B-2016-2537 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2537
22076 RAE LN CUPERTINO,CA 95014-4031(356 07 028) PLUMBING TECH INC
SAN JOSE,CA 95173
OWNER'S NAME: LEE KEIBOCK AND MINAE DATE I SUED:08/17/2016
OWNER'S PHONE:408-955-5572 PHONE o:(408)347-0000
LICENSED CONIRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#933572
Contractor PLUMBING TECH INC Date 07/31/2017 X BLDG _ELECT X PLUM
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 affirm under penalty of perjury one of the following two declarations: REPIPE;SFD(COPPER)-FUL ;REPLACE WATER MAIN SERVICE
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.
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:$10000.00
APPLICANT CERTIFICATION
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: Occupan y Type:
and state laws relating to building construction,and hereby authorize 356 07 028
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 F PERMIT ISSUANCE OR
Additionally,the appI' nt understands and will comply with all non-point
source regulations r the Cupertino ipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 08/17/2016 Issued by:MELISSA NAMES
Date:08/17/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the ZOOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. L as owner of the property,or my employees with wages as their sole installed without first obtaining an ir spection,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:08/17/2016
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 Certifica[e 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 mate Lais 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 Co e,Sections 25505,25533,and 25534. 1 will
permit is issued. maintain compliance with the Cu erdno 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 5532(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 devices which emit hazardous
air contaminants as defined by th�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 Cod¢,Sections 25505,25535.and 25534.
Labor Code,I must forthwithcomply with such provisions or this permit shall
be deemed revoked. ;Owner or authorized agent:
APPLICANT CERTIFICATION Date:08/17/2016
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 and state laws 1 hereby affirm that there is a construction lending agency for he-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 mentionedproperty for inspection purposes. (We)agree 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 AR HIT . T'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be usied as public records.
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Licensed
Signature Date 08/17/2016 Professional
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GENERAL PERMIT APPLICATIONMEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
UPEFsTtIY� (408)777-3228•FAX(408)777-3333•buildingOcupertino.org
MISC
❑PLUMBING ❑MECHANICAL [:]ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS
OWNER NAME PHONE E-MAIL
STREET ADDRESS CITY, STATE,ZIP FAX
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CONTACT NAME PHONE E-MAIL'
STREET ADDRESS CITY,STATE, FAX
El ovmTTER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 111 ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME 6 LICENSE NUMBER LICENSES E BL' .L
COMPANY NAME E L FAX
STREET ADDRESS CITY, ATE,ZIP PHONE
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ARCHITECTIENGINEER NAME LICENSE NTUMBER BUS.LIC
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF R<SFD Or Duplex El Multi-Family PROJECT IN WILDLAND PROJECT N
STRUCTURE: ElCommercial URBAN INTERFACE AREA ❑ Yes [INo FLOOD ZONE ElYes ElNO
DESCRIPTIONT OF WORK {
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TOTAL VALUATION: RECEIVED BY', "
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B in signature below,I certify to each of the following: I am the property owner or authorized agent to act on the roe owner's behalf. I have read this
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application and the information I have provided is correct. I have read the Description of IATork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building ronstruction. I auth resentatives of Cupertino to enter the abrod properfor inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED x.o>FICE USE oniY,
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SMOKE CARBON.MONOXIDE ALARMSHL
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OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERT11NIf3 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228 FAX(408)777-3333.e buildingCcDcupertino.org
Permit No.
Address a e 0 7(7 C 6Le- ii t�tyte► � #of Alarms Smoke: Carbon Monoxide:
PERNIIT CANNOT BE FINALED ASVD COMPLETED UNTIL THIS CERTIFICATE
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 CO ALARM �Y =
Outside of each separate sleeping area in the immediate vicinity of the X X '
bedroom(s)
On every level of a dwellin 'unit including basementsX 10,0 X
Within each sleeping room p X J
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 alterations 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 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 comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
Si nature.....:: ........ ........... ......... . ....................................................Date:*
..
Contractor Name:
Signature...................................................................Lic.#......................................Date: ...................
Smoke and CO fornzdoe revised 03118114
WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION FILECU.PE'�'�"INO 10300 TORRE AVENUE CUPERTINO,CA 95014-3255Pn�
p (408)777-3228• FAX(408)777-3333•building(d)cupertino.oea
Owner Name �'i lc__`�d1irl- Lea= 21e `r� ( �� Permit No 1_T_�0?G 7
Address ` D 76 gzu Lmaes p x1! -► (`
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 of form.
VNo 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 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.
VNo 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.
VNo 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 of form.
V 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 resWntial real property. See Civil Code Section 1101.4.
Ori 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. 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- 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 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 Signature: Date:
Upon completing and signing this Certificate,please,rellim it to the Building Division in order to final your building permit.
SB40'7 2015.doc revised 08126115