B-2016-2023 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2023
21095 RED FIR CT CUPERTINO,CA 95014-4228(359 05 034) CUPERTINO
PLUMBING INC
SAN JOSE,CA 95124
OWNER'S NAME: BOWER KEITH D AND HELVIA B DATE ISSUED:05/25/2016
OWNER'S PHONE:408-253-7480 PHONE NO:(408)253-0618
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC-36 Lie.#E24905
Contractor CUPERTINO PLUMBING INC Date 04/30/2018 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:
COOPER REPIPE
I hereby affirm under penalty of perjury one of the following two declarations:
t. have and will maintain a certificate of consent to self-insure for Worker's
ompensation,as provided for by Section 3700 of the Labor Code,for the
X,Performance of the work for which this permit is issued.
2 I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$6000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN
information is correct.I agree to comply with all city and county ordinances Number: Occupancy Type:
359
and state laws relating to building construction,and hereby authorize 359 OS 034
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 u� ds"ill comply with all non-point
source regulations per t e p rt' icjp r- e,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signa:: Date 5/25/2016 Issued by:AbbA endejM
Date:05/25/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RF.-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
r. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:5/25/2016
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
z. 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 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
Worker's Compensation laws of California. If,after making this certificate of Hill maintain compliance with the Cupertino M ipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,,j� ,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall C
be deemed revoked. Owner or Authorized agent: ./
APPLICANT CERTIFICATION Date:5/25/2016
I certify that I have read this application and state that the above information is CONS UC ON LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 52 /2016 Professional
GENERAL PERMIT APPLICATION MER
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
(408)777-3228> FAX(408)777-3333• building(a1cupertino.org
CUPERTINO: I °3-201(e-�3
PLUMBING ❑MBC kmc.AL E ELECTRICAL ❑MISCELLAIQEOUS
PROJECT.4DDRESS C I APNn F✓{''C5'—0
OWNER NAME �e� �O F'W_7 I �� � �� rte J E-MAIL
STREET ADDP.ESS ® 'Rea CITY, STATE,ZIP r, T ICA /a'Zq I FAX
CONTACT NAME PHONE(Cd�—�73'-4mf� L--A24IL
STREET ADDRESS CITY,STATE, ZIP FAX
cam. i
El olAwER ❑ Ow1vr�,t-BUII.DER ❑ OH'N'FRAGENT �4CTOR ❑CONTRACTOR.4GENT ❑ ARCHITECT ❑ENGLN'EER ❑ DEVELOPER ❑ TENAI:T
CON ACTOR NAME f7r��
4E I JO L BUS.LIC 9&I
CO hE-MAIL FAX
STREETADD CITY;STATE,ZIP � i
ARCHITECT/ENGINEER.NAME LICENSE NUMBER BUS.LIC'
COMPANY NAME E-MLML FAX
STREET ADDRESS CITY,STAT E,'LIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN R'II.DLA.ND ❑ YES PROJECT JN ❑ YES IS THE BLDG AN ❑ 'VFs
BUILDNIG: ❑COMN,ERCI.4L URBAN 1N'TERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOMxE? ❑ No
DESCRIPTION OF IVORK
TOTAL VALUATION: I 0 oo RECEIVED Bl VYl
�vvl
By 1ny signature below,I certify to each of the following: I am the propel-ty,owner or authorized agent to act on the property Amer's be al£ I have read this
application and the infonnation I have provided is COlrect. I have read Descri ti n of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to build o n upertino to enter the above-,identified property for inspection purposes.
Si--mature of Apphcant�Agent: Date: J r l
Supvt MEI7TAL D IFOR14ATION REQLJIREDOFFICE USE'ONLI" .,;
c s u
5
y ❑ OVER THE COUNTER `
s J
< I `RGEx. -.
l:� ❑ k M� S
AlEPAWtsc,9pp_2011.do remised 06/21/11
SMOKE / CARSON MONOXIDE ALARMS. —
IFILE
OWNER CERTIFICATE OF COMPL'IANC'E
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
GUPIrITNt3 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228 FAX(408)777-3333•building(a)cupertino.org
Address ro / fiFt � ermit No. "�
l 9 loDt 14JO !!1 of Alarms Smoke: Carbon Mo oxide:
l�� TT CANNOT B��'�NALUI��COMPLU'.FED UNTIL THIS GEE1ZTiT�CAT `
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 Carb Dn
Monoxide alarms. When the valuation of additions, alterations,or repairs to existing dwelling units exceeds
$1000.00, CRC Section 8314 and CSC 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 CoALARM I
Outside of each separate sleeping area in the immediate vicinity of the X vX
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 con iply 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,basem nt 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 ave 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
t � Qb�l Signature,.... . ................... .......................................... ate: . .:,.:.. ...
...Y ..
Contractor Name:
U p 68 1 1 A)Q 1 p
M 9 i%A)6 Signature........................................._.........................Lic.#..................................... ate: .................,.
Smoke and CO form.doe revised 0.3/18/14
FILE
WATER-CONSERVING PLUMBING FIXTURES --
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building()cupertino.org'
Owner Name 9_J` Permit No.
Address q A e V Y i dl
1. Is your real property a registered historical site?-
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
jNo Go to Question 2.
2. Does your real property have a licensed plumber certifying that,due to the age or configuration of the property oi its
plumbing,installation of water-conserving plumbing fixtures is not technically feasible?
Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed.plumber's certification has been provided to the Building Division,
Skip the rest of the form and sign bottom of form.
❑ 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.110,1.8 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:
Do' 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 1,201 ,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 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 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 replace 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 f tures 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 manu acturer'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: ;