B-2016-1880CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1880
22283 N DE ANZA CIR CUPERTINO, CA 95014-3950 (356 02 024)
GAGNE BROTHERS
ENTERPRISES INC
NOVATO, CA 94949
OWNER'S NAME: AUSTIN L SCOT AND DONNA M TRUSTEE
DATE ISSUED: 05/03/2016
OWNER'S PHONE: 408-446-2724
PHONE NO: (415) 506-0400
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class PLUMBING Lic. #857357
Contractor GAGNE BROTHERS ENTERPRISES INC Date 04/30/2017
X BLDG _ELECT X PLUMB
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
license is in full force and effect.
JOB DESCRIPTION:
REPLACE MAIN WATER SERVICE LINE
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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.
E"veand 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: $5066.00
ermit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
56
356 02 024
3
and state laws rel a ' o w i construction, and hereby authorize
representativ of this city to en r upon the above mentioned property for
inspection� purposes. (We) a e to save indemnify and keep harmless the
EXPIRES IF WORK IS NOT STARTED
City o.Cupertino against I' ilities, judgments, costs, and expenses which
PERMIT
ma accrue against ' City in consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
the a scant derstands and will comply with all non-point
rditionally,
o, rce regulati s er t ertino Municipal Code, Section 9.18.
180 DAYS FRO SPECTION.
n Date 05/3/2016
Issued by: MELISS
Date: 05/03/2016
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:
t. 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. 1, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 05/3/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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.
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
'
maintain compliance with the Cue uni al Code, Chapter 9.12 and the
permit is issued.
s. I certify that in the performance of the work for which this permit is issued, I
Health &Safety Code ecti'on 25532(, should I s e or handle hazardous
material. Additionally,should I use equipment or devi s which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants s defined by the Bay Area Air Qua ' Management District I
Worker's Compensation laws of California. If, after making this certificate of
�,� maintain coin fiance with the Cupertino Muni ' al Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Healt &Safety Code, Sectio 5533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized age —
APPLICANT CERTIFICATION
Date: 05/3/2016
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
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
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's (dame
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
Code, Section 9.18.
I understand my plans shall be used as public records.
Licensed
Signature Date 05/3/2016
Professional
CUPERTINO
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 In
(408) 777-322.8 • FAX (408) 777-3333 , buildingCcDcupertino.orcl IVI U
PLUMBING ❑ MECHANICAL ❑ ELECTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS 2-Z23f3 1 ` D� /1 I`Zd CI
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OWNER NAMEDb vW A Aurum
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CONTACT NAME n
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E-MAIL
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CITY, STATE, ZIP st (., 1 --_
FAX -
❑ OWNER ❑ OWNER -BUILDER LJ OWNER AGENT + CONTRACTOR ❑ CONTRACTOR AGENT EI ARCHITECT ❑ ENGIlAEER ❑ DEVELOPER ❑ TENANT
ONTRACTOR '`AI�v A A "�I - ,
LICS_E ER�
LICENSE TYPE e
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E-MAIL
FAX
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PHONE j e,,•'%i(�, ��
AR CH�ITFCT/E�NG`INIIEER NAME
LIC TSE NUMBER'V
BUS. LIC n
TOTAL VALUATION; RECEIVED
By my signature below, I cerA to eachoft followin am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the infolmat on I have pr ded is corre ave read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to I ding co ntatives of Cupertino to enter the above-idntifie property for inspection purposes.
Signature of Applicant/Agent: Date: 15 , (,
SUPPLEMENTAL INFORMATION REQUIRED
MEPAIiscApp__2011.doc revised 06/21/11
COMPANY NAME
E-MAIL
FAX
S'T'REET ADDRESS
a rY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMII YPROJECT
BUILDING: C] COMMERCIAL
IN WILDLANEl ]D ES
URBAN INTERFACE AREA ❑ NO
PROJECT IN
FLOOD ZONE
El YES
❑ NO
IS THE BLDG AN El YES
EICHLER HOME? ❑ NO
DE/SSCRIP�TIOON/OF WORK
Qi7,
TOTAL VALUATION; RECEIVED
By my signature below, I cerA to eachoft followin am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the infolmat on I have pr ded is corre ave read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to I ding co ntatives of Cupertino to enter the above-idntifie property for inspection purposes.
Signature of Applicant/Agent: Date: 15 , (,
SUPPLEMENTAL INFORMATION REQUIRED
MEPAIiscApp__2011.doc revised 06/21/11
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(aa)cupertino.orq
r
Address
`22" ';�'S3 p1
C(
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 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 V( 41Act,�` v'
ave read and a rQeo comnly with Pheterms and conditions of this statement
Owner ( Ow e Ag nt's) ame:
Si nature.. .: .... ........ .. ...� . ...:................................................... Date: ! .�4(
C ractor'N'ame:
A
Siat ....................... Lic.# .... Date: ................
Smoke and CO form. doe revised 03118114
Owner Name _
Address _
WATER -CONSERVING PLUMBING FIXTURES 1F
I L
OWNER CERTIFICATE OF COMPLIANCE,..
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
{408) 777-3228 • FAX (408) 777-3333 -,building @cuperIino.org ra
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply
No Go to Question 2.
Skip the rest of the form and sign bottom of form.
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 110 1. 1 through 1101.8 do not apply, _
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest ofthe form and sign bottom of form.
'�r`lo Go to Question 3.
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 110 1. 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.
"ETYes 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..
Tease 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.
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 peijury 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:
Date:
Upon completing and signing this Certificate, please return it to the Building Division in order to final your building permit.
SB4072015.doc revised 08126115