B-2016-2109 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2109
10073 HILLCREST RD CUPERTINO,CA 95014-1021(326 16 013) ATKINSON
CLIMATROLLERS INC
SAN JOSE,CA 95112
OWNER'S NAME: TOM LANCE E AND HOLLY W DATE ISSUED:06/10/2016
OWNER'S PHONE:408-209-8832 PHONE NO:(408)294-6290
T ICEN D CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class$ Lic.#2.58540
Contractor ATKINSON CLIMATROLLERS INC Date 12/31/2016 X BLDG _ELECT _PLUMB
I hereby affirm.that I am licensed under the provisions of Chapter 9(commencing X MECH X RESII)ENTLAL— — —COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
ADD A/C REAR OF HOUSE
I hereby affirm under penalty of perjury one of the following two declarations: REV#1 REPLACE FURNACE(SAME 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.
z. 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:$8963.00
APPLICANT CERTIFICATION
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 32616 013
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 L Date 10-6-2016 Issued by:AbbyAvende
Date:06/10/2016
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. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044;Business&Professions Code)
2. 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: 11L-6-2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
Health&Safety Code, 25532(a)should I store or handle hazardous
a. I certify that in the performance of the work for which this permit is issued I Section
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
be deemed revoked.
.Owner or authorized agent:
_&/
APPLICANT CERTIFICATION Date:10-6-2016
I certify that I have read this application and state that the above information is CONSTRUCTION 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
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 10-6-2016 Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTfNO
(408)777-3228•FAX(408)777-3333•buildingO cupertino.ong
i
❑NEW CONSTRUCTION ❑ ADDITION ❑ .ALTERATION 1 TI REVISION/DEFERRED ORIGINAL PERMIT
PROJECT ADDRESS /> J APP
OWNER NAMEPHONEtt' V /
��✓t��'��. O �� 4 V`i✓ E-)`ZAIL
STREET.ADDRESS102-73 i 1 1 CITY:STATE.ZIP 5o pAX
Pe
CONTACT NAME ) PHONEE-MAIL
t ((
STREET ADDRESS 1 A( (� i a CITY;STATE,ZIPi FAX
❑ OWNER ❑ owi\'ER-BUn.DEER ( (�1=mvNERAGENT CONTRACTOR ❑CO1\7RACTORAGENT ❑ ARCHITECT ❑ENGLNEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR?vAME LICENSE NUMBER LICENSE TYPE BUS.LIC 4
efr
x-5 8 5 p C
COMPANY NAME V E-I�aAIL (� lFAX
STREET ADDRESS jIJ VV � > CITY;STATE,ZIP
1 /� I PHONE Q�Zq _ q
Ln
ARCHITECT/ENGINEER NAME LICENSE Nbb4BER J V hfh BUS.LIC
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP I PHONE
DESCRIPTION OF WORK
EXISTAG USE PROPOSED USE CONSTR.TYPE - r STORIES
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEE40 TOTAL - - -
AREA AREA AREA. NET AREA
BATHROOM - KITCHEN OTHER
REMODELAREA REMODELAREA REN40DELAREA
PORCH AREA DECK AREA LTE]
TAL DECK-TORCH AREA - GARAGE AREA:. DETACH
ATTACH
D WELLING UNITS: IS A SECOND UNIT ❑YES SEC05D STORY ❑YES
BEL"._DED? El NO ADDITION? []NO
PRE-APPLICATION F-1YES IF YES;PROVIDE COPY OF IS THE BLDG AN ElYES RE IVE Y �-� �,� - TOTAL VALUATIO\:
PLAINS `GAPPL-- ❑NO PLAANZNGAPPROVAL LETTER EICHLERHOME? ❑NO
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read 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 urlding co str cation. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature ofApplicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED rl \CHEcxT1PE..,, ., 2 _,. .xouTl tc_sLIP...
New SFD or Multifamily dwellings: Apply for demolition pennit for ] 0� Iz THR coI .TER Ll BUILDING Pl ar.izE��E�
existing building(s). Demolition pen-nit is required prior to issuance of building , v
permit for new building. Ll EiPxEss I] PLANtL*NGFLAN iE�IEY3>
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STA—D' kRD ❑. PLBLIC i ORItS,'
form if any Hazardous Materials are being used as part of this project. =
LARGE` � FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior t0 � ALAJOR Y � ❑ S4�ITAR1 SERERDISTRICT �
submittal of Building Permit application. x r
Bldg1pp_2011.doc revised.06/21111
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2109
10073 HILLCREST RD CUPERTINO,CA 95014-1021(326 16 013) ATKINSON
CLIM.ATROLLERS INC
SAN JOSE,CA 95112
OWNER'S NAME: TOM LANCE E AND HOLLY W DATE ISSUED:06/10/2016
OWNER'S PHONE:408-209-8832 PHONE NO:(408)294-6290
I
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lie.#258540
Contractor ATKINSON CLIMATROLLERS INC Date 12/31/2016 X BLDG _ELECT _PLUMB
X MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapteri9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license Is in full force and effect. JOB DESCRIPTION:
ADD A/C-REAR OF HOUSE
I hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. I
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. I Sq.Ft Floor Area: Valuation:$8963.00
APPLICANT CERTIFICATION
I certify that 1 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 326 16 013
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,thepplicant understands and will comply with all non -point
source regulatio pert 9
a Cupertino Municipal Code,Section .18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 6 1/ 0/2016 Issued by:Abby Ayende
Date:06/10/2016
OWNER-BUIL DER 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 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(Scc.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sce.7044,Business&Professions Code). Date:6/10/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. 1 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
a. 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 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, Frons 2 505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:6110/2016
I certify that I have read this application and state that the above information is
CONSTRUCTION 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
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 6/10/2016 Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDINGDIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 ICUPERTINO (408)777-3228•FAX(408)777-3333•building0-cupertino.org S C
[:]PLUMBING /// ❑MECHANICAL [:]ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS ( V `�� I (l�1 aces APN#
OWNERNAME .�� V ��� PHONE 140g Sk of g(,Z Jfj E-MAIL
1owe Ij tJ lJJ 32-
STREETADDRESS g QCITY, TATE,ZIP i q,®` V FAX
CONTACT NAME t4 PHONE��d �� �� E-MQIL v C Q&
STREET ADDRESS �(q tI` CITY,STAT4 ZFYIP )no, Ct> fA;S(l7 FAX4 LAZ
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT YIONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER �(I`\ LICENSE TYP (J, BUS.LIC# f j
COMPANY NAME 1 rU 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 EICHLER HOME? ❑NO
DESCRIPTION OF WORK
i
7777
TOTAL VALUATION:
I2EC IVED dvi
er ,,
By my signature below,I certify to each oft a following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provi e s co ect. 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 buildi tion. I authorize representatives of Cupertino to enter the abov -ide_/iified property for inspection purposes.
Signature of Applicant/Agent: Date: 4 L 6
SUPPLEKtNL77INFORMATION REQUIRED s
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CERTIFICATE OF COMPLIANCE CF1R-ALT-02-E
Alterations to Space Conditioning Systems(formerly CF-1R-ALT-HVAC) (Page 1 of 3)
Project Name: 2015-0772 Lance Tom Date Prepared: 2016-06-08
A.General Information
MR-ALT-02 is applicable to multiple space conditioning systems contained within a single dwelling unit.When multiple dwelling units must be documented,
use one MR-ALT-02 document for each dwelling unit.
01 Project Name 2015-0772 Lance Tom 02 Date Prepared 2016-06-08
03 Project Location 10073 Hillcrest Rd 04 Building Type Single family
05 CA City Cupertino 06 Dwelling Unit Name 2015-0772 Lance Tom
07 Zip Code 95014 08 Dwelling Unit Conditioned 1650
Floor Area(ft2) -
Number of space conditioning .
09 Climate Zone 4 10 (SC)systems in this dwelling 1
unit.
B.Space Conditioning(SC)System'`Information �°
t� � m
01 02 { ' 04
'66"' 07 0� 09 10
w
ww
Is the SC Installing a a
SCS stem SCS stem CFA served
System y > systema refrigerat nstalhng neve listailrng tallrng installing
Identification or Location or Area by this SC ducted containing system more than 40 a tirely new 'entirely new
Name Served System(ft2) system? component? components? feet of ducts? duct system? SC system? Alteration Type
Furnace
Replacement,Add Whole House 1650 Yes Yes Yes No No No Altered space
AC conditioning system
C. Extension of Existing Duct System,Greater Than 40 Feet(Section 150.2(b)1Diib)
This section does not apply to this project.
Registration Number:216-A0212947A-000000000-0000 Registration Date/Time: 2016-06-08 14:16:52 HERS Provider:CalCERTS
CA Building Energy Efficiency Standards-2013 Residential Compliance Report Version:2013 Rev 1.007 Report Generated:2016-06-08 14:17:07
Schema Version:0.555SDD
r
F' -
CERTIFICATE OF COMPLIANCE CFiR-ALT 02-E
Alterations to Space Conditioning Systems(formerly CF-IR-ALT HVAC) (Page 2 of 3)
D.Altered Space Conditioning System(Sections 150.2(b)IE and F)
01 02 03 04 05 06 07 08 09 10 11 12
Heating Cooling
System Heating Altered Heating Minimum Altered Cooling Minimum Required New or
Identification System Heating Efficiency Efficiency Cooling Cooling Efficiency Efficiency Thermostat Replaced New Duct
or Name Type Components Type Value System Type Components Type Value Type' Duct Length R-Value
Furnace All new All new This field or This field or
Replacement, Central gas heating AFUE 80 Central split cooling SEER 14 Setback section is not section is not
Add AC furnace components AC
components applicable applicable
Required Documentation:
2R--MCH-01-E-Space Conditioning Systems'Ductsand Fans: - -
- - -
-Duct insulation requirement for new plenums:R6.
CF211=MCH-20-H&CF311-MCH-20-11-Duct Leakage testing required when heating or cooling components are installed in ducted systems,or when more than 40 ft of duct length is replaced.
-Leakage rate compliance:515%,or<_10%leakage to outside;or,seal all accessible leaks.
CF2R-MCH-25-H&CF3R-MCH-25-H Refrigerant Charge Verification required when refrigerant containing components are installed or altered(applicable in CZ 2,8-15).
CF2RCF3R-MCH-23&CF3R-MCH 23 Air F,I_OW 300 CFM/ton requWedwhen.MCH-25 is required
Exceptions:
Duct systems registered with HERS provider as previously sealed are exernp#fromVC*20 Duct Leakage TesYigg requirements
-Heating-only systems and Air Handler/Furnace changes don require venficatW of Air Flow MC 28V efrige nt'Cha§a M"64 H 2S
Existing duct systems constructed,insulated or sealetlwith-asbestgsare exempifrom MCH= u L kage Test w ergs x k
� ,.
o
a v. y.. cks axa k - WX ;.-�V
E. Entirely New or Complete Replacement Duct item,with or Without Equipment Changed it(Sections ',f1 2 Dila and.AS0.2(b)1E,F)
.: ..,r. n
This section does not apply to this project.
F. Entirely New or Complete Replacement Space Conditioning System(Section 150.2(b)1C)
This section does not apply to this project.
Registration Number:216-A0212947A-000000000-0000 Registration Date/Time: 2016-06-08 14:16:52 HERS Provider:CaICERTS
CA Building Energy Efficiency Standards-2013 Residential Compliance Report Version:2013 Rev 1.007 Report Generated:2016-06-08 14:17:07
Schema Version:0.555SDD
r
CERTIFICATE OF COMPLIANCE CF1R-ALT 02-E
Alterations to Space Conditioning Systems(formerly CF-IR-ALT HVAC) (Page 3 of 3)
Documentation Author's Declaration Statement
1. 1 certify that this Certificate of Compliance documentation is accurate and complete.
Documentation Author Name: Documentation Author Signature:
Faulkner,Cindy
Company: Signature Date:
ATKINSON CLIMATROLLERS INC dba VALLEY HEATING,COOLING&ELECTRICAL 2016-06-08 14:16:52
Address: CEA/HERS Certification Identification(if applicable):
1171 NORTH 4TH STREET
City/State/Zip: Phone:
---------SAN-JOSE CA 95112 -- ---- 408-294-6290
Responsible Person's Declaration statement''
I certify the following under penalty of perjury,under the,laws ofthe State of California:
1. The information provided on-thi5, 11s Certificateaom
f Cpiiance,is true and correct.
2. 1 am eligible under Division 3bfthe 6usiriess`and Professions Code to,.accept=responsibilityfor the building design or system design identified on this Certificate of Compliance(responsible designer).
3. That the energy features and performance specifications materials Components and man ufac u ed deyices for the building design or system design identified on this Certificate of Compliance conform to the
requirements of Title 24,Part 1 and Part hof the Cahfornia`Code of dations
4. The building design features or system,design features identified o his Certificatiof Compliance ar tent wtt the informa&n provided on tither "cabl1ompliance documents,worksheets,
calculations,plans and specifications submitted to the a forcemen en fa, p*val with this bwl in rr t a icatio
5. 1 will ensure that a registered co of tfiis,Certificat df C liance sYsat � �
g copy d,p l trt' ea,ailal)le with,the buiidittg,permit. issugd ford buildii g,and�..ace ava Iablei ;tF) nforcement Y a enc for applicable licable
g
inspections.I understand that a regisfefed copy of this,Cei`fjcate of Compliance i�required to Jae induded w(th thelocumerlationthebuilder provides to tjie builfmg owner at occupancy.
Responsible Designer Name: ., Responsible Designer Signature.
Faulkner,Cindy c� AX�;/lLPh
Company: Date Signed:
ATKINSON CLIMATROLLERS INC dba VALLEY HEATING,COOLING&ELECTRICAL 2016-06-08 14:16:52
Address: License:
1171 NORTH 4TH STREET 258540
City/State/Zip: Phone:
SAN JOSE CA 95112 408-294-6290
Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document and in noway implies Registration Provider responsibility for the accuracy of the information.
Registration Number:216-A0212947A-000000000-0000 Registration Date/Time: 2016-06-08 14:16:52 HERS Provider:CaICERTS
CA Building Energy Efficiency Standards-2013 Residential Compliance Report Version:2013 Rev 1.007 Report Generated:2016-06-08 14:17:07
Schema Version:0.555SDD
T.
SMOKE / CARBON MONOXIDE ALARMS F I Ut!
OWNER CERTIFICATE OF COMPLIANC
1
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•building(Wcupertino.org
�(� P rmit No.
Address �_ + `� - r ��. #of Alarms Smoke: Carbon Monoxide:
U-11-MI -IT,CANNOT BF,FINALED AND COW,LETED ilNiffi THIS CERTIFICATE
SAS BEEN At�1�BFTIJR1irED TO THE Bt1ILD1NG 1VI$10N
zX 3tY rh `w".a'n s s s a Gr k$ >
.. »,
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Ca bon Monoxide Alarms for
compliance with 201.3 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 wl iere no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shall be provided with Smoke A arms and Carbon
N-fo;-ioxi.de alarms. When the valuation of additions, alterations,or repairs to existhig dwelling units exceeds
$1000.,001 CRC Section R314 and CBC Sections 907.2.11.5 and.420.6 require that Smoke Alarms and/or Carbon
Monoxide Al.arms be installed in the following locations:
AREA SMOKE A ARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the X X
bedroozn:ts)
On eve level of a dwelling unit including basements X X
Witl in each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-L urning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CIBC 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 existin-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 meansof attic,basement or crawl
space.Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2.An electiical 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)refere ced above has/have been
installed in accordance with the manufacturers 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 complylyNrtM terms and conditions of this statement
Owner(or Owner„gent's) Jam:
Q YV1 Si nat Date:
Contractor Nar-ne:
Sinature...................................................................Lic.#.....................................Date:-...,.-------------
Sino x and COfo7m.doc revised 03118119
WATER-CONSERVING PLUMBING FIXTUR S �
OWNER CERTIFICATE OF COMPLIANCE � ](
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
11300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (D
CUPERT040 I
(408 3228•FAX(408)777-3333,building((b-cupertino.org 6`
Owner Name _
Address
{ Permit No.
'
1. is your real property are historical site?
❑ Yes ' Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the forma d sign bottom of form.
Vr 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?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
El The licensed plumber's certification has been provided to the Building Division.
Ship the rest of the form and sign bottom of form.
c
No iso 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 d sign bottom of form.
[2"No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
El 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 d 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 ON13 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 mpliant plumbing fixtures
to be replaced with water-conserving plumbing fixtures throughout the building.On or befo e January 1,2017,all non-
compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
Cl 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 n n-compliant
plumbing fixtures to be replaced with%.,iter-conserving plumbing fixtures.
On or before January 1,2019,all non-compliant plumbing fixtures shall be replaced with water-
conserving,
ter-conserving plunibing fixtures throughout the building(regardless of whether property under Does alterations or
improvements)-
Cl My property is a commercial real property. See Civil Code Section 1101.5.
On and after Januaiy 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 altera ons or improvements).
I,as the owner or owner's agent of this property,certify under penalty of perjury that non-coin liant plumbing fixtures will be
replaced prior to date specified above with water-conserving plumbing fixtures in accordance NAth Civil Code Sections 1101.1
through 1101.8,the current California Plumbing Code and California Green Building Standards Code,and manufacturer's
installation requirements,and that the water-conserving plumbing fixtures comply with the reqlireinents as indicated in the
table on the following age.
Owner or Owner Agent'sgnature: Date:
Upon completing a d signing this rti at ;please ret it to the Building Division in order to final your building permit.
SB4072015.doc revised 08/26115