B-2016-2401 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2401
10290 JOHNSON AVE CUPERTINO,CA 95014-3812(375 25 057) OWNER/BUILDER
OWNER'S NAME: SLAWINSKI LUKASZ DATE ISSUED:07/28/2016
OWNER'S PHONE:408-916-8117 PHONE NO:
LICENSED—CO-N-TRACTOR'S DF T RATIGN BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Date X BLDG X ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH 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:
I hereby affirmunder penalty of perjury one of the following two declarations: UPGRADE PANEL(200 AMP);RE-WIRE KITCHEN;ADD
DEDICATED CIRCUIT FOR ELECTRIC FIREPLACE INSERT
i. 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.
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:$3600.00
APPLICANT CERTHFICATION
1 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 375 25 057
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 the granting all
this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and willl comply with all non-point.
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM L AL PECTION.
Signature Date Issued by:MELIS
Date:07/28/201t--
OWNER-BUILDER
7/28/201O R-B ILDER 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.
?_sIale(Sec.7044,Business&Professions Code)
,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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
ermit is issued. P P P � P
s�Tcertify 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 us quipment or devices which emit hazardous
air contaminants as defined by the Ba Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the u rtino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cod , tions 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:
I certify that I have read this application and state that the above information is N TR TI N I ENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is an ruction 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(See.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, ostand expenses which may accrue against said City in Lender's Address
consequent of sthe, granting of this permit. Additionally,the applicant understands
and will com with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Sectio .18. 1 understand my plans shall be used as public records.
/ C� ® IefGensed
Signatur Date / fessional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333 buildina(_a)cuDertino.Org misc
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PLUMBING MECHANICAL I ELECTRICAL MISCELLANEOUS
FPROJECTESS J g� } APN#
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STREET ADDRESS .. of i�lra FAX
CONTACT NAME e 2 7` PHONE ®may
STREET ADDRESS O i� C %P'W �C 44
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OWNER ❑ OWNER-BUILDER 1101---- GENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME R LICENSECPE 1. BUS.1,IC -
COMPANY NAME 10 01 120 �"� F 0 !�L:. f' ��! -l✓` FAX. -.
m✓
STREET ADDRESS y-,�r�
( � .-1 CITY STATE,ZIP ` p j ` PHONE-'-"/ �a
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ETsFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WBALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ S
BUILDING:. ❑COMMERCIAL URBAN INTERFACE.AREA MAO FLOOD ZONE ®1NO EICHLER HOME?
DESCRIPTION OF WORK
iqyv
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TOTAL VALUATION:
3600
(`)
By my signature below,I certify to eacblofmw 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 pro ' d 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 buildi construction. I authorize representatives of Cupertino to enter the above-id nt'led p for inspection pu oses.
Signature of Applicant/Agent: Date:
S PPL MENTAL INFORMATION REQUIRED
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MEPMiscApp 201 Ldoc revised 06/21/11
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333•buildinciCcDcupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
„improvements specified at:
SITE ADDRESS 2A,�C �� APN _ BP#
OWNER NAME ,OWNERADp,D,RESS ,fir
DESRIPTION OF WORK: 'fir
AIN
,v
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make yoavCv,�areof
your responsibilities and possible risk you may incur by having this permit issued'in your name as the Owner-Builder. We
will not issue a'building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain.an"Owner-
Builder"building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. 1,as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensedperson and his or-her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
/_�5_2. I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
/--53. 1 understand as an "Owner-Builder"I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
�5 5. 1 understand if I employ or otherwise engage any persons,other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer"under state and federal law.
Z6. I understand if I am considered'an "employer" under state and federal law, I must register with the state and
federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
ZCJ 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
/is performed under contract with a licensed general building Contractor.
C� 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
0w71e7-Bui1de7For7n2010.doc revised 04/14/10
9. f understand I may obtain more information regarding my obligations as an"employer"from the Internal
Revenue Service, the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)at 1-300-321-CSLB(2752)or www.cslb.ca.gov for more information about licensed
contractors.
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be-unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be is ued,this form must be completed and signed by the property owner and
returned to the agency responsibI f r issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other venficatio ceptable to the city may.be required to be presented when the permit is issued
to verifythe property owner's si net r
Property Owner's Signature: J` Date: '
(NOTE: The following Authorizati Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OwnelBuildeJForm 2010.doc revised 04114110
fi SMOKE I(A BUN ,, , 1gA RMIS
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° OME ' fI'C-A '� "SIF COMPLIANCE
COMMUNITY DEVELOPMENT'aEP3ARl MENT®>>
BUILDING,DIVISION,
VVIV f 1C 10300 TOAVENUE CUPEl�TINC},'CA 95094-3255
{448)777 3228 a FAX('408,)777- 333 m buil'tlirra*eupertno org .-
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77
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This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
cornplim-ce with,2013 CRC Section R814,2013 CBC Sections 420.6 and 907.2.11.2 where no interior access.for
iizspec'tions are required.
G1 NU L I `QRjIAA[j0,.\`l
tXistin sile faxnil
g=rt g y and multi-faiYiily dwellings shall be provided with,Smoke Alarms and Carbon
Monoxide alarms Wien 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/o'r Carfi�on
Murmide Alarms be installed in the following locations:
AFS IIL A A lCU AARI-
Outside of each,separate sleeping area in the immediate vicrriify of tfie Xi
f�ed7®ori si
Ort eye-,levet of a dwelling unit inclitd q4- basements
X
Wit,hi eadz:9fee in root;; X I
Carbon Monoxide alarms are not required in dwel m -gs which dig not ccntarrr fuel-bulmim"gappliances and that
do nrotlzatve a�attached gaga{ge Carbo71 moznox�de alar<rrtseon b-fined with smotke alarms shall comply wit
CBC Section 4I2Q'.6 and sl2all be aMoved by the Office of the State.Fire Marshal.
Power Supply:Tit=dwelling unmts aitJ1 ruo=co ercial power supp>Iyr alarnn(s)t inay be soXely bettee-r operated.,
I�n exi�strg d`well'ing units,alarrm�s are permii-ted to be snletly battery operated wliere repaErs ax altera�tiro�ls dog
not result a�tthe rerxtoval of walk �zd eeilutig,finishes or dt�ere is ino access by me�anst ajf'attf�c,b�asezxn t�o�crawll
space.,Defer to.CI.C'Secfol�T3%14 and CBC Sectsoyns 9'07.2..11.4 and X20 6.2..Am eIect�rcal per:_ is, e ;aired fog
alarms;wlnicl�must bte coiuneeted to the burldirig wiring.
1\0
AAs owner o1 the above refereiic d property,I hnereb>y certify`tlitat tlne alarixi(s),referemce-d abov: a en,
instalITed im accordaizce wit,h the ���a,inmfa.ctUrer`s instructiens aind i no,conap Rance with.the CaI'` :ar Build tig
amd.Cah€6mla Iles R,A,1 Co'des'.The alarms.IIZave been tesEed and,are opera;Tonal,as,of the date sighted
biel'ow.,
Y, 1'tnave,ready ands a .e.e'to,co G; with thea ter as aad coradctrons,:d"t;Afa,s btemenfi'
AM, IVB
— �t at[Ireb
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€ SPgnat�re ...._. ................Dates
WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT,BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
408)77 -32 8•FAX{40 )777-3333•buildingCa7cupertino org
Owner Name
.: � _- Permit No,: )
Address
C
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.
/ 1Y 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?
El Yes Civil Code Sections 1101.1 through 1.101.8 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.
JE,J No Go to Question 3.
3. Is water service permanently disconnected for your building?
Q Yes Civil Code Sections 1101`:1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
t lV No Go to Question 4.
4. Is>your real property built and available for use or occupancy on or before January 1, 1994?
L�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.
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. Pease check ONE of the following:
yea
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).
My property is a multifamily residential real property. Sec 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 properly undergoes al ra ons 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-comp ran
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 wat ons g
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 fixtures will be
replaced prior to date specified aboveth water-conserving plumbing fixtures in accordance with Civil Code Sections 1101.1
through 110 1.8,the current California lumbing Code and California Green Building Standards Code,and manufacturer's
installation requirements,and that the ter-conserving plumbing fixtures comply with the requirements as indicated in the
table on the followingpage.
h s '
Owner or Owner Agent's Signatur Date:
Upon completing and signing this tedificate,please return it to the Building Division in order to final your building permit.
SB4072015.doc revised 08126115
r � :
ori-CoMpiiapt ,
Water-Conserving Plumbing Fixture
PlumbirF Fixture i ' (Fixture Complying with Current Code Applicable to New Construction)
Fixture Type Maximum!Mater fUsa a/Flow'Rate
Water Usage ' 2013 CPC Ch.4 2013 CPC Ch.4 2013 CPC Ch.4
/Flow Rate 2013 CALGreen Div.4.3 2013 CALGreen Div.4.3 2013 CALGreen Div. 5.3
Single-Family Multi-Family Commercial
}Nater Closets Exceed 1.6 =average
Residential
(Toilets) e flush toilets 1.28 gallons/flush
Gallons/flushgallons/flush effective flush volume(the composite,
Urinals me of two reduced flushes and one full flush
Exceed 1.0
Gallons/flush 0.5 gallons/flush
showerheads EXceed 2.5 2.€0 gallons per minute @ 80 psi.,Also certified to the performance criteria of
gallons per minute U.S. EPA;haterSense Specification for Showerheads
(A hand-held shower is considered a showerhead.)
For multiple showerheads serving one shower,the combined flow rate of all
showerheads and/or other shower outlets controlled by a single valve shall not
exceed 2.0 gallons per minute @ 80 psi,or the shower shall be designed to
allow only one shower outlet to be in operation at a time.
f=aucets— Exceed 2.2 gallons Maximum 1,5 gallons per Within units: 0.5 gallons per minute @ 60
Lavatory per minute minute @ 60 psi;minimum Maximum 1.5 gallons psi
Faucets 0.8er allons minute
g p a@ per minute @ 60 psi;
20 psi minimum 0.8 gallons
per minute @ 20 psi
i
in common and public
I use areas: 0.5 gallons
per minute @ 60 psi
1.8 gallons per minute
60 psi
Faucets— _ '
1=xceed 2.2 gallons € .8 gallons per minute @ 1.8 gallons per minute 1..8 gallons per minute @ 60
Kitchen per minute 60 psi @ 60 sisi
Faucets I May temporarily increase May temporarily i?
up to 2.2 gallons per increase up to 2.2
minute @ 60 psi, arid must gallons per minute @
6 default to maximum 60 psi,and must
i 1.8 gallons per minute @ default to maximum
60 psl 1.8 gallons per minute
s Where faucets meeting @ 60 psi
the above are unavailable, Where faucets meeting
aerators or other means the above are
may be used to achieve unavailable, aerators or
reduction. other means may be
used to achieve
l reduction.
1. If the existing plumbing fixture water usage/fElow rate is equal to or lower than the figure shown,it is not required to be upgraded.
.SB407 2015.doc revised 08126115