B-2016-2138 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2138
20669 SHELLY DR CUPERTINO,CA 95014-2923(359 11025) RANDO AAA HVAC
INC
SAN JOSE,CA 95125
OWNER'S NAME: LUU KENNETH K AND PHAM LE-VINH TRUSTEE DATE ISSUED:06/15/2016
OWNER'S PHONE:408-252-3370 PHONE NO:(408)293-4717
LICENSED CONTRACTOR'S DECLARATION BUILDING PERNUT INFO:
License Class C-36 Lic.#768871
Contractor RANDO AAA HVAC INC Date 09/30/2017 X BLDG —ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
_NIECH 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:
REPLACE 50 GALLON WATER HEATER
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,
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:$2266.00
APPLICANT NT RTIFT ATION
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 359 11 025
representatives of this city to enter upon they`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 regulat" r the Cupertino Municipal Code,Zection 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Si re Date 6/15/2016 Issued by:Abby y@nde
Date:06/15/2016Lin
{QM(A^
OWNER-BUILDER DECLARATION
I herebyaffirm that I am exempt from the Contractor's License Law for one of the All roofs shall lie inspected prior to any roofing material being installed.If a roof is
P I i
following two reasons. P P Y g g
t. 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: i
contractors to construct the project(See.7044,Business&Professions Code). Date:6/15/2016
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 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 MTERIALS DISLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirement 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 Municipa Code,Chapter 9.12 and the
s. 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
shall not employ any person in any manner so as to become subject to the
material. Additionally,should I use equipment or(evices which emit hazardous
air contaminants as defined by the Bay Area Air Q ality Management District I
Worker's Compensation laws of California. If,`after making this certificate of will maintain compliance with the Cupertino Muni ipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code Sec' 533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agen
APPLICANT CERTIFICATION Date:6/15/2016
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 6/15/2016
Professional
I
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333-building(c)cupertino.ora — WO-011
NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
`n ,{rte�
PROJECT ADDRESS VIV
LIU�!iV V APN# *� ®®"1
OWNER NAME '. -. -.. PHONE r�//y^�;& (�... -.
VWn _ !iJ -39
E-MAIL
STREET ADDRESS CITY, STATE,ZIPUpp
FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑-ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER B„�jI LICENSE TYPE BUS.LIC#
COMPANY NAME IV4 iS E-MAIL�
STREET ADDRESS 'e�, t CITY,STATE,ZIPSay)d Oj PHONE
(4(&)
CA
ARCHITECT/ENGINEER NAME - LICENSE NUMBER BUS.LIC# j
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK _ I O®
I
EXISTING USE PROPOSED USE - CONSTR.TYPE #STORIES - - -- -USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL -AREA AREA AREA NET AREA
I
BATHROOM
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: DETACH - -
ATTACH.
#DWELLING UNITS: isASECOND UNrr ❑YES SECONDSTORY ❑YES -
BEING ADDED? FIND ADDITION? []NO
PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YE$ RECI1$Y TOTAL VALUATION:
PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? []NO
Iola
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on he 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 build' construction. I authorize representatives of Cupertino to enter the above-idntifie �ropQrty for inspection purposes.
Signature of Applicant/Agent: Date: 11
SUPPLEMENTAL INFORMATION RE D ` riAN CItECYfi Tob�Iiv -SLiR
_New SFD or Multifamily dwellings: Apply for demolition permit for ❑ aye `CavNTER �I sY11LDmTG rI AI�REVIr iv
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.. ❑ xPR> s ❑ PLANNING'P
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑.sTANDAxn ❑ PUBLIC yvo12zs
form if any Hazardous Materials are being used as part of this project.
❑.;LARGT't„ ` ❑ FIR�Drs`P7` -,' 1
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ ivrAloR ❑ SANITARY 5E4YER DISTRrCT
submittal of Building Permit application.
�.&TVV.IRONIyITaNI'ALHEALTH,
BldgApp 2011.doc revised 06121111
�J F` �
SMOKE / CARBON MONOXIDE ALARMS F «,
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
r_VP RT1t40 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•build ing(c�cupertino.org
��,, ] No.
Address i" �,,(�l � UCJI� vylv&
_ ____#of Alarms Smoke: Carbon Monoxide: j
.PERMIT CANNOT BE FINALED ANII CO)PLETED UNTIL THIS CERTIFICAT
j , H SEE a A RFS Yh
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 unJ is 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 ever-level of a dwelling 1mit including basements X X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning applian ces 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 batter 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,basemE 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/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 igned
below.
/have read and agree to comp! with the terms and conditions of this statement
Owner(or Owner Agent's)Name: j /^
Sinature.......:.. ......�' ... .............." .........................................�.... ate/,_`
Contractor Name:
JIMkoyAt Signature.. .... ... ....................... Lic.#.... LY• �.1.........I Date:
Smoke and COfonn.doc revised 03118114
a
h
MF «''
WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
GUPtTIIC +E 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
K�t (408)777-3228•FAX(408)777-3333 building(a7cupertino.org
Owner Name((�\� \/ Permit No. U
Address w�! ,V o �o
L %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 ol 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 form.
i, 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.
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. "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-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 requirenon-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-compliantplumbing 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 manu acturer's
installation requirements,and that the water-cons evirig plumbing fixtures comply with the requirements as indicated in the
table on the following page.
Owner or Owner Agent's Signature:. __._______.____ Date:
- _Upon completing-and signing this Certificate,please return it to the Building Division in order to final your b 'di g permit.
SB407 2015.doc revised 08126115