B-2016-2089 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: I CONTRACTOR: PERMIT NO:B-2016-2089
21662 COLUMBUS AVE CUPERTINO,CA 95014-4711(356 18 049) RELIABLE AIR
MECHANICAL
SAN JOSE,CA 95136
OWNER'S NAME: KNOCK RICHARD TAND LINDA J TRUSTEE DATE ISSUED:06/08/2016
OWNER'S PHONE:4082556921 PHONE NO:(408)266-7267
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC20 Lic.#954400
Contractor RELIABLE AIR MECHANICAL Date 11/30/2016 X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapte 9(commencing X MECH X RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Co a and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE FURNACE,SAME LOCATION;INSTALL(N)A/C UNIT,(N)
I hereby affirm under penalty of perjury one of the following two declarations: LOCATION
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.
p 2. I have and will maintain Worker's Compensation Insuranc Ie,as provided for by
Jam— Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. I Sq.Ft Floor Area: Valuation:$18000.00
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 autf Ionze 356 18 049
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 expeAses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of 1this 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 INSP ION.
k- I
Signature—'fel-U14 Date 6/8 2016 Issued by:PAUL O'SULLNAN iL®
IV Date:06/08/2016
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 asI 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. I,as owner of the property,am exclusively contracting wi licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business& rofessions Code). Date:6/8/2016
I hereby affirm under penalty of perjury one of the following tb declarations:
t. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS„A„OR BETTER
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 Insuranc ,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 th 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
3. I 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
material. Additionally,should I use equipment ordevices 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 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensatio provisions of the the Health&Safety Code,Sections 25505,255 3,and 25534.
Labor Code,I must forthwith comply with such provisio or this permit shall
be deemed revoked. I Owner or authorized agent:
APPLICANT CERTIFICATION Date:6/8/2016
I certify that I have read this application and state that the above information is O STRU LENDINGA Y
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 represe tatives 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 apblicant understands
and will comply with all non-point source regulations per the Cdpertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 6/8/2016 Licensed
9 T Professional
I
GFENERAL PER�IT APPLICATION Lvo1 -o"Dg,' - MEP
W COMMUNITY DEVELOPMIENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CUPERT[N0
(408)777-3228 • FAX(4 aal
8)777-3333• building cuDertino.org MISC
❑
PLUMBING LJ A�iECH4]v7CAL ❑ELECTRICAL ❑NISCELLANEOUS
IAPNPROJCTADDRESS I VC
OWNER NAME �n 1,�'fIJ l�h`.A d ?ND. 0.
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STRFETADDRESS`a I( n�` I CITY, STATE;ZIP I FAX
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CONTACT\A 4E PHONE E•1 iAIL
STREET ADDRESS Zi! Ca'lj CITY,STATE,ZIP FAX
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AR CHITECT/ENGLNEERNA.AIE LICENSE N7 MBER BUS.LIC
COMPANY NA.MF E-I"IAIL FAX
STREET ADDRESS CITY,STATE,ZIP I PHONE
USE OF ❑SFD OrDUPLEXX ❑ MWLTI•FAIti4ILY PROJECT IN,WILDLA-N'D ❑ YES PROJECT Its ❑Y-Es IS THE BLDG AN ❑ YES
BUILDNIG: Com"''iERCLAL L'P.B.A. INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
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TOTAL VALUATION: / / I RECEIVED BI
By my si=natere below,I certify to each of the folio-wing: I am the property owner or authorized agent to act on the propem1 oH•ner's behalf. I have read this
application and the information I have provided is collect. I have read the Description of l ork and verify it is accurate. 1 agree to comply with all applicable local
ordinances and sate laws relating to buildinz construction. I ad horize r presentatives of Cupertino to enter the al?pve identi ed property for inspection purposes.
Signature ofAnplicant!'gent: Date: (/d
SU PLE'NIENTAL IITFORMATION REQUIRED nFFIc [sE or`Li x
ALOOR
" Ol ER TrIE COULTER
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❑ STAT�334RD� s�? f. �Z �
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AIEPh4'iscApp_20]J.doc revised 06121/11
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P�UPE TINA JUN 0 0 Z516
COMMUNITY DEVELOPMENT DEPARTMENT ��y
BUILDING DI�liSION-CUPERTINO
This set of plans and specifications MUST be kept at the
joo during construr_-ion. It is unlaWfUl to n?ak ny .
� �praleS�Fi'eY2tivPr:Irl ?. { LSG`^ J�Gjt Y
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the rc�rn,without approv-t i. t3uilu;ing Official.
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TIl�S�ani. ino of h;A play and specificaticns SHALL. T' C�Qs1G� 1 -
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re c to be an approval c`r the viol tion
BY
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PERMIT N0.
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SMOKE / CARBON MONOXIDE ALARMS L Z
OWNER CERTIFICATE OF COMPLIANCE � t�
COMMUNITY DEVELOPMENT DEPARTMENT,BUILDING DIVISION
CVPER .I N. I 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•building(a)cupertino.org
P.
X501 mit No.
Address RO d1 #of Alarms Smoke:; 1 Carbon Mo oxide:
PERMIT CANNOT BE FINALED AND COMPLETED,LINTILyTHIS
CERTIFICA N
H ESN + AND RFT �R1T D TO THF ITILaIl DIVISION
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 COALARM
Outside of each separate sleeping area in the immediate vicinity of the X X'
bedroom(s)
On every level of a dwelling unit including basements X X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply:In dwelling units with no commercial power supply,alarm(s)may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alte ations 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 CaliforniaBuilding
and California Residential Codes.The alarms have been tested and are operational, as of the date signed
below.
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agents)Name:
I.00AIAa 041 Signature........ Kf!"...... ate: �lg
Contractor Name:
halr Si nature......................................................................Lic.#......................................Date: ...................
Smoke and CO form.doc revised 03/18/14
WATER-CONSERVING PLUMBING FIXTURES FILE
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
liTl N 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
//gg"" (408)777-3228•FAX(408)777-3333•build ing(a.cupertino.org
C �y c
Owner Name (!(+,((A C(. (�64 in Permit No. �j
Address 2-1-662— e* q51
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 01 form.
No Go to Question 2.
2. Does your real property have a licensed plumber certifying that,due to the age or configuration of the property o 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 forin.
>�No Go to Question 3.
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom ol 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 ol 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. P ase 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 1,201'j,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 replaced with water- conserving
plumbing fixtures throughout the building(regardless of whether property undergoes alterations or improvements).
I,as the owner or owner's agent of this property,certify under penalty of perjury that non-compliant plumbing ffictures 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 mann acturer's
installation requirements,and that the water-conserving plumbing fixtures comply with the requirements as indic ited in the
table on the following page. _
Owner or Owner Agent's Signature: Date: -14
Upon completing and signing this Certificate,please return it to the BuildirfDivision in order to final your buil g permit.
SB407 2015.doc revised 08126115