B-2016-1797CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1797
10120 PASADENA AVE CUPERTINO, CA 95014-5919 (357 17 027)
F W H ACQUISITION
CO LLC
BOTHELL, WA 98011
OWNER'S NAME: MICHAEL AND DOROTHY C TRUSTEE PAPP
DATE ISSUED: 04/19/2016
OWNER'S PHONE: 408 253 7351
PHONE NO: (425) 636-7078
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class PLUMBING Lic. #987398
Contractor F W H ACQUISITION CO LLC Date 10/31/2017
X 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:
REMOVE/REPLACE 50 GALLON GAS WATER HEATER
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
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
Sq. Ft Floor Area:
Valuation: $1530.00
permit is issued.
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
357 17 027
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 O12
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date
Issued by: Patricia Garcia
Date: 04/19/2016
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
inspection.
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:
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
2. 1 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(a) should I store or handle hazardous
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
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
Date:
CONSTRUCTION LENDING AGENCY
correct. I 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
ARCHITECT'S DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
1 understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date
Professional
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
'WPERTINO (408) 777-3226 - FAX (408) 777-:1333 - LudlrlinmMtu aertino,ofp misc
16
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❑ OWNER ❑ OWNER -GUILDER IJ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AOENT ❑ ARCHITECT 13 ENGINEER ❑ DBVBLOPIM O TENANT
CONTRACTOR NAME�L)so/V)
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EMAIL
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ARCHITECTIENOTNABRNAME
LICENSE NUMBER '.
808- LIC
COMPANY NAME
P.MA1L
FAX
STREET ADDRESS
CITY, STATE,ZTP
PI IONS
USE Or 0orDUPLEX ❑ MULTI -FAMILY
PKOJECTINWILDLAND ❑ YES
PROJC%Cti'IN ❑ YES
ISTIIGILDGAN ❑ YBS
DUTLDMG:El COMMIERCIA1,
URBAN INTORFAC2 AREA NO
FLOOD ZONE ❑ NO
91CHLER ROMST d NO
DESCRIPTION OF WORK
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TOTAL VALUATION:
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By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the prgperty ownaT's behalf, f bane read this
appliCation and the information [have provided is correct. 1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws rotating to building a8nstruceion. l authorize representatives 0f Cupe(tlno to anter the above-tdenti Iod proparty or inspection purposes.
``
Signature of ApplicantlAgent: .0 �,J y9� Date,
SUPPLEMENTAL iNI=ORMATION REQUIRED
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"C,P1v isc.,lpp Z0II.doc revised 06/21/11
SMOKE f 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 ftupertino,ora
111 �m
Mi
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Address
PURPOSE
This affidavitisa self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, 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.
I have read and agree to comply with the terms and con jitions of this statement
Owner (or Owner Agent's) Name:
1
.........
Signature..................................Date: 1
Contractor Name:
Signature................................................................... Lic.#...................................... Date:...................
Smoke and CO form.doc revised 03/18/14
CUPERTINO I
Owner Name
WATER -CONSERVING PLUMBING FIXTURES CD F1 L r
OWNER CERTIFICATE OF COMPLIANCElb
9
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ;10
10300 TORRE AVENUE CUPERTINO, CA 95014-3255
(4 777-32'2 • 'AX�401) 7V7-3_ 33 • buildin cupertino.ong
10 ry �'�� �(�7W Permit No
Address f C AVE
1. Is your real property a registered historical site?
EhYes, Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
,No Go to Question 2.
2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its
plumbing, installation of water -conserving plumbing fixtures is not technically feasible?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
tNo 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.
�, No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
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.
e' Yes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. " Check one of the three following statements and sign
bottom of form..
5. Please check ONE of the following:
My property is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non-
compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
❑ My property is a multifamily residential real property. See Civil Code Section 1101.5..
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water -
conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
improvements).
❑ My property is a commercial, real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
4.
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 ter -cone ing pl_ bing ix es comply with the requirements a Indic ted in the
table on the following page. est . �f-
Owner or Owner Agent's Signature: - Date:
Upon completing and signing this Certificate, please return it to the Building Division in order to final your building permit.
SB407 2015. doe revised 08/26/15