B-2016-1955 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1955
19975 PRICE AVE CUPERTINO,CA 95014-3338(369 05 040) CLEAR OAK DESIGNS
INC
SAN JOSE,CA 95112
OWNER'S NAME:POCHYLSKI THOMAS TAND KATO SHIRLEY A TRUST DATE ISSUED:0511612016
OWNER`S PHONE:408-255.7575 PHONE NO:(408)436.5448
LICENSED CONTRACTOR'S DECLARATION ARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRA TOR LIS.#453544
Contractor CLEAR OAK DESIGNS INC Date 08/31/2017 3X BLDG—ELECT_PLUMB
I hereby affirm that I am licensed under the provfsions of Chapter 9(commencing.
_MECH Z 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:
'
- I hereby affirm under penalty of perjnhy one of the following two declarations: REMODEL(E)MASTER&HALL BATHS,LIKE FOR L1IO(195 .F.)
1. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided Burby Section 3700 ofthe Labor Code,for the
erfm•mance 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 die performance of the work for which this
.permit is issued. Sq.Ft Floor Arca: Valuation:531000.00
APPLICANT CERTIFI A TON
1 certify that l 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 369 05 040
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 START ED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE R
Additionally,the ap cant undo glands and will comply with all non-point
source regula�tionnsserr thhe Cu ertino Municipal Code,Section 9.18, 1$101DAYS FROM LA INSPECTION.
Signatureate 0511612016 Issued by:MF,LI A
Date:05/16/20
OWNER-BUILDER DECLAIM _
I hereby affirm that I am exempt from the Contractor's License Law for one of the '-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a rooris
r. I,as owner ofthe property,or my employees with wages as their sole installed without fust obtaining an inspection,j agme to remove all new mate•als for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(See.7044,Business&Professions Code)
2. 1,as owner orthc.property,am exclusively contracting with licensed Signature of Applicant:
contractus to construct the project(Sec.7044,Business&Professions Code). Date:0511612016
°« I hereby affirm under penalty of perjury one of the fallowing three declarations: ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
i, I have and will maintain aCertificate ofConsent to self-insure forWorker's
Compensation,as provided for by Section 3700 of the Labor Cade,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 if the
Section 3700 orthe Labor Code,for the performance of thte woric 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 2 rd 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 hazar tons
shall not employ any person in any manner so as to become subject m the material.Additionally,should I use equipment or devices which emit h rdous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after snaking this certificate of tylll maiinain compliance with the Caper fro Municipal Code,Chapter`912 and
exemption,l become subject to the Worker's Compensation provisions of the the Health&Safety Code,See.ons 25 Oj. 533,and 25534,
Labor Code,I must forthwith comply with such provisions or this permit shallbe deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:0511612016.
I certify that I have read this application and state that the above information is f_41Y5T TO L--
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 perfo mance
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, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITEC'T'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Signature Date 05/15/2016 Licensed
Professional
x
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinana cuper lno.orn
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❑NEW CONSTRUCTION ❑ ADDITION ✓ ALTERATION 1 TI ❑ REVISION I DEFERRED ORIGINAL PERMrr#
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❑OWNER ❑OWNER-BUILDER ❑OWNERAGENT ❑CONTRACTOR ❑CONTRACTOR AGENT 0 ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TSNA qT
CONTRACTOR NAME LICENSE M5R�; TYP LICENSEBUS.LIC# z/9
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STREETADDRESS CITY TB,ZIP PH NE
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ARCHITECTIENUINEER NAME LICENSE NUMBER EUS.LIC#
COMPANY NAME E-MAIL FAX
STREETADDRESS C1TY,STATE,ZIP - PHONE
DESCRIPTION ON WORK - AD W1
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EXISTING USE PROPOSED USE CONSTRTYPE
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-Occ' VALUATION
EJOS'I'G NEW FJMR DEMO TOTAL
AREA AREA AREA NIlTAREA
BATHROOM n�/ KITCHEN OTHER __-. ..
REMODEL AREA t REMODELAREA. REMODELARHA
PORCH AREA DECK,AREA 'rOTALDECR/PQRCH AREA GARAGEAREA:❑DETACH
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F DWELLING UMTS: I.SASECOND UNIT
❑YES SECONDSTOnY ❑YFs '
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By my signature below,I certify to each of the following: I am the property owner or authorized agent to ac a property owner's behalf.I have 1-ad thI
application and the information I have provide is correct. I have read the Description of Work and veriffiTis accurate. I'agree to comply with all applicable local
ordinances and state laws relating to bui 'n ns cti . l.autiro' representatives Of CUperthlo to enter the above-i entifie pmporty for inspection purposes.
Siglla(ureofApplieantlAgent, Date; (p
SUPPLEMENTAL TEAL IN ORMATION REQUIRED PLAN CHECx PE ROUTING SLIP
New SPD or Multifamily dwellings: Apply for demolition permit for ❑ or ER THE CUDr TER ❑ Bw Dlnc PLA 1 REv[Etf
existing building(s). Demolition permit is required prier to issuance of building .
permit for new building. C7'EXPRESS _ L7 pLAI�A7\'G PLAN REt IEFV
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ srAnnaRD = ❑ ptJ'Hi is csoRxs
fornt if any Hazardous Materials are being used as part of this project.
❑ T�iIRGE - ❑.FIRE DEPT
_
Copy of Planning Approval Letter or Meeting with Planting prior to
❑ 31l9JOR ._` ❑ SANITARY SES\ER DISTRICT
submittal of Building Permit application.
_ENIHRONRIENTAL]IEALTH.
B1dgApp_2011.doc revised 03/16/11
COMMUNITY DEVELOP:MENT!DEPARTMENT•BUILDI .G DIVISION
10300 TORRE AVENUE-CUPERTINO,'CA 95014-3255
(408)777-3228 FAX,(408)777-3333 a�jbuilding(@.cupertino oro
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PURPOSI
Tliis 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 acce s.for
inspections are required.
GVIO Ail.,WORMATION
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 8314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or C irbon
Monoxide Alarms be installed in the following locations:
AREA SMOKE AILARIWI -CC)AL \j-p,
Outside of each separate sleeping area in the immediate vicinity of the X X
bedrooms)
Oftevery level of a dwelling unit includin,..baasements X
Within eacz slee in room
Carbon Mwonoxide alarms are not requ-iced in dwellings which do not contain fuel-burning appliances and that
do not have ari 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 comm, ercial power supply,alarms)may be solely battery opE,rated.
In existipg,dwelling units, alarms are permitted to be solely battery operated where repairs or alteratzo s do
not res&I in the removal of wall and ceiling finishes or there is no access by means of attic,basement o crawl
space:.Defer to CRC Section 8314 and CBC Sections 99,7.2.11.4 and 420.6.2.An electrical permit is.req,u` ed,for
alarms,whic11 must be connected to the building wiring.
As owner of the above-referenced property,I hereby certify that the alarm(s)referenced above has./hava been
instalTed in,accordance with the ,}Manufacturer's instructions,and in compliance with the Cal-d rrua R ui`dung,
and CaRfa-n,da Residential Codes.The alarms-have been tested arad are operational,as of the date slignEd
below'.
1.haus read and a rae to corn;.G;-w�f1i;Elie Cecros and conditions of this statement
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WATER-CONSERVING :PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION.
CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777=3228•FAX(408)777-3333•building(a)cuperti_no.org
Ow er N ie j T�rr Pa c v I s k'a 5 h,a r t�1® 1 ag o % . erinit N o 415 5
Aess 129 7 Price, Avenue, Cubes+ano_ CA '1501y
1. Is your real property a registered historical site?
11 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 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.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
L jW 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 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?
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 and sign bottom of form.
EA 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 ign
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 1,2017,all non-
compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
El' 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- cons wing
plumbing fixtures throughout the building(regardless of whether property undergoes alterations or improvemeits).
I,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-conserving plumbing fixtures comply with the requirements as indicated in the
table on the following page. _
Owner or Owner Agent's SignatuIre: I .f9 Da'-Ce-.---)-7/1 1(r,
Upon completing and signing this Certificate,please return it to the Building Division in order to final your building permit.
SB4072015.doc revised 08/26115