B-2016-2745CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-2745
901 FERNGROVE DR CUPERTINO, CA 9501411664 (375 39 053)
GLEN GILBERT
SAN JOSE, CA 95154
OWNER'S NAME: TORREY LEON AND MARGARET
DATE ISSUED: 09/16/2016
OWNER'S PHONE: 468-4464718
PHONE NO: (408) 377-9990
LICENSED CONTRACTOR'S DELL R TION
BUILDING PERMIT INFO:
License Class S:A2 Lie. #$77475 1
Contractor GLEN GILBERT Date 09/30/2017
X BLDG _ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
_ MECH X RESIDENTIAL _ COMMERCiAi,
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
REPLACE SEWER MAIN - PROPERTY LINE CLEAN OUT
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
r i ;
Section 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $3250.00
1 permit is issued.
APPLICANT CERTIFICATION
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
375 39 053
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.
Additionally, the applicant understands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cup ino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 9/16/2016
Issued by: AbbyAyende
Date: 09/16/2016
OWNER -BUILDER 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
r. 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 (See.7044, Business & Professions Code)
2. 1, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 9/1. 6/2016
I hereby affirm under penaltyof the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
n ve and 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 foz which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
2. 1 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
permit is issued,
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. 1 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
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
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, ns 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: 9/16/2016
1 certifythat I have read this application and state that the above information isCONSTRUCTION
LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
relating to building construction, anti 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
T' DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHIT .
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 9/16/2016
Professional
e1/
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION'
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408);777-3228 - FAX (408) 777-3333 building(ft pertino.org
PLUMBING j ❑ MECHANICAL [:]ELECTRICAL ❑MISCELLANEOUS
MEP
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OWNER NAME �Pnn :10f feuPHONE
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❑ OWNER. ❑ OWNER -BUILDER ❑ OWNER AGENT NrCONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPERS ❑ TENANT
CONTRACTOR NAME t�u'm '
LICENSE NUMBER 1
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BUS. LIC #
COMPANY NAME
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ARCHITECTIENGINEER NAME
LICENSE NUMBER.
BUS. LIC. #
COMPANY NAME.
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE. OF SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL :
PROJECT IN WILDLAND '.❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES.
FLOOD ZONE ❑. NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑. NO
DESCRIPTION OF WORKinsiM` 1 Py-pen�
TOTAL VALUATION: ` i 010
By my signature beloww,, 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 provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances state tin tilding constru ionZIauorize representatives of Cupertino to enter the above-idenfor inspection purposes.
Signature ofApp cant/AgenDate: U
SUPPLEMENTAL ]NFORMATION REQUIRED
MEPMiscApp_2011.doc revised 06/21/11
SMOKE ! CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255'
(408) 777-3228 • FAX (408) 777-3333 • buildingC@cupertino.org
4
Address
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 CSC 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
bedroom(s)
X
X
On every level of a dwelling unit 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, 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.
l have read and agree toe�mply with the ter d conditions of this statement
Owner (or Owner Agent's) Name:
L, .
Signature .......... ................................................. Date:.. ..... .
Contractor Na e:
Signature................................................................... Lic.#.......... .:............. ............. Date: ...................
Smoke and CO form.doc revised 03118114
NEI
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
Owner N
.Address
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 foam and sign bottom of form.
No Go to Question 2.
7. 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 isnot 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.
o Go to Question 3. Y
3. _ Is water service permanently disconnected for your building?
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
'DRr 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 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 bf the form and sign bottom of form.
*es 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..
5XPP11'e secheck 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).
0 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 unprovements)..
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 watey,4onserving plum ' tures comply with the requirements as indicated in the
table on the following page. Z -n,
Owner or Owner Agent's Signature:(_d' E Date: `
Upon completing and signing this Cee 'ficate, please return it to the Building D' ision in order to final your building permit.
SB407 2015.doc revised 08126115