B-2016-1891 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1891
10525 MADRONE CT CUPERTINO,CA 95014-6578(342 61 038) CURT BERG-OWNER
OWNER'S NAME: BERG CURT G AND SHIELA M DATE ISSUED:05/05/2016
OWNER'S PHONE:650-996-2722 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Tic.# X BLDG —ELECT X PLUMB
Contractor CURT BERG-OWNER Date —
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:
GAS METER UPGRADE PER PG&E.
I hereby affirm under penalty of perjury one of the following two declarations:
t. 1 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. 1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$0.00
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 342 61 038
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date Issued by:Phuon_Devries
Date:05/05/2016
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 fust 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:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. 1 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
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
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 &4�
be deemed revoked. Owner or aut orized agent:f��Al
APPLICANT CERTIFICATION Date/� 1 G
I certify that I have read this application and state that the above information is /�J CONSTRUCTION LENDING A
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending age cy 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
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section . 8. n 1 understand my plans shall be used as public records.
Signature ' Dat �7Licensed
e
Professional
... ........................
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 In Em Is AP%
�� Na (408)777-3228• FAX(408)777-3333• building(a.cupertino.org
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PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS IC J /��(/ �jP 7�y� C APN n
OWNER NAME
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STREET ADDRESS ��,�e CITY�A E, / �r��/✓v f� ����)` FAX
CONTACT NAMEl �Q J
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STREET ADDRESS (� S
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OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC n
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO a EICHLER HOME? El NO
DESCRIPTION OF WORK1 a'"'We /e —3J27--&- ca-<-f-
0 peg 5� �/2)n 64 aa)6 < Z U
TOTAL VALUATION...;D RECEIVED B ,
By my signature below,I certify to eachof the f wing: am the property owner or authorized agent to act on the rty o ner's behalf. I have read this
application and the information I have r ovid is c nect. have read th scnption of Work and verify it is accu e I agre to mply with all applicable local
ordinances and state laws relating to buildin constrtio authorize en tives of Cupertino to enter the abov 'de
ucd tgoperty for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQU D oTi icE clsE'onL
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MEPMiscApp_2011.doc revised 06/21/11
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTthiO (408)777-3228 • FAX(408)777-3333•buildina(a.cuoertino.org —
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at: -
SITE ADDRESS - Cdvegrm)o
BP#
OWN NER ADDRESS-
DESCRIPTION OF WORK:
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
C?Z. . I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Build r" building permit that erroneously implies that the property owner is providing his or her own labor and material
Personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an Allicensed person and his or her employees while working on my property. My homeowner's insurance may not
proe coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
C b . I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
C,J' 3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
pro It t myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
C1 01.4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
C,35. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tota!Jvalue of my construction is at least five hundred dollars ($500), including labor and materials, I may be
congidered an "employer" under state and federal law.
C� 'iii 6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
tl
meQto serious financial risk.
C, 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licen ed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
C, �,t3, I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any fil ancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defe in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
D .
r:
CL9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
Rrzyenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand l may contact the California Contractors' State
Liense Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
co- ractors.
C � c 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am,t! e party legally and financially responsible for proposed construction activity at the site address listed above.
X11. I agree that, as the party legally and financially responsible for this proposed construction activity, l will abide
by 91111,applicable laws and requirements that govern Owner-Builders as well as employers.
Q a12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information-I-have-provided on this form. Licensed contractors are regulated by-laws designed to protect.the..public. If .
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a.result of a complaint..-Your only remedy against unlicensed
Contractors maybe in-civil court. If is also important for.you-to understand that if an unlicensed Contractor or
employee of that individual or firm is injured.while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or note
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the fbllowing construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's drivers license,
form notarization, or other verification acc ab to th city may e required to be presented when the permit is issued
to verif the property owners si nature.
(Property Owner's Signature: Date: .S /
-
--------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and car airy its accuracy. Note:A copy of the property owners drivers license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owners
signature.
Property Owner's Signature: Date:
OwneYBuilderForm 2010.doc revised 04/14/10
ARMS 6
SMOKE / CARBON MONOXIDE AL X1a�,
OWNER CERTIFICATE OF COMPLIANCE
2 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
I
CU ERTINQ
(408)777-3228•FAX(408)777-3333•building(cDcupertino.org
Permit No, --2616- g
Address j®� �1 C�� i #of Alarms Smoke Carbon Monoxide
n
PERMIT CANNOT BE'FINALED AND C�OMPLE'�ED UNTIL THIS CERTIFICATE
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
i
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 X X
bedroom(s)
On ever level of a dwellingunit includingbasements X X
Within each sleeping xoom 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.
1 have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
4f U F f 5�9 a sign,ure......... .... ..........._ . .!tLic.#
.............................................Date:
Contractor Name:
Signature................................................
......................................Date: ...................
Smoke and CO form.doc revised 03/18/14
PLUMBING FIXTURES
PL
WATER-CONSERVING ,
OWNER CERTIFICATE OF COMPLIANCE
Fa
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
��� ;,,�„� 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
NO 408)777- 2 8• AX(408)777-3333•buildina((Dcupertino.ora ZOr�y
Owner Name 1'ermitnNo.
Address 0
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 fonn.
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?
El 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.
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 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 improvementsshall 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).
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 water-conservig plumbi fixtures comply with the requirements as indicated in the
table on the following a e. S
Date:
Owner or Owner Agent's Signature:
Upon completing and signing this Certificate,please return it to the B ding Division in order to final your building permit.
SB407 2015.doc revised 08126/15