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B-2016-1821 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1821 21311 COLUMBUS AVE CUPERTINO,CA 95014-4921(362 05 033) A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC MEMPHIS,TN 38120 OWNER'S NAME: PRANTIS ROBERT J TRUSTEE DATE ISSUED:04/22/2016 OWNER'S PHONE:408-446-2129 PHONE NO:(901)271-9700 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL ENGINEERING CONTRACTOR Lic.#765155 ContractorA R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC X BLDG —ELECT X PLUMB Date 07/31/2016 _MECH X 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 JOB DESCRIPTION: license is in full force and effect. REPLACE 50 GAL WATER HEATER IN GARAGE I hereby affirm under penalty of perjury one of the following two declarations: 1. 1 have and will maintain a certificate of consent to self-insure for Worker's ompensation,as provided for by Si tion 3700 of the Labor Code,for the performance of the work for which spermi . ssuedz. have and willmaintain Worker's Cmpensation 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:$3896.00 permit is issued. APPLICANT CERTIFICATION APN I certify that I have read this application and state that the above 62OS 033 Number: Occupancy Type: 3 information is correct.I agree to comply with all city and county ordinances 362 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 PERMIT EXPIRES IF WORK IS NOT STARTED City of Cupertino against liabilities,judgments,costs,and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point 180 DAYS FROM LAS CTION. source regulations per the Cupertino Municipal Code,Section 9.18. ` Issued by: IF Signature Date 04/22/2016 Date:04/22/2016 OWNER-BUILDER DECLARATION RE-ROOFS: 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 following two reasons: installed without fust obtaining an inspection,I agree to remove all new materials for 1. 1,as 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: z. 1,as owner of the property,am exclusively contracting with licensed Date:04/22/2016 contractors to construct the project(Sec.7044,Business&Professions Code). 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 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 z. I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous 3. 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 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and Worker's Compensation laws of California. If,after making this certificate of the Health&Safety"de,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 a t: be deemed revoked. Date:04/22/2016 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 understands ARCHITECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records. Code,Section 9.18. Licensed GENERAL PERMIT APPLICATION WEP EPARTMENT, BUILDING DIVISION COMMUNITY DEVELOPMENT D 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 1 S C (408)777-3228• FAX(408)777-3333 e building(d-)cupertino.oL9 CUPERTIN �. X016 �PLU1\013NIG ❑MECI ANICAL ❑ELECTRICAL ❑1\ iSCELLANEOUS PROJECT ADDRESS 17 n V APN 4 ` — v r O UTA�'ER N.Ahg 1 PHONE. E-MAIL � STREET ADDRESS CITY, STATE,ZIP FAX C-Q)W,n.-\b(As AA) er nes @(A 9T\LI CONTACT S © ' PHONE E-1111P �Sc (c�Q- Q�-L-OSI C Co STREET ADDRESS CITY,STATE, ZaP 1 FAX 2 OS �1 a!�l ❑ OR7\7ER ❑ OA NER.BUILDER ❑ O—WNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORN E 'tel LICENSE NUMBER LI SE TYPE A BUS.LICaZr3O� COA4PANY NAMfr ?S l s t �. � �41�, 1i' E-MAIL I FIl.l�S 11/tGy.�70 -C�yY� FAX STREET ADDRESSCITY,STATE,ZIP(Si, HONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC 4.� t COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMILY I PROJECT LN wILDLANTI) ❑ ITS PROJECT IN ❑ YES I IS THE BLDG AN ❑ YES B=IN'G: ❑COMNIEERCLAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ No DESCRIPTION OF WORK L^ TOTAL VALUATION: t 1 By my signature below,I.certify to each of the following: I am the property owner or authorized agent to act on the pro a 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 relati a to buil a construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature ofApplicant/Age4 Date: SUPPLEA4ENTAL INTFORA4ATION REQUIREDoFi ICE osE onLi. i E)PRESS x ', ❑ STAII'D4RD '' v AIAdOR 'r k'EPA7isc,9pp_2011.doc revised 06/21/11 SMOKE / CARBON MONOXIDE ALARMS . -M OWNER CERTIFICATE 4F COMPLIANCE `z:!, COMMUNITY DEVELOPMENT DEPARTMENT+BUILDING DIVISION f ��,1P�FtTt'NO 10300TORRE AVENUE• CUPERTINO,CA 95014-3255 (408)777-3228-FAX(408)777-3333• buildin-g(cDcupertinomg 'U�Affidigl§ TOTIMB�, • 'X� ."' *mat .w ,. R, '` PURPOSE This affidavit is a 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 ALARMCO ALARM Outside of each separate sleeping area in the immediate vicinity of the X X bedroom(s) 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, alarms)may be solely battery operated.. In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not,result iii 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-refereiaced property,I hereby certify that the alarm(s)referenced above has/have been installed in accordance with the'manufact,urer s instructions and in compliance with the Cahforrua.Buildiii,g. and Cahfonua Residential Codes.The alar ms.have;been tested and are operational, as of the date sighed below. t have read and a. ree to com:2l with;the terms and conditions of this statement ., l It, ., S.i riafUre: ,m1A ate. .1 Snafure .................................................................. iG#. :....................................xpte';................... WATER-CONSERVING PLUMBING FIXTURES �t OWNER CERTIFICATE OF COMPLIANCE �2 � COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION CUPERTIINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•buIIdingftcuaertino.org p Owner Name �I✓Ll ;�, VaA rls Permit No-) tJ� o-@ )4 -JS�-� Address !f 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. 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 110 1.1 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. 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. Yes My real property is built and available for use or occupancy on or before January 1, 1994. / Civil Code Sections 11013 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). El 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. 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). I,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. Owner or Owner Agent's Signature'f « Date: 1 a S Upon completing and signing this Certificate,please return it to the Building Division in order to final your building permit. SB407 2015.doc revised 08126115