B-2016-2677CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2677
21230 RAINBOW DR CUPERTINO, CA 95014-4985 (366 51 014) HOMEOWNER/BUILD
�ER
OWNER'S NAME:
OWNER'S PHONE:
LICENSED CONTRACTOR'S DECL RATION
License Class Lic. #
Contractor HOMEOWNER/BUILDER Date
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
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.
z. 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.
APPLICANT 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
and state laws relating to building construction, and hereby authorize
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
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 Code, Section 9.18.
Signature Date 9/8/2016
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
to construct the project(Sec.7044, Business & Professions Code).
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
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
I c 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.
a. I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the
Worker's Compensation laws of California. If, after making this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
APPLICANT 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 and state laws
relating to building construction, and hereby authorize 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,
Signature
DATE ISSUED: 09/08/2016
PHONE NO:
BUILDING PERMIT INFO:
X BLDG —ELECT —PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
REROOF; TEAR -OFF; INSTALL TILES - (30 SQ)
Sq. Ft Floor Area: I Valuation: $20000.00
APN Number: Occupancy Type:
366 51 014
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Abby Avende
Date: 09/08/2016
RE -ROOFS:
All roofs shall be inspected prior to any roofing aterial be' installed a roof is
installed without first
Date: 9/8/2016
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality M genre District I
will maintain compliance with the Cupertino Mu ipal e, Cha r 9.12 and
the Health & Safety Code
Owner or authorized agent:
Date: 9/8/2016
CONSTRUCTION LI(NDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
9/8/2016 Professic
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinq(acupertino.orq
CUPERTINO V' Za
PROJECT ADDRESS U > 1 I \
yl
APN# � % (Q ^4/ — ,l
OWNER NAME 0
�O�vL
PHONE '/
— Y
E-MAIL
G^nl AI•K.& 6ki LML
STREET ADDRESS
ctoLl/
CITY, STATE, ZIP /J FAX
CONTACT NAME
��tt
PHONE - E-MAIL
STREET ADDRESS _ I
S
CITY, STA);C,, ZIP
1 col—
FAX
1
WNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TIi\:SFT
CONTRACTOR NAME �- • 16, // )
LICENSE NUMBER
F7777
BUS. LIC. #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECTIENGINEER NAME
LICENSE NUMBER
BUS. LIC. #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF SFD or Duplex ❑ Multi -Family
STRUCTURE: ❑ Commercial
ROOF AREA:
���
VALUATION:
D boo
EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES D SHINGLES ❑ OTHER (SPECIFY)
REMOVE /REPLACE XES
13
13 NO
I IF NO,
# LAYERS:
PLYWOOD 13w, 13PLYWD
THICKNESS: ❑ 5/8"
13OSB
TYPE: ❑ CDX
PITCH:
' 12
ROOF
CLASS:
�
PROPOSED ROOF TYPE: ❑ BUILT-UP ROOF 13 ASPHALT SHINGLES 13 WOOD SHAKES 13 WOOD SHINGLES THER
ICC -ES REPORT
DESCRIPTION OF WORK: l
l .4 =14
IjS t� ► r%
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WW
ng:, la th perty er or authorized agent to act on the property owner's behalf. I have read this
By my signature below, I certify to each of the f�i�'!omply with all applicable local
ordinances and state laws relatingto ding cc n. oriz esentatives of Cupertino to enter thnerty for ' pection purposes.
application and the information I have pr vided L I ha ad th scription of Work and verify it iWRP
Signature of Applicant/Agent: Date:0
SUPPLEMENTAL FORMATION REQUIRED
_ If building is associated with a Home Owner's Association, provide letter
of approval from HOA.
Provide Planning approval to verify if there any restrictions.
Provide copy of Manufacturer's Installation Specifications.
Provide signed copy of Cupertino's Tear -Off Policy.
OFFICE USE ONLY
PLAN CHECK TYPE
ROUTING SLIP
I QSVER-THE-COUNTER
❑ ExPRESS
❑ STANDARD
❑ BUILDING PLAN REVIEW
❑ PLANNING PLAN REVIEW
❑ FIRE DEPT
❑ OTHER:
ReroofApp_2011. doc revised 03116111
CUPERTIN&
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.orq
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 AP N, BP#
OWNER NAM OWNER ADDRESS
DESCRIPTION OF WO K:
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 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
(DIREqTI S: Please read and initial each statement below to signify you understand or verify this information.)
Y. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
u' der" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, 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
Ine
r ce coverage fol- injuries to workers on my property.
. I understand building permits are riot required to be signed by property owners unless they are responsible for
iecit
truction and are not hiring a licensed Contractor to assume this responsibility.
understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
Dmyself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
na e . stead of my own.
i 4. 1 nderstand Contractors are required by law to be licensed and bonded in California and to list their license
nu e on permits and contracts.
. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
otal al e of my construction is at least five hundred dollars ($500), including labor and materials, I may be
con re an "employer" under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
ederal 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
/residential
s ou financial risk.
I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licens d contractors and the number of structures does not exceed four within any calendar year, or all of the work
is pffinalnu
ed under contract with a licensed general building Contractor.
derstand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any cial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
Oli'77erBuilder17'o7-m 2010.doc revised 04/14110
///11'
9. 1 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 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
con rs.
I 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.
I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
Ale laws and requirements that govern Owner -Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
' formation 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 issued, this form Fe�ray
st be completed and signed by the property owner and
returned to the agency responsible for issu'ng thermit. Note: A py of the property owner's driver's license,
form notarization, or other verification a pt /e to be re red to be presented when the q�rmit r issued
to verifv the orooertv owner's sionatu� / - /— �/
-------------------------------------------------------------------------------------------------------------------------------------------
(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 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:
Address of Authorized Agent:
Tel No
I 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:
O11'77ci-Bllilde7'F01771 2010.doc remised 04/14/10
CUPERTINO
REROOF TEAR -OFF POLICY
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(d)cupertino.orq
PROJECT ADDRESS I/
A \ r
APN #OWNERNAME:
(�V
�1
PI1t iNP:
E-MAILLy_� I
STREET ADDRESS_
( '
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I'll), STATE, ZII
F '
C( )NTRACTOR NAMF
t 8
LIt'ENSE W'Ml3FR
LICENSE TYPE
131 S. LIC. 4
COMPANY NAME
E-MAIL
FAN
STRP.FT ADDRESS
CITY, STATE, ZIP
PHONE
I UNDERSTAND AND AGREE TO THE FOLLOWING:
1. The re -roof project shall comply with all applicable provisions of the 2013 California Codes.
2. An inspection request can be scheduled up to one business day before the requested inspection date.
Please schedule inspections online or call (408) 777-3228 from T30-3:30pm (Mon-Thurs) or 7:30-
2:30pm (Friday) to schedule inspection. For Tear -Off and Nailing Inspections, you must also call on the
day of the inspection only after that phase of the work is completed. The building inspector will be
available within one hour. The hours for this service are: 7:30-10:30am and 12:30-3:30 (Mon-Thurs)
and 7:30-10:30am and 12:30-2:30 (Friday). Final Inspections will be given a two hour window.
3. Tear -Off Inspection is required. Any and all dry -rotted wood shall be replaced prior to this inspection.
Unless new plywood roof sheathing is proposed throughout, all the nails/fasteners shall be either
completely knocked -down or removed prior to this inspection.
4. If plywood is installed, a plywood Nailing Inspection is required.
5. Roofing shall not be applied without first obtaining all prior inspection and written approvals from the
building inspector. Any roofing which is applied without first obtaining an approved inspection will
require the removal of all new material down to the sheathing so a proper inspection can be performed.
6. A Final Inspection and approval shall be obtained from the building inspector when the re -roofing is
completed. To receive a final sign -off, the following items will be verified:
a. Flat roofs shall have a minimum of 1/4" per foot of slope and demonstrate there is no ponding.
b. Listings from approved testing agencies for all pre -manufactured products used shall be
available on-site to review at the time of the inspection.
c. Proper spark arrestor installation, vents painted, gutter/downspouts installed, debris removed.
7. NOTE: If you call for a tear -off or plywood nailing inspection and the work is not complete, you will be
charged a re -inspection fee. The re -inspection fee shall be paid before another inspection can be
scheduled.
By my signing below, I certify each of the following is true: 7I am the property owner or authorized agent to act on the
property owner's behalf. I understand and agree to mp ' it e re -roof policy stated above. I also understand that
smoke detectors and carbon monoxide de ect s re ' ed a installed in accordance with Sections R314 and 31 5 of
the 2013 California Residential Code.
Sip -nature of Applicant/Agent:
ReroglPolicv 2014.doe revised 01 15 14
Corona Tapered -'Miss%onTM - NaturaCR.ed&,FCash.eddCoCors .a EME
Clay Roof Tile
OP/OVERALL PRODUCT
For the timely elegance of old world tradition,
M.C.A. uses new technology to create our
Corona Tapered MissionTM Tile. Originally
handcrafted by molding clay to the body's
thigh this heritage has spanned the centuries
for today's installations. Old Spanish or
Mediterranean designs are well suited for Corona
Tapered MissionTM Tile and will enhance the
beauty of your project. Custom blends and colors
are also available.
B338 Palace Blend A#
INSTALLATION METHOD
(1) At roof pitches of 3:12 and steeper, provide a
minimum of one layer ASTM D-226 Type II No.
30 (14kg) felt or upgraded material.
Provide in strict accordance with pertinent
requirements of governmental and/or other
agencies having jurisdiction.
(2) Install birdstop or 1 x 2 (18mm x 36mm) wood
strip at eave to boost first course of tile.
(3) Install first row of tile leaving a 3" (76mm)
overhang with a minimum of one corrosion -
resistant nail not less than No. 11 gauge
(3mm dia.), 5/16" (7.9mm) head per tile or
tile tie system.
(4) Install booster tile above birdstops.
(5) Install starter tiles directly above booster tile.
(6) Install 2 x 6 (36mm x 140mm) nailer on hip
and ridge, set neatly in ASTM C-270 Type M
cement mortar.
(7) Install rake tiles (if required) on all gable using
2 nails per tile.
(8) Install 2 x 3 (36mm x 64mm) nailer under first
row of cover tile after gable roll with adjacent
2 x 2 (36mm x 36mm) nailer along rake side.
TILE SPECIFICATIONS:
Actual size:
Exposed size: 16" x 12" O.C.
Weight per square: 1050 lbs
Weight per piece: 7 lbs
No. of pieces per sq: 150 PCs
METRIC TILE SPECIFICATIONS:
Actual size: 483MM x 222mm (151 mm)*
Exposed size: 406mm x 305mm
Weight per M2: 51.27 kg
Weight per piece: 3.18 kg
No. of pieces per M2: 16.15 PCs
Metric conversion of lumber is actual dimensions of lumber, use
lumber of the closest dimensions available.
'Dimension of the head of the tile.
Bellagio Resort, Las Vegas, NV Various Custom Blends
16- RIDGE EXPOSURE
RIDGE
TldEM011M CEMENT MORTAR //7
OPTIONAL R
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FIELD DETAIL
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FLASHING AT WALL
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BIRD STOP GAME DETAIL
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B338 Palace Blend A#
INSTALLATION METHOD
(1) At roof pitches of 3:12 and steeper, provide a
minimum of one layer ASTM D-226 Type II No.
30 (14kg) felt or upgraded material.
Provide in strict accordance with pertinent
requirements of governmental and/or other
agencies having jurisdiction.
(2) Install birdstop or 1 x 2 (18mm x 36mm) wood
strip at eave to boost first course of tile.
(3) Install first row of tile leaving a 3" (76mm)
overhang with a minimum of one corrosion -
resistant nail not less than No. 11 gauge
(3mm dia.), 5/16" (7.9mm) head per tile or
tile tie system.
(4) Install booster tile above birdstops.
(5) Install starter tiles directly above booster tile.
(6) Install 2 x 6 (36mm x 140mm) nailer on hip
and ridge, set neatly in ASTM C-270 Type M
cement mortar.
(7) Install rake tiles (if required) on all gable using
2 nails per tile.
(8) Install 2 x 3 (36mm x 64mm) nailer under first
row of cover tile after gable roll with adjacent
2 x 2 (36mm x 36mm) nailer along rake side.
TILE SPECIFICATIONS:
Actual size:
Exposed size: 16" x 12" O.C.
Weight per square: 1050 lbs
Weight per piece: 7 lbs
No. of pieces per sq: 150 PCs
METRIC TILE SPECIFICATIONS:
Actual size: 483MM x 222mm (151 mm)*
Exposed size: 406mm x 305mm
Weight per M2: 51.27 kg
Weight per piece: 3.18 kg
No. of pieces per M2: 16.15 PCs
Metric conversion of lumber is actual dimensions of lumber, use
lumber of the closest dimensions available.
'Dimension of the head of the tile.
Bellagio Resort, Las Vegas, NV Various Custom Blends
16- RIDGE EXPOSURE
RIDGE
TldEM011M CEMENT MORTAR //7
OPTIONAL R
a. ..�--•--^+� -.. ru \-, CLO ..
QABLE
- QLD __ URE
FLASWN G DETAIL AT WALL WOODSTRIP
OR BIRDSTOP
..
a.wAAfA QAKE04 GABLE RRI
FIELD DETAIL
1 11"OFAIpY[Wf 6,Ar
OVFA M000IW.ER
uoeu� wiILwnruwWa
.,y► warowRAYOMMWEMf
iS1t CsoonalnF
.oaAT[a ml FAKE DETAIL
FLASHING AT WALL
.OA.IBM
,. HFLA MB DETAIL AT WALL
*aWmw mAL
i
BIRD STOP GAME DETAIL
800-736-6221 3
The .deader in Custom CoCors & Blends
Clay Roof Tile
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Pacific Highlands Ranch Fire Station, San Diego, CA - 75% B301 Old Mission Blend and 25% 2F34 Carmelo
a
Club House, Lake Las Vegas, NV - 301 Old Mission Blend® with Turret Tile®
4 www.mca-tile.com
0�
i
SMOKE 1 CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION
La 10300 TORRE AVENUE ® CUPERTINO, CA 35014-3255
t (408) 777-3228 • FAX (408) 777-3333 ® building(a cupertino.org
Address 2145 O w &1vJ-0 `J
PERMIT CANNOT BE FINALED AND COMPLETED UNTIL TI -IIS CERTIFICATE
HAS BEEN ;IQJ2 .AND RFTUjJNED TO THE BUILDING DIVISION
PURPOSE
This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section 8314, 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 8314 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
I
-
On every level of a dwellingunit including basements
X
X
Within each sleeping room _
X
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, alarms) 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 907.2.114 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
bel(
Smoke and CO form. doc revised 03118114
F?,t, L
WATER -CONSERVING PLUMBING FIXTURES *Ms 16 19
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
UPERTi i
(' 8) 777- 28 • F • b
(408) 777-3333 uilcling(a)cupertino.org
Owner Name 0. Permit N o.
.9
Address
1. Is your real property a registeredhistorical 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. /Do'e's 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.
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 of form.
o 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 properly 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 fonn and sign bottom of form.
4Ye-�--- IiF� real properly is=o�ili ani�avaMable- fir= -use -or o4oupaiicy oil or-before•-Jar�aly-1,-a J94— _~---_-,-------------�
Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign
bottom of form..
please check ONE of the following:
My property is a single family residential real property. See Civil Code Section e all nn. -
On and after January 1, 2014, building alterations or improvements shall require all on -compliant plumbing fixtures
ng fixtures throughout the building. On or before January 1, 2017, all non -
to be replaced with water -conserving plumbi
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- conserving
plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements).
1, 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 accordanceStandards Code, Civil Code Sections
101.1
through 1101,8, the current California Plumbing Code and liforria n Bui g
installation requirements, and that the water -conserving in es co with the requirements as indicated in the
table on the following page. Date: .t
Owner or Owner Agent's Signature:
Upon completing and signing this ertifrcate, ease return it to the Building Division in order to final your b ldin permit.
SB407 2015.doc revised 08126115