Solar
Reflectance
Thermal
Emittance
SRI
(Optional)
Orientations ft2
Area Only ft2
Maximum
Maximum
Maximum
Maximum
The Greater
The Greater
Addition
Allowed
Allowed
Allowed
Allowed
Type ft2
U -factor
U -factor
SHGC
SHGC
Comments
Maximum
Maximum
Calculated
Maximum
Calculated
Maximum
(Windows)
(Skylights)
(Windows)
(Skylights)
based on
Calculated
based on
Calculated
Allowed %
Allowed ft2
Allowed %
Allowed ft2
Notes:
• Any roof area covered by building integrated photovoltaic panels and solar thermal panels are exempt from the above Cool Roof requirements.
• Liquid field applied coatings must comply with installation criteria from section 110.8(i)4.
H. Fenestration/Glazing Allowed Areas and Efficiencies (Section 150.2(a)l)
01
02 T 03
04 05
06
07
08
09
10
Maximum Allowed
Maximum Allowed
Fenestration Area for All
West -Facing Fenestration
Orientations ft2
Area Only ft2
Maximum
Maximum
Maximum
Maximum
The Greater
The Greater
Addition
Allowed
Allowed
Allowed
Allowed
Type ft2
U -factor
U -factor
SHGC
SHGC
Comments
Maximum
Maximum
Calculated
Maximum
Calculated
Maximum
(Windows)
(Skylights)
(Windows)
(Skylights)
based on
Calculated
based on
Calculated
Allowed %
Allowed ft2
Allowed %
Allowed ft2
LA rsuuoing tnergy trnciency Standards - 2013 Residential Compliance October 2015
STATE OF CALIFORNIA
'Prescriptive Residential Additions 300 Ft2 or Less, or Additions That Do Not Require HERS Field Verification
CEC-CFIR-ADD-02-E Revised 10/15 CALIFORNIA ENERGY COMMISSION
[CERTIFICATE OF COMPLIANCECFIR ADD 02 E
escriptive Residential Additions 300 Ft or Less, or Additions That Do Not Require HERS Field Verification(Page 6 of 9)
ect Name:
Date Prepared:
I. Fenestration Proposed Areas and Efficiencies
Note: If meeting Exception 1 to 150.1(c)3A, Installing 5 3ft2 glass in door, it is assumed to meet the minimum required U -factor (0.32) & SHGC (0.25).
If meetine Fxcention 1 to 1Sn 11r)gA Inctmrlinn _ lftz j_1;_L._
01
02
.
03
. I
04
-- ---____._.
05
_..,..o..,,
06
....,...,.....,�.......,
07
`I'll U.1 uui",,'Uiii
08
icy
09
WIT cu U-IdLLUf
10
11
.IU.JU).
12
13
14
Tag/I
D
Fenestration
Type
Frame Type
Dynamic
Glazing
g
Orientation
N, S, W, E
or Roof
Number
of
Panes
Proposed
Fenestration
Area ftZ
Proposed West
Facing
Fenestration
Area ftz
Proposed
p
U -factor
Source
Proposed
SHGC
Source
Exterior
Shading
Device
Combined
SHGC from
CF1R-ENV-03
W1
-M;F
nrz
N
—
v, 3 v
Jv%C_
a,I-
Aim -Mzz-
�Iv-N-F_
L
—
v 2 z
v ys
N C_
--
G
-M
C_
v �
c_
15
Total Proposed Fenestration Area
16
Maximum Allowed Fenestration Area
17
Compliance Statement Total Proposed Fenestration Area 5 Maximum Allowed Fenestration Area XYes ❑ No
18
Total Proposed West -Facing Fenestration Area
19
Maximum Allowed West -Facing Fenestration Area
U
20
Compliance Statement Total Proposed West -Facing Fenestration Area 5 Maximum Allowed West -Facing Fenestration Area Yes ❑ No
21
Proposed Fenestration U -factor (Windows)
22
Required Fenestration U -factor (Windows)
L
23
Compliance Statement
Proposed Fenestration U -factor 5 Required Fenestration U -factor )< Yes ❑ No
24
Proposed Fenestration SHGC (Windows)
a2 vT-
25
Required Fenestration SHGC (Windows)
26
Compliance Statement Proposed Fenestration SHGC 5 Required Fenestration SHGC Yes ❑ No
X
27
Proposed Fenestration U -factor (Skylights)
28
Required Fenestration U -factor (Skylights)
29
Compliance Statement Proposed Fenestration U -factor < Required Fenestration U -factor ❑ Yes ❑ No
30
Proposed Fenestration SHGC (Skylights)
31
Required Fenestration SHGC (Skylights)
_
32
Compliance Statement
Proposed Fenestration SHGC _5 Required Fenestration SHGC ❑ Yes ❑ No
t_A building Energy Efficiency Standards - 2013 Residential Compliance October 2015
SiA1E OF CALIFORNIA
Prescriptive Residential Additions 300 Ft2 or Less, or Additions That Do Not Reauire HERS Field Verifir_atinin n
GEC-CFIR-ADD-02-E Revised 10/15)CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF1R-ADD 02 E
Prescriptive Residential Additions 300 Ft or Less, or Additions That Do Not Require HERS Field Verification (Page 7 of 9)
Project Name: ` /
MD D I v K.%j Date Prepared: /
J. Space Conditioning (SC) Systems — Heating/Cooling (Prescriptive section 150.2(b).
Alterations to Space Conditioning Systems shall be exempt from HERS verification requirements as prerequisite for use of the CF1R-ADD-02 and CF2R-ADD-02 Compliance Documents. If new space
conditioning systems are installed or existing systems are altered and are not exempt from HERS verification, then a CFIR-ADD-01 shall be completed and registered with a HERS Provider Data
Registry. In each row below for each dwelling unit in the building, check the box that indicates the exemption from HERS verification compliance:
❑ a: space conditioning system was not altered;
❑ b: less than 40 ft of ducts were added or replaced;
❑ c: (exempt from duct leakage testing) if: the existing duct system was insulated with asbestos;
❑ d: (exempt from duct leakage testing) if: the existing duct system was previously tested and passed by a HERS Rater.
01
02
03
04
Dwelling Unit Name
SC System Identification orName
SC System Location or Area Served
Exemption from HERS Verification
sNi/�17i+
At%Til�.,rv,D
� LS b ❑ c ❑ d
0 0 0 0
0 0 0 0
0 0 0 0
0 0 El 13
0 11 0 0
0 0 El 0
0 0 El 11
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
CA Building Energy Efficiency Standards - 2013 Residential Compliance October 2015
STATE OF CALIFORNIA
Prescriptive Residential Additions 300 Ft2 or Less, or Additions That Do Not Require HERS Field Verification
CEC-CFIR-ADD-02-E (Revised 10/15) CALIFORNIA EN
CERTIFICATE OF COMPLIANCE
Prescriptive Residential Additions 300 Ft or Less, or Additions That Do Not Require HERS Field Verification
Project Name:("/ Date Prepared:
K. Water Heating Systems (Section 150.1(c)8)
List water heaters and boilers for both domestic hot water (DHW) heaters and hydronic space heating.
nl I n7 III
MMISSION 4z
CFIR-ADD-02-E
(Page 8 of 9)
Dwelling Unit
Name
Water Heating
System
Identification or
Name
Water Heating
System Location
or Area Served
Water
Heating
System
Type
Water
Heater
Type
# of
Water
eaters
:inSystem
U/
Water
Heater
Storage
Volume
(gal)
Ua
Fuel Type
Uy
Rated
Input
Type
lU
Rated
Input
Value
11
Heatin g
Efficiency
YP
Type
12
Heating
g
Efficiency
Value
13
StandbyExterior
Loss
(%)
14
Insulation
R -Value
15
Back -Up
Solar
Savings
Fraction
CA Building Energy Efficiency Standards - 2013 Residential Compliance October 2015
STATE OF CALIFORNIA
Prescriptive Residential Additions 300 Ft2 or Less, or Additions That Do Not Require HERS Field Verification 121
CEC-CFIR-ADD-02-E Revised 10/15)CALIFORNIA ENERGY COMMISSION
OF COMPLIANCECF1R-ADD-02-E
Prescripesidential Additions 300 Ft or Less, or Additions That Do Not Require HERS Field Verification(Page 9 of 9)
[CERTIFIC]ATE
rotect Name _
Date Prcparcd:��---
DOCUMENTATION AUTHOR'S DECLARATION STATEMENT
1. 1 certify that this Certificate of Compliance documentation is accurate and complete.
Documentation Author Name: _ ` qtr l Documentation Author Signature:
Company: Signature Date:
Address:
Z L,r � CEA/ HERS Certification
n Identification (if applicable):
City/statePh
/Zip: �% i� / v
one:
RESPONSIBLE PERSON'S DECLARATION STATEMENT
I certify the following under penalty of perjury, under the laws of the State of California:
I. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for the building design or system design identified on this Certificate of Compliance (responsible
designer).
3. That the energy features and performance specifications, materials, components, and manufactured devices for the building design or system design identified on this Certificate of
Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the California Code of Regulations.
4. The building design features or system design features identified on this Certificate of Compliance are consistent with the information provided on other applicable compliance documents,
worksheets, calculations, plans and specifications submitted to the enforcement agency for approval with this building permit application.
5. 1 will ensure that a registered copy of this Certificate of Compliance shall be made available with the building permit(s) issued for the building, and made available to the enforcement agency
for all applicable inspections. I understand that a registered copy of this Certificate of Compliance is required to be included with the documentation the builder provides to the building
owner at occupancy.
Responsible Designer Name: Responsible Designer Signature
Company
Address: Date Signed:
License: /
-7-Z LI 1,A--� � L 7 g6 �
City/State/Zip:
t°�-rl&'V / � Phone: 11-0 t ¢6k 7f
For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: 1-800-772-3300.
CA Building Energy Efficiency Standards - 2013 Residential Compliance October 2015
�gUDsf
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildino o)cupertino.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: _ A
SITE ADDRESS _ . APN 3 7 B #7 ( S
O Irk NAME _ OWNER ADDRESS
fff, Fl
i
OF WOR
We are providing you with an Owner -Builder Acknowledgment 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.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
O�) 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder" building permit that erroneously implies that the property 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
insurance coverage for injuries to workers on my property.
hejI understand building permits are not required to be signed by property owners unless they are responsible for
_nstruction and are not hiring a licensed Contractor to assume this responsibility.
n3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
prot ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
nam instead of my own.
4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
nu bers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tota 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 I understand if I am considered an "employer" under state and federal law, I must register with the state and
fed ral 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.
r 7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
resi ntial 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.
. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any fi ancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defec in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
F
{ 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Rev nue 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 www.cs[b.ca.gov for more information about licensed
contractors.
10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
amt e party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by al applicable laws and requirements that govern Owner -Builders as well as employers.
l
2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
ation l have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
ntract with someone who does not have a license, the Contractors' State License Board may be unable to
you with any financial loss you may sustain as a result of a complaint.. Your only remedy against unlicensed
Contractors may be in civil court. It 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 owners signature
Property Owner's Signature: Date: 7 —qj
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I 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:
Address of Authorized Agent:
Tel No
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 certify 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:
OwneYBuilderForm 2010.doc revised 04/14110