B-2016-2634 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2634
22740 SAN JUAN RD CUPERTINO,CA 95014-3935(342 21 012) OWNER BUILDER
OWNER'S NAME: KOTTKE NELSON AND AMANDA T DATE ISSUED:09/01/2016
OWNER'S PHONE:408-397-4346 PHONE NO:
LICENSED CONIRACTOR'S CONTRACTOR'SDECLARATION ARATION BUILDING PERMIT INFO;
License Class Lic.#
Contractor OWNER BUILDER Date X BLDG —ELECT X 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 affirm under penalty of perjury one of the following.two declarations: (N)GAS LINE OUTLET;INTERIOR;REMOVE(E)GAS FIREPLACE
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:$500.00
APMICANT CERTIFICATION
I 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 342 21012
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 all
this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,.the applicant understands and will comply with ali non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date Issued by:Kim Dunbar
Date:09/01/2016
OWNER-BUILDER DF ARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
folio two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
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(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicant:
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
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. HAZARDOUS MATERIALS DISCLOSURE
z. 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 willermit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12'and the
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 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: �— -
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 ARCIIITECT'S DECLARATION
Code,Section 9.18A 1 understand my plans shall be used as public records.
Signature Date ` 41/�� Licensed
Professional
GENERAL PERMIT APPLICATION
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COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE.CUPERTINO, CA 95014-3255
(408)777-3228 FAX(408)777-3333 building Q@
CUPERTIN0 cupertino.org
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❑PLUMBING ❑MECHANICAL [:]ELECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS �a / -/ ()ry (J _R1 7N# p 2-1 - 0I
OWNER NAM - l /So E A l�I� �! PHONE 408 f 3� E-MAIL r l kaly mcg>�[-w+
STREET ADDRESS 00-7L /�} 5o ,!7� CITY, STATE,ZIP (A r�%j CA 0_14
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CONTACT NAME/�oe, /`a l � PHONE %t p 9-3YA s�1��/f E-MAIL k6 ax-I C00"t
STREET ADDRESS [t CITY,STATE,ZIP (� 'T�f4•� FAX
❑ mvNER OVnHR-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑. ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
4NAME �I 1/ LICENSE NLW13ER LICENSE TYPE BUS.LIC
COMPANY NAME ` J� E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# '
COMPANY NAME F.-MAIL FAX v
STREET ADDRESSp� CITY,STATE,ZIP PHONE
USE OF yy SFDorDuplex ❑ Multi-Family PROJECTINWILDLAND PROJECT IN
STRUCTURE: (❑ Commercial URBAN INTERFACE AREA ❑ Yes No FLOOD ZONE ❑ Yes NO
DF_SCRIPTION OF WORK
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TOTAL VALUATION: ( (� RECO D - ,
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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 pro ided is correct. I h ve read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bu a construction. uthorize representatives of Cupertino to enter the above=identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
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'MEPMiscApP_201 Ldoc revised 03/16%11
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•building ancupertino.ora
Ct,1PERTlNO
-2,01(p -ob-34
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 �43 6y CaVt�V0_ APN 1 /i� /� _ -6P# 1 3
OWNER'NAME OWNER ADDRESS
Rk C„Pe,4 ,z CAR
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DESCRIPTION OF VNORI(;_.__`i,� 0 Q 1 v i e ,,y, ® cwt /,)IL- Ay .-_x4,,
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issuedin 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.)
T�.1 1 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 unlicensed person 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.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
e construction and are not hiring a licensed Contractor to assume this responsibility.
�3. I 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
e instead of my own.
r _
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
umbers on permits and contracts.
5. I understand if 1 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, L may be
considered an"employer"under state and federal law.
6. l 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.
7. I 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.
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.
OwnerBuildeYFonn 2010.doc revised 04/14110
9. I understand Imay 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 1-800-321-CSLB(2752)or www.cslb.ca.gov for more information about licensed
contractors.
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10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that Ie 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
bapplicable laws and requirements that govern Owner-Builders as well as employers.
X12.
all 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: /V
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification ac eptable tote city may be required to be presented when the permit is issued
to verify the property owner's signatur ,
Property-Owner's-Signature: , Date: I l
---- -
- -- ------- -------------------------------- -------------------------------- -------------------------------------------------
(NOTE. The following Authorization 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 mypersonal responsibility, 1 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:
1 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:
OwnerBuilderForm Z010.doc Devised 04/14/10
SMOKE / CARBON,MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTI.I�t.0
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 "
(408)777-3228•FAX(408)777-3333 e buildino(a.cupertino.org
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PermitNo. aG3�f
Address ed D7 9 Q Lam.®. !i (Ap&mtAof Alarms Smoke: ( Carbon Monoxide: a
V
I�ERII CAB OT BE +WALED D UNTlL THIS CERTIFICATE
H iEEl SI T� D ANIj R N A �7,1111EUII�DING 2 JVUS "YN
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1 01.2
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
Outside of each separate sleeping area in the immediate vicinity of the X X
bedroom(s)
On every level of a dwelling'unit including basements X X
Within each sleeping room _ X
Carbon Monoxide alarms are not'required in dwelluzgs 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,l 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.
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's) -Name: q
kljsk ro+4 :Si, ature....... ... ........................:......Date: .[:.
......... .... . ...... ......I.. .._...... .
Contractor Name:
Signature............................. .....................................Lic.#......................................Date: ...................
Smoke a71d CO for7n.doe revised 03118114
WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE FILE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 977 e
y-
1, 1' -I I? C3 10300 TORRE AVENUE.CUPERTINO, CA 95014-3255CER
-�
(408)777-3228• FAX(408)777-3333•building(a)cupertino.org
Owner NamePermit No S•3ui.• 14
Address J, 790 njra . R1 cijae* 0 (A !S'O/el
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.
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. a
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?
❑ 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. Please check ONE of the following:
My property is a single-family residbntial 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. 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 lumbing fixtures comply with the requirements as indicated in the
table on the following page. If
Owner or Owner Agent's Signature: '1 Dater 16
Upon completing and signing this Certificate,please return it to the Building Division in order to final your building permit.
SB4072015.doc revised 08126115