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B-2016-1852CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1852 7423 FALLENLEAF IN CUPERTINO, CA 95014-5804 (359 28 027) S M P CONSTRUCTION & MAINTENANCE INC LIVERMORE, CA 94551 OWNER'S NAME: YUN YU AND CHEN HSIANG TRUSTEE WANG DATE ISSUED: 05/02/2016 OWNER'S PHONE: 408-255-2380 PHONE NO: (925) 961-9012 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class PILE DRIVING/PRESSURE FOUNDATION JACKING Lic, X BLDG _ ELECT _ PLUMB #273851 Contractor S M P CONSTRUCTION & MAINTENANCE' INC Date 06/30/2016 _ 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. INSTALLATION OF PP288 PUSH PIER SYSTEM IN (4) LOCATIONS AT ONE CORNER OF RESIDENCE. I hereby affirm under penalty of perjury one of the following two declarations: Rev#1 -ADD 2 MORE PIERS - ISSUED 7/6/2016 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 ^I erformance of the work for which this permit is issued. �2. 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: $10000.00 permit is issued. 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 359 28 027 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 LAST CALLED EqSPECTION. source regulations per the Cupertino Municipal Code, Section 9.18. 7/6/2016 Issued by: ABBY AYEN12E "7 Signature Date Date: 9 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 ben ig installed. If a roof is following two reasons: installed without first obtaining an inspection, I agree to rem ve all new materials for 1. I, 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: 2. I, as owner of the property, am exclusively contracting with licensed Date: 7/6/2016 contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" DR BETTER 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 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 2. I have and will maintain Worker's Compensation Insurance, as provided for by California Health & Safety Code, Sections 25505, 255 3, and 25534. 1 will Section 3700 of the Labor Code, for the performance of the work for which this maintain compliance with the Cupertino Municipal Cod , Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store r handle hazardous permit is issued. 3. I certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or device which emit hazardous air contaminants as defined by the Bay Area Air Quality Nlanagement District I shall not employ any person in any manner so as to become subject to the 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 Code, tions 25505 2553 3, and 2553 . - 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 agent: be deemed revoked. Date: 7/6/2016 APPLICANT CERTIFICATION certify that I have read this application and state that the above information is S I hereby affirm that there is a construction lending agen y for the performance correct. I agree to comply with all city and county ordinances and state laws of works 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 ARCHITECT'S LARATIO 'T consequence of the granting of this permit. Additionally, the applicant understands uas public records. ap I understand my plans shal1l1 be e used and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Licensed Professional Signature Date 7/6/2016 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228- FAX (408) 777-3333 • buildingRcupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI VREVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 77N# Y�- Flff ile4�' LN3-�-2 -26P- 09-7 OWNER NAME PHO VAJ U4y� US- 2S�s -.238 0 E-MAIL STREET ADDRESS . CITY STATE, ZIP f FAX 7 � � /( .tJlPo4 G C v?t°t ,, /10 S i� CONTACT NAME PHO E- L STREET ADDRESS T I CITZY, STATE,,, ZI loge C.ly ! 7" S-I ^ W 90/Sr OWNER ❑ OWNER -BUILDER 0 OWNER AGENT El CONTRACTOR/ 0 CONTRACTOR AGENT ❑. ARCHITECT ❑ ENGINEER ❑ DEVELOI ER ❑ TENANT OR LICENSE NUMBER � 73 Q� r LICENSE TYPE Q BUS. LIC # COMPANY NAME �C�s�/�i�lO�% E-MAIL /��l�' _��eC � �dlD F L*�'jO/ STREET ADDRES CI STATE ZIP P q -�C -�G/2 ARCHITECT/ENGINEER NAME ��✓ { LICENSE NUMBER f f `{ BUS. LIC # COMPANYNAME r E-MAIL F CI i4T/ ,,ZIP o DESCRIPTION OF WORK ! ✓Od i V - --hoo M o AP e10 ,GH id i fLz/',q EXISTING USE PROPOSED USE CONSTR TYPE # STORIES I USE TYPE OCC. SQ.FT. ALUATION ($) EXISTG .NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM - KITCHEN - .OTHER REMODEL AREA REMODEL AREA REMODEL AREA. PORCHAREA DECK AREA TO TALDECK/PORCHAREA GARAGEAREA: DETACH - I ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES - BEING ADDED? NO ADDITION? NO PRE APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THE BLDG AN El YES IVED�Y - 4 TOTAL VALUATION: PLANNINGAPPL# ENO PLANNING APPROVAL LETTER. EICHLERHOME? ENO s ✓ x i�, �. � V V By my signature below, I certify to each of the following: I am the property owner or authorized agent tb act on e property owner's behalf. I have red 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 relating to build' P7construction. 4 authorize rep fives of Cupertino to enter the above-'d/enti ed//property for inspectionpurposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMA ON REQ UIRED WLIP �; , PLAN GH CI YP ROUiIl S New SFD or Multifamily dwellings: Apply for demolition permit forbYER Tim c0GNT A� ©BttiLDlNc Pl AN yjE- existing building(s). Demolition permit is required prior to issuance of building ��XPREss permit for new building. C1 PLANNINGP- ivi w� Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Cl STANDARD ,.. PIrBLIC vvoRxs Form if any Hazardous Materials are being used as part of this project. ❑" ";_ 'SIRE 'LARGE .,. �, DEPT ,. _ Copy of Planning Approval Letter or Meeting with Planning prior to n�AapR p sArrrnRY sE DISTRICT submittal of Building Permit application. s B1dgApp_2011.doc revised 06121111 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1852 7423 FALLENLEAF LN CUPERTINO, CA 95014-5804 (359 28 027) S M P CONSTRUCTION & MAINTENANCE INC LIVERMORE, CA 94551 OWNER'S NAME: YUN YU AND CHEN HSIANG TRUSTEE WANG DATE ISSUED: 05/02/2016 OWNER'S PHONE: 408-255-2380 PHONE NO: (925) 961-9012 LICENSED CONTRACTOR'S DECLARATIOON BUILDING PERMIT INFO: License Class PILE DRIVING/PRESSURE FOUNDATION JACKING Lic. X BLDG #973851 _ELECT _PLUMB Contractor S M P CONSTRUCTION & MAINTENANCE INC Date 06/30/2016 _ 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. INSTALLATION OF PP288 PUSH PIER SYSTEM IN (4) LOCATIONS AT ONE CORNER OF RESIDENCE. 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. Ic 6*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: $10000.00 permit 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 3 59 59 28 027 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 LAST CALL INSPECTION. source regulations per the Cupertino Municipal Code, Section 9.18. �, Issued by: MELISSA Signature Date 05/02/2016 Date: 05/02/2016 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 first obtaining an inspection, I agree to remove all new materials for 1. I, 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: 2. I, as owner of the property, am exclusively contracting with licensed Date: 05/02/2016 contractors to constrict 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 i. 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 2. I have and will maintain Worker's Compensation Insurance, as provided for by California Health & Safety Code, Sections 25505, 25533, and 25534. 1 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 air contaminants as defined by the Bay Area Air Quality Management District I shall not employ any person in any manner so as to become subject to the 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 Code 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 agenQ4 be deemed revoked. Date: 05/02/2016 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 Professional Signature Date 05/02/2016 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • build ingCcDcupertino.orq[I NEW NEW CONSTRUCTION " ❑ ADDITION ALTERATION ! Ti ❑ REVISION / DEFERRED ORIGINAL PERIAIT # `v 1 PR0IECT ADDRESS •� L APN # r OWNER NAME ) . ` i L Ii1 , ! f'1 PFIQNEAr Z �� .�� � E-MAIL STREET ADDRESS ^7(/� /,� 7� f'(UI /(}►�/�1� FAX CONTACT NAME nI!- rOFCA • Go STREET ADDRESS ❑ OwNP1t ❑ `OWNER-BUnDER ❑ OWNER AGENT CONTRACTOR © CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME J(/{/J %�`lA / ILICENSENUM�tB"!273��/r LICENSETY BUS.L1C# C �f COMPANYNAM!�''J 1 7 / L%Y/iJr f�� ►( LV y`C/jL7' �V{�J ,erg 1901f 9 STREET11T5 ���A , � ^ fitL ST - � 6 � t r',.� / PHONE rARCIETECT/ENOMEERNAME !J--e-r� `�t�iJ,�,� I.[CENSF.NUMBERfY'/'� '/afj` l BUS, LIC4 COMPANY NAM IL '^ nC S� 6Y0 6 L(.� LPL l� E M IL` I '� `"����lV t-CY �C� n^ f l 117?o e eYN'�7L(ff7•>``� (J�1��✓,r/ i7Y 1 ��J DESCRIPTION OF WORK eAIS1 e 0r4 EXISTING USE I PROPOSED USE 1 CONSTR. TYPE 1 N STORIES EXISTG NEWFLOOR DEMO TOTAL ..::_�_::o :• ::;::: ................. .:__:.:::.:.:.:::_:_;::<:.:, .__.;1.;=`.>.t:'i-: is 3t:. s::::_:::.-5:::s:s ::::::,:` AREAAREA AREA NET AREA ....:.....:......... :......................_...........,.,.._._.........._......_........_._............_......._............. BAT [iROOM KITCHEN - - -- - ::t; :'; =' :: : ' - - - - :::•::.:: .,•-: ,.• .:: ,.. _..,................... ...._..�_.. --- - - -___ - ----- - - REMODEL AREA REMODEL AREA REM DELAREA PORCH AREA CKAREA DEDECK/PORCH� 'TOTAL AREAFARAOFARFA. ❑D&TACIT .:..:............:::. ....,.......... �:==:'':f==S::CC .............::._•.:.:._.:.:-_::_:_::_.::: _(]::i�i�'i;:3is:i'2t�i::xi':�:::i'.icri:! . ::......:-::,:::•:.:.;....:•::.::_.: _ ❑ ATTACH ..._. _._.............._.:...... •...._.......... .....0 __: _: _. ......... _.s-':-::•::.::;::•;:::�: flDSECOND WELLING UNITS: 1 'E ND U 'IT Y SAS CU 11 PS SE •OND STORY YES C - BEING AUDL+D7 NO ADDITION? ❑ NO .......... ....... ..:........... .: ::-::::: ' ':_:-:::.. ...:.- .....- ,......._ ._.... ...... ................ ....,-...........-:, PRE-API'rrCATLON ❑ -YES 1P YES, PROVIDE COPY Oil PLANNER'S NAME: �•. - -.-:: , _; _. '• L:TOTAI:YALUATION`` _ PLANNINGAPPLp NO PLANNING APPROVAL LETTER _-^ ... ............__ _ _ _ _ By my signature below, I certify to each of the following: I am the property owner -or authorized agent to act on toe property owner's behalf, fhave read this application and the infonnation I have provided is correct. I have read he Description of Work. and verify it is accarate, I agree to comply with all applicable local ordinances and state laws relating to Lr 9ding c stru tion. I author' entatives of Cupertino to enter the above-identif d property for inspection purposes. Signature Applicant/Agent: of _ Date: SUPPLEMENTAL INFO ATI I Ol\ 1tEQUIRED ;::: =::=_ ::::: _::.::::- .::...:. .:.:.::.:.:..:.:...:... .::::::. CFfECK:TYPE:;`. ::::: ,::::,-_-::::.;_:.-::::::::.:>:.._::::_.;:.:::_:..:=:--:;:: - '':I20UI1HG SLIP.: as> -.':i - -- - SFD or Multifamily dwellings: for demolition permit1 for buildin (s . Demolition permit is required red prior to Issuance of building "•:: `- ; YER 1Hi-CO.tr :::::::....existin wa ..)::.t.;:'.• .;:.E_;:...:..;:....a..... :_:,.:.,e_..:.::.:_,.-..:•.: permit for new building. :; ....'�:_ :: .:N_New •I.- •s Commercial Bld s• Provide acorn completed a g .p Hazardous Materials Disclosure �.:_..._SlAH1)..Attt) ?;pr`:>.':::: ,-... _:;. �"•"� • � '� ' " ��• '" CJ EUBLIC,.�'l!ORKS:'.=:`:`i- fo rm if an Hazardous Materials are being u i used attofth s project. :.:........:. ,....:........ .....:...::....: - :,...;.•..::.-;:::..,::...:.�,..:..:::.::..:::.�:.._:,::.•: �•:•::.�..:. - 4- Copy of Planning Approval Letter or Meeting with h Planning prior r to::{.1 .L:>t-J:-O:_.:R:�:.:::-.`:: •:.`. �._':=.:....:=:.::.:.:=:=..:_;,_s::.. : .:.. =:: _,:.:,:: ,, :�.::_,�-.;:.::, �:.--:::;:: _.: E�ERDI.STR::ICT su—bnuttal of Building Permit application.: .::.:-: _.. :;_.;.;:c .BldgApp_2011.doc revised 03116111 CUPERTINO STATEMENT OF SPECIAL INSPECTIONS, 2013 CBC COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingCcDcupertino.org SITEADDRESS 7`{ 13 1/fA 1 f41"" L Ae• APN �! S��// ` �O �p OZ�' # Z.Oi 6 -) ............................................................ Owner.... �.. iv,........ 4A-n Contracttor ../` a4t... Phe%........................... .. . ................ Address...7./.. 23......1 .Ipp ......L ................. Address/..�(J../6.....R City/St..0 1.M....Zip... !. t.......Phone "Z� ifn.....4>I"...........Vn./�.. _p......... City/St.t�!.vo.lt �O..re../"K!......-Z-ip. .7' �... Phone ...gIRI.:./..al Ch&Applicant ..........fir.... ....... ....... ........ .....''..99...... . ,!�•�'"��,�., Engineer/Architect.ZIT.7.....FJ..ft h......................................... ��� ..... k43.f!4t..�........ r:....v��..C! ......................Idv Address... ... wash Address ....... ............................................. 1 2.... ...e ... p1551...... Phone ....`1.i11:71City/St..��YK/! ;City/StL/m�e.../CA.Zip.... ZipT.7rr1. Phone, PROJECT DESCRIPTION: This "STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This form is structured after and used by permission from the Structural Engineer Association of Northern California's (SEAONC) mode statement of Special Inspections. Also, included with this form is the following: ❑ "LIST OF SPECIAL INSPECTION AGENCIES (page 2). A list of testing agencies and other special inspectors that will be retained to conduct the tests and inspections for this project ❑ "SCHEDULE OF SPECIAL INSPECTION" (page 3 — 6). The Schedule of Special Inspections summarizes the Special Inspections and tests required. Special Inspectors will refer to the approved plans and specifications for detailed special inspection requirements. Any additional tests and inspections required by the approved plans and specifications shall also be performed. Special Inspections and Testing will be performed in accordance with the approved plans and specifications, this statement and CBC Sections 1704, 1705, 1706, 1707, and 1708. Interim reports will be submitted to the Building Official and the Registered Design Professional in Responsible Charge in accordance with CBC Section 1704.1.2. A Final Report of Special Inspections documenting required Special Inspections, testing and correction of any discrepancies noted in the inspections shall be submitted prior to issuance of a Certificate of Use and Occupancy (Section 1704.1.2). The Final Report will document: • Required special inspections. • Correction of discrepancies noted in inspections. The Owner recognizes his or her obligation to ensure that the construction complies with the approved permit documents and to implement this program of special inspections. In partial fulfillment of these obligations, the Owner will retain and directly pay for the Special Inspections as required in CBC Section 1704.1. This plan has been developed with the understanding that the Building Official will: • Review and approve the qualifications of the Special Inspectors who will perform the inspections. • Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and are performing their duties as called for in this Statement of Special Inspection. • Review submitted inspection reports.: • Perform inspections as required by theAo6al building code. I have read and agree to comply_wj/h the Wrms and conditions of this statement Prepared By: Project h Engineer ❑ Architect „ '1 Registered Design Professional in Charge Signature... ...k.. .................................... ......... Lic.#....................................... Date:.......................... Owner Name:/u� l ,/ A Owner's Authorizatio Si nature ... . !................................................................................. Date: ... Inspection Agency / Inspector Name: fkW- q i- -..A n � � Si naturg:�.. .................... Lic.#....................................... Date: ............ Building OfFiCal or d6f ignee: Signature.................................................................................................................... Date:.......................... // SpecialnspectionFornn 2012.doc revised 09106112 LIST OF SPECIAL INSPECTION AGENCIES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and special inspector shall be recognized by the Building Official prior to performing any duties. Special Inspection agency's listed on this form must be pre -approved and listed on Cupertino's approved Special Inspector's list. Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the California Council of Testing and Inspection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a "Stop Work Order' and possible permit revocation. To be pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout. Please allow two weeks to complete the application process. The following are the testina and special inspection aaencies that will be retained to conduct tests and inspection on this project: EXPERTISE FIRM / INSPECTOR INFORMATION 1. Special Inspection (except for geotechnical) Firm�....."........ �. ttV ..... . ...... Addr.. ............... eag. 4 5.. .........�..�.�....�...7...... ......................................... Cityl!1�.............. .... . State ... ip ... ;T�...�.7. / ,S�Q.G�...-�� Telephone. ax............................................ Email ...4! 4�'.�r................ .............. 2. Material Testing Firm..S..59..... .......%.n.... ar.Mp. ....... Addr... !.�LO..........!..........n...S ..... city...�orf..l.�.Al..... .... .. ..State ..............Zip ..�.7............... ����`` Telephone. 6.gl..��..Ij....Fax............................................ Email-J119!..'�Q. 19 ....... `.1.. ... . 3. Geotechnical Inspections Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax ............................................ Email......................................................... 4. Other: Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax ............................................ Email......................................................... *All agencies specified on this form must be pre -approved and listed on the City of Cupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic -force -resisting system and designated seismic systems subject to special inspections as per Section 1705.3: The extent of the seismic -force -resisting system is defined in more detail in the construction documents. WIND REQUIREMENTS Section 1705.4.1 Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind -force -resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionFonn 2012.doc revised 09106112 SCHEDULE OF SPECIAL INSPECTION SITE ADDRESS 7Y-23 Fakh Gea� Ian& APN BP# PROJECT D SCRIPTION: , , c I S40 C�G //'n 11-e ve/ Me /'M ( L. Notation Used in Table: Column headers: C Indicates continuous inspection is required. P Indicates periodic inspections are required. The notes and/or contract documents should clarify. Box entries: X Is placed in the appropriate column to denote either "C" continuous or "P" periodic inspections. --- Denotes an activity that is either a one-time activity or one whose frequency is defined in some other manner. Additional detail regarding inspections and tests are provided in the project specifications or notes on the drawings. VERIFICATION AND INSPECTION C p REFERENCED IBC REFERENCE STANDARD INSPECTION OF FABRICATORS 1. ❑ Inspect fabricator's fabrication and quality control --- --- 1704.3 procedures. INSPECTION OF STEEL 1. Material verification of high -strength bolts, nuts and washers. ❑ Identification marking to conform to ASTM stds AISC 360, specified in the approved construction documents. --- X Section A3.3 and applicable ASTM material standards ❑ Inspect fabricator's fabrication and quality control X procedures. 2. Inspection of high -strength bolting: ❑ Snug -tight joints. --- X ❑ Pretensioned and slip -critical joints using turn -of -nut with matchmarking, twist -off bolt or direct tension --- X AISC 360, indicator methods of installation. 1704.3.3 Section M2.5 ❑ Pretensioned and slip -critical joints using turn -of -nut without matchmarking or calibrated wrench methods X --- of installation. 3. Material verification of structural steel and cold -formed steel deck. ❑ For structural steel, identification markings to conform AISC 360, to AISC 360. X Section M2.5 ❑ For other steel, identification markings to conform to Applicable ASTM ASTM standards specified in the approved --- X material standards construction documents. ❑ Manufacturer's certified test reports. --- X SpecialnspectionFonn 2012.doc revised 09106112 VERIFICATION AND INSPECTION C P REFERENCED STANDARD I IBC IREFERENCE 4. Material verification of weld filler materials: ❑ Identification marking to conform to AWS specification in the approved construction documents. --- X AISC 360, Section A3.5 and applicable AWS A5 documents --- ❑ Manufacturer's certificate of compliance required. --- X --- --- 5. Inspection of welding: a. Structural steel and cold -formed steel deck: ❑ Complete and partial joint penetration groove welds. X --- AWS D1.1 1704.3.1 ❑ Multipass fillet welds. X --- ❑ Single -pass fillet welds > 5/16" X --- ❑ Plug and slot welds. X El Single -pass Single -pass fillet welds <= 5/16" --- X ❑ Floor and roof deck welds. --- X AWS D1.3 b. Reinforcing steel: ❑ Verification of weldability of reinforcing steel other than ASTM A 706. --- X AWS D1.4 ACI 318: Section 3.5.2 ❑ Reinforcing steel resisting flexural and axial forces in intermediate and special moment frames, and boundary elements of special structural walls of concrete and shear reinforcement. X --- ❑ Shear reinforcement. X --- ❑ Other reinforcing steel. --- X 6. Inspection of steel frame joints details for compliance: ❑ Details such as bracing and stiffening. --- X --- 1704.3.2 ❑ Member locations. --- X ❑ Application of joint details at each connection. --- X VERIFICATION AND INSPECTION C p REFERENCED STANDARD IBC REFERENCE INSPECTION OF WELDING 1. ❑ Welded studs when used for structural diaphragms. --- X --- 1704.3 2. ❑ Welding of cold -formed steel framing members. --- X 3. ❑ Welding of stairs and railing systems. --- X SpecialnspectionFonn 2012.doc revised 09106112 VERIFICATION AND INSPECTION C p REFERENCED STANDARD IBC REFERENCE INSPECTION OF CONCRETE 1. ❑ Inspection of reinforcing steel, including prestressing --- X ACI 318: 3.5, 7.1-7.7 1913.4 tendons and placement. 2. ❑ Inspection of reinforcing steel welding in accordance AWS D1.4 ACI 318: with Table 1704.3 Item 5b. ___ --- 3.5.2 --- 3. ❑ Inspection of bolts to be installed in concrete prior to and during placement of concrete where allowable X --- ACI 318: 8.1.3, 1911.5, 1912.1 loads have been increased or where strength design 21.2.8 is used. 4. ❑ Inspection of anchors installed in hardened concrete. --- X ACI 318: 1912.1 5. ❑ Verifying use of required design mix. 1904.2.2,1913.2, --- X ACI 318: 1913.3 6. ❑ At time fresh concrete is sampled to fabricate ASTM C 172 specimens for strength tests, perform slump and air X --- ASTM C 31 1913.10 content tests and determine the temperature of the concrete. ACI 318: 5.6, 5.8 7. ❑ Inspection of concrete and shotcrete placement for X --- ACI 318: 5.9, 5.10 1913.6, 1913.7, proper application techniques. 1913.8 8. ❑ Inspection for maintenance of specified curing --- X ACI 318: 5.11-5.13 1913.9 temperature and techniques. 9. Inspection of prestressed concrete: ❑ Application of prestressing forces. X --- ACI 318: 18.20 ❑ Grouting of bonded prestressing tendons in the X --- ACI 318: 18.18.4 seismic force -resisting system. 10. ❑ Erection of precast concrete members. --- X ACI 318: Ch. 16 --- 11. ❑ Verification of in -situ concrete strength, prior to stressing of tendons in posttensioned concrete and --- X ACI 318: 6.2 --- prior to removal of shores and forms from beams and structural slabs. 12. ❑ Inspect formwork for shape, location, and dimensions --- X ACI 318: 6.6.1 --- of the concrete member being formed. 13. ❑ Bolts Installed in Existing Masonry or Concrete ❑ Direct tension testing of existing anchors. --- X See ICC ES Reports form special inspection requirements for proprietary products ❑ Direct tension testing of new bolts. --- X ❑ Torque testing of new bolts. --- X ❑ Prequalification test for bolts and other types of X anchors. --- 14. ❑ Other: SpecialnspectionForm 2012.doe revised 09106112 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 530/ASCE 5 530/ASCE 6 INSPECTION OF LEVEL 1 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved --- X --- --- Art. 1.5 submittals shall be verified. 2. ❑ Verification of f'm and f aac prior to construction ___ X --- --- Art. 1.413 except where specifically exempted by this code. 3. ❑ Verification of slump flow and VSI as delivered to X --- --- --- Art. 1.5B.1.b.3 the site for self consolidating grout. 4. As masonry construction begins, the following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar. --- X --- --- Art. 2.6A ❑ Construction of mortar joints. --- X --- --- Art.3.313 ❑ Location of reinforcement, connectors, --- X --- --- Art. 3.4, 3.6A prestressing tendons, and anchorages. ❑ Prestressing technique. --- X --- --- Art. 3.66 ❑ Grade and size of prestressing tendons and --- X --- --- Art. 2.413, 2.4H anchorages. 5. During construction the inspection program shall verify: ❑ Size and location of structural elements. --- X --- --- Art. 3.3F ❑ Type, size, and location of anchors, including . 1.2.2(e), Sec other details of anchorage of masonry to --- X --- 1.16.1 ___ structural members, frames or other construction. ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and --- X --- Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X --- --- --- ❑ Preparation, construction and protection of masonry during cold weather (temperature below ___ X Sec. 2104.3, Art. 1.8C, 1.8D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing X --- --- --- Art. 3.613 force. 6. Prior to grouting the following shall be verified to ensure compliance: ❑ Grout space is clean. --- X --- --- Art. 3.2D ❑ Placement of reinforcement and connectors and --- X --- Sec. 1.3 Art. 3.4 prestressing tendons and anchorages. ❑ Proportions of site -prepared grout and --- X --- --- Art. 2.613 prestressing grout for bonded tendons. ❑ Construction of mortar joints. --- X --- --- Art. 3.313 7. Grout placement: ❑ Grout placement shall be verified ensure X --- --- --- Art. 3.5 compliance. ❑ Observe grouting of prestressing bonded X --- --- --- Art 3.6C tendons. SpeciabispectionForm 2012.doc revised 09106112 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 530/ASCE 5 530/ASCE 6 8. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be --- X 2105.2.2, --- Art. 1.4 observed. I 1 1 2105.3 INSPECTION OF LEVEL 2 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved --- X --- --- Art. 1.5 submittals. 2. ❑ Verification of fm and f aac prior to construction and for every 5,000 square feet during --- X --- --- Art. 1.413 construction. 3. ❑ Verification of proportions of materials in premixed or preblended mortar and grout as --- X --- --- Art. 1.513 delivered to the site. 4. ❑ Verification of slump flow and VSI as delivered to X _ r Art. 1.5B.1.b.3 the site for self consolidatingrout. 5. The following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar, grout, and ___ X _-- ___ Art. 2.6A prestressing grout for bonded tendons. ❑ Placement of masonry units and construction of ___ X _-_ ___ Art. 3.36 mortar joints. ❑ Placement of reinforcement, connectors and ___ X --- Sec. 1.15 Art. 3.4, 3.6A prestressing tendons and anchorages. ❑ Grout space prior to grouting. X --- --- --- Art. 3.2D ❑ Placement of grout. X --- --- --- Art. 3.5 ❑ Placement of prestressing grout. X --- --- --- Art. 3.6C ❑ Size and location of structural elements. --- X --- --- Art. 3.3F ❑ Type, size, and location of anchors, including other details of anchorage of masonry to X --- --- Sec.1.2.2(e) structural members, frames and other construction. ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and --- X --- Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X--- __- Sec. 2.1.9.7.2, --- 3.3.3.4 (b) ❑ Preparation, construction, and protection of masonry during cold weather (temperature below ___ X Sec. 2104.3, _-_ Art. 1.8C, 1.8D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing X --- __- __- Art. 3.613 force. 6. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be X --- 2105.2.2, --- Art. 1.4 observed. 2105.3 SpecialnspectionFonn 2012.doc revised 09106112 VERIFICATION AND INSPECTION C p REFERENCED STANDARD IBC REFERENCE INSPECTION OF WOOD 1. ❑ Inspect prefabricated wood structural elements and assemblies in accordance with Section 1704.2. --- 1704.6 2. ❑ Inspect site built assemblies. --- --- 3. Inspect high -load diaphragms: ❑ Verify grade and thickness of sheathing. --- --- ❑ Verify nominal size of framing members at adjoining panel edges. --- --- --- 1704.6.1 ❑ Verify nail or staple diameter and length, --- --- ❑ Verify number of fastener lines, --- --- ❑ Verify spacing between fasteners in each line and at edge margins. 4. ❑ Metal -plate -connected wood trusses spanning 60 feet or greater: Verify temporary installation restraint/bracing and the permanent individual truss --- X --- 1704.6.2 member bracing are installed in accordance with the approved truss submittal package. REQUIRED VERIFICATION AND INSPECTION OF SOIL 1. ❑ Verify materials below footings are adequate to X achieve the desired bearing capacity. -_- 2. ❑ Verify excavations are extended to proper depth and X have reached proper material. --- 3. ❑ Perform classification and testing of compacted fill materials. X --- Table 1704.7 4. ❑ Verify use of proper materials, densities and lift thicknesses during placement and compaction of X --- compacted fill. 5. ❑ Prior to placement of compacted fill, observe subgrade X and verify that site has been prepared properly. REQUIRED VERIFICATION AND INSPECTION OF DEEP DRIVEN FOUNDATION ELEMENTS 1. Verify element materials, sizes and lengths comply X --_ with the requirements. 2. Determine capacities of test elements and conduct X _-- additional load tests, as required. 3. Observe driving operations and maintain complete X --- and accurate records for each element. 4. Verify locations of piles and their plumbness, confirm type and size of hammer, record number of blows per --- Table 1704.8 foot of penetration, determine required penetrations to X --- achieve design capacity, record tip and butt elevations and document any damage to foundation element. 5. For steel elements, perform additional inspections in accordance with Section 1704.3. 6. For concrete elements and concrete filled elements, perform additional inspections in accordance with --- --- Section 1704.4. SpecialnspectionFonn 2012.doc revised 09106112 VERIFICATION AND INSPECTION C P REFERENCED STANDARD IBC REFERENCE 7.X For specialty piles, perform additional inspections as determined by the registered design professional in --- --- --- Table 1704.8 responsible charge. REQUIRED VERIFICATION AND INSPECTION OF CAST -IN -PLACE DEEP FOUNDATION ELEMENTS 1 X Observe drilling operations and maintain complete and X --- accurate records for each element. 2. )i� Verify placement locations and plumbness, confirm element diameters, bell diameters (if applicable), lengths, embedment into bedrock (if applicable), and X --- --- Table 1704.9 adequate end -bearing strata capacity. Record concrete or grout volumes. 3. For concrete elements, perform additional inspections in accordance with Section 1704.4. HELICAL PILE FOUNDATIONS 1. Record installation equipment used, pile dimensions, X --- --- 1704.10 tip elevations, final depth, final installation torque. SPRAYED FIRE-RESISTANT MATERIALS Physical and visual tests 1. Condition of substrates. ❑ Inspect surface for accordance with the approved fire - resistance design and the approved manufacturer's --- --- written instructions. ❑ Verify minimum ambient temperature before and after X application. --- 1704.12.1 ❑ Verify ventilation of area during and after application. --- X 2. ❑ Measure average thickness per ASTM E605 and Section 1704.12.4. --- 3. ❑ Verify density of material for conformance with the approved fire-resistant design and ASTM E605. (Ref. --- --- Section 1704.12.5) 4. ❑ Test cohesive/adhesive bond strength per Section 1704.12.6. 5. ❑ Condition of finished application. MISCELLANEOUS 1. Mastic and Intumescent Fire -Resistant Coating. --- --- --- 1704.13 2. Exterior Insulation and Finish Systems (EIFS). Water - resistive barrier coating when installed over a sheathing --- --- --- 1704.14 substrate. 3. Special Cases --- --- --- 1704.15 4. Smoke Control System --- --- --- 1704.16 5. Seismic Resistance ❑ Suspended ceiling systems and their anchorage. --- --- --- 1705.3 [4.3] SpeciahispectionFonn 2012.doc revised 09106112 VERIFICATION AND INSPECTION C p REFERENCED STANDARD IBC REFERENCE 6. Wind Resistance ❑ Roof cladding and roof framing connections. --- --- --- ❑ Wall connections to roof and floor diaphragms and framing. ❑ Roof and floor diaphragm systems, including collectors, drag struts and boundary elements. ❑ Vertical wind -force -resisting systems, including braced frames, moment frames, and shear walls. ❑ Wind -force -resisting system connections to the foundation. ❑ Fabrication and installation of systems or components required to meet the impact resistance requirements --- --- --- of Section 1609.1.2. SPECIAL INSPECTION FOR WIND REQUIREMENTS 1. Structural Wood ❑ Inspect field gluing operations of elements of the main X --- wind-force-resisting system. --- 1706.2 ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the main windforce-resisting --- X system, including wood shear walls, wood diaphragms, drag struts, braces and hold-downs. 2. Cold -Formed Steel Framing ❑ Welding of elements of the main wind -force -resisting --- X system. ❑ Inspection of screw attachments, bolting, anchoring, and other fastening of components within the main --- 1706.3 wind -force -resisting system including shear walls, --- X braces, diaphragms, collectors (drag struts) and hold- downs. 3. Wind -resisting components ❑ Roof cladding. --- X --- 1706.4 ❑ Wall cladding. --- X SPECIAL INSPECTIONS FOR SEISMIC RESISTANCE 1. ❑ Special inspection for welding in accordance with the X --- 1707.2 quality assurance plan requirements of AISC 341. 2. Structural Wood ❑ Inspect field gluing operations of elements of the X --- seismic-force-resisting system. ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the seismic -force -resisting 1707.3 system, including wood shear walls, wood --- X diaphragms, drag struts, braces, shear panels and hold-downs. 3. Cold -Formed steel light -frame construction ❑ Welding of elements of the seismic -force -resisting --- X 1707.4 system. SpecialnspectionForm 2012.doe revised 09106112 ❑ Inspection of screw attachments, bolting, anchoring, and other fastening of components within the seismic- --- X force -resisting system including shear walls, braces, diaphragms, collectors (drag struts) and hold-downs. 4. Storage racks and access floors ❑ Anchorage of storage racks 8 feet or greater in height X 1707.5 and access floors. 5. Architectural components ❑ Inspect erection and fastening of exterior cladding weighing more than 5 psf and higher than 30 feet --- X above grade or walking surface. ❑ Inspect erection and fastening of veneer weighing more than 5 psf.and higher than 30 feet above grade --- X or walking surface. --- 1707.E ❑ Inspect erection and fastening of all exterior non - bearing walls higher than 30 feet above grade or --- X walking surface. ❑ Inspect erection and fastening of all interior non - bearing walls weighing more than 15 psf and higher --- X than 30 feet above grade or walking surface. 6. Mechanical and Electrical Components ❑ Inspect anchorage of electrical equipment for X emergency or stand-by power systems. --- ❑ Inspect anchorage of non -emergency electrical -__ X equipment. ❑ Inspect installation of piping systems and associated mechanical units carrying flammable, combustible, or --- X --- 1707.7 highly toxic contents. ❑ Inspect installation of HVAC ductwork that contains X hazardous materials. --- ❑ Inspect installation of vibration isolation systems X where required by Section 1707.7. --- 7. ❑ Verify that the equipment label and anchorage or mounting conforms to the certificate of compliance --- 1707.8 when mechanical and electrical equipment must be seismically qualified. 8. ❑ Seismic isolation system: Inspection of isolation --_ X _-_ 1707.9 system per ASCE 7 — Section 17.2.4.8 9. ❑ Obtain mill certificates for reinforcing steel, verify compliance with approved construction documents, --- --- --- 1708.2 and verify steel supplied corresponds to certificate. 10. ❑ Structural Steel: Invoke the QAP Quality Assurance --- 1708.3 requirements in AISC 341. 11. ❑ Obtain certificate that equipment has been seismically --- 1708.4 qualified. r2. ❑ Obtain system tests as required by ASCE 7 Section 1708.5 17.8. --- --- ___ SpeciahispectionFonn 2012.doc revised 09106112 SMOKEIGA MONOXIDE ALARMS 'T ERTI OWN C' MCA,, E OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE AVENUE -CUPERTINO, CA 95014-3255 (408) 777-32,28 FAX (408) 777-3883 - buiId1nq,(a)cvpertjno-orQ gwr&80-3 7 �z M PURPOSE This affidavit is a self -certification for the *installation of all required Smoke and Carbol Monoxide Alarms for compliance with 2013 CRC Section R314, 2013 CtC Sections 420.6 and 907.2.11.2 whey E no interior access for inspections are required. I GENERAL, IN FORMATIONT Existing single-family and multi -family dwellings shall be provided with Smoke Alarr is and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section R314 a--ndC'8C Sections 907.2.11.5 and 420.6 require that Smoke klarms and/or arbor Monoxide Alarms be installed in the following. locations: I AREA SMOKE AL ',M —COACA—IRM Outside of each separate sleeping area in the immediate vicinity of the bedroom(,s,) X On ever y level of a dwelling imit including, basements X X Within eac1l. sleeping -room X Carbon. Monoxide alarmsare not required in dwellings which do not contain fuel-bu J ling apphance,�: and that r don,,otha,,vea-�,n.attacl-tedga�,rage. Carbon monoxide alarms combined with smoke alarms, shall con pxjy with C'9C Section 420.6 and shall be approved by the Office of the State Fire Marshal. Power Supply. In dwelling units its with, no, commercial power supply, alarm(s) may besolely battery operated. In existing dwelliang'units, alarms are permitted to be solely battery operated where rE pairs or alteratiolls do not result u.: the removal of wall and ceiling finishes or there is no access bymeans of ittic,basement Or crawl-, space,..Refer toCRC Sect,'iio,,,nR,'3,14w--�L.�d CBC Sections 907.2.11.4 and 420.6.2. An, electric ;tlipermit isreq,,fired for ailarins, wltich, must be connected to the bufl1di n.,,g wiriiigo. As owner of the above -referenced property,, I hereby, certify that the alarm(s) referenc d above hasihave been installed in accordance with the manuf achatzer's instructions and in compliance with. t 'le California Bi iildlilqmg-, and Cafifomriia, Residential-- Codes. The alarms have been, tested and are, operational, a,, of the date sigpied- below. , /-- / haves rp;Mianti qorat- f,(.,) rnmnlv w;fh;- f,,hp- fprm- Q,. qndl nnndifinnc,, nffhic- ......... ................ ...... ............ ......................... .......... ................... Si"nature ........ .................................................... ........ ..... ..................... Da e;_.............._.. E CUPERTINO Owner Name T LIN WATER -CONSERVING PLUMBING FIXTURIS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (�08)i�7y772,8�• FyAX (4Q8)�7n77-3333 • in cu ertino.orp Y V!J [ f't�Q'C7 �i�t-tYl� uA, ;r rr_ F Address 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 nd sign bottom o form. G No Go to Question 2. 2. Does. your real property have a licensed plumber certifying that, due to the age or configuratioi of the property or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible? Q 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 forth 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 aid sign bottom o form. VSL 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 Lnd sign bottom of foam. 19. 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 followi g statements and sign bottom of form.. 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-c Dinpliant plumbing fixtures to be replaced with water -conserving plumbing fixtures throughout the building. On or bef re January 1, 20 17, all non- compliant plumbing fixtures shall be replaced with water -conserving plumbing fix es (regardless of whether property undergoes alterations or improvements). ❑ My property is a multifamily residential real property. See Civil Code Section 1J01.5. On and after January 1, 2014, specified building alterations or improvements shall require i on- 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 ter - conserving plumbing fixtures throughout the building (regardless of whether property unde goes alterations o 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 i on- 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- con erving plumbing fixtures throughout the building (regardless of whether property undergoes altera 'ons or improve ents). I, as the owner or owner's agent of this property, certify under penalty of perjury that non-com pliant plumbing fixtures will be replaced prior to date specified above with water -conserving plumbing fixtures in accordance through 1101.8, the current California Plumbing Code and California Green Building Standards installation requirements, and that the water -conserving plumbing fixtures comply with the requirements vith Civil Code S Code, and man as indicated ctions 1101.1 facturer's in the table on the following age. Owner or Owner Agent's Signature: Date: % / l Upon completing and signing this Certificate, please return it to the Building Division in order o tinal your building permit. SB407 2015. dorevised 08126115