B-2016-2921 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2921
875 BROOKGROVE LN CUPERTINO,CA 95014-4633(375 39 019) ROSENTHAL
PLUMBING INC
- SANTA CRUZ,CA
95062
OWNER'S NAME: NELSON ALLEN M AND JO ANN M TRUSTEE DATE ISSUED:10/14/2016
OWNER'S PHONE:408-202-7278 PHONE NO:(831)476-4756
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT TWO:
License Class D Lic.'#923778
Contractor ROSENTHAL PLUMBING INC Date 04/30/2017 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 ofperjury one of the following two declarations: REPLACE/EXTEND MAIN WATER SERVICE;RE-PIPE SFD
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 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:$11400.00
APPLICANT CERTIFICATION
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 39 019
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 OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature,' Date 10/1412016 Issued by:MELI
Date: 10/14/2016
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
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.
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:10/14/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
a. 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. 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
a. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)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,Sons 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall f,f
be deemed revoked. Owner or authorized agent
APPLICANT CERTIFICATION Date:10/14/2016
1 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 1 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 ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 10/14/2016 Professional
EP
GENERAL PERMIT APPLICATION
' COMMUNITY DEVELOPMENT DEPARTMENT-'BUILDING DIVISION.
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228• FAX(408)777-3333•building(@-cupertino.orgCUPERTINO: misc
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PLUMBING [:]MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
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STREE S$— CITY STATE,ZIP 0 FAX
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Q P ONE o� 7r S E-MAIL
STREET ADD.. SS CITY,S= FAX
(OWNER '❑ OwNER-BUILDER ❑ OWNER AGENT ❑-CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT n ENGINEER ❑ DEVELOPER ❑TENANT
CONN�RR NAME LIC 1 LICE TE BUS.LIC
CObU�AIW¢AM� rE�_ Q �ISI�L ELY4� e FAX
SIRE DARES CIT ,STAT ZIP C 2S_( Pn- -y73-
ARCHITECT/ENGINEER NAME I ICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SID or DUPLEX ❑ MULTI-FAMII,Y PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS.THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? NO
DESCRIPTION OF WORK
14 Com--- k/- 5-k/
d L C T "P-0 0&-n 4e-r Im e A
TOTAL VALUATION: / IVED EY -
By my signature below,I certify to each of the following: I am the property owner or authorized agent e alf�have d thisapplication and the information I have provided is correct. I have read the Description ofWork and verify it is accura comp y We local
ordinances and state laws relating to buil co S ion. I authorize representatives of Cupertino to enter the above-i ntifie property for ippurposes. .
Signature of Applicant/Agent: Date: � �`
SUPPLEME TAL INFORMATION REQUIRED OFFICE USE ONLY,_,;__
OVXPR'THE:COUNT'ER
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� � EXPRESS
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0�STANISa1RD yh,e
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MEPMiscApp_2011.doc revised 06121111
SMOKE f CARBON MONOXIDE ALARMS
I
OWNER CERTIFICATE OF COMPLIANCE i
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION t~C
CUPERTINO 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333 building(a3cupertno ora
U
��P�ERMZT GANN"OT B�E)[NAI��D I7N�IL�THIS C�RTIETG�T�H_ASB�EN
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 X X
the bedroom(s)
On every level of q dwelling unit includiE_g basements X X
Within each slee in`°r'oom 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 alanns 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 alann(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 specified below have been tested and are operational, as of the
date signed below.
Address: C'dc s.
`--�' Lk1? C-�}(1.0 —Permit No. ��
Specify Number of Alarms: #Smoke Alarms: #Carbon Monoxide Detectors:
l have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
Signature
J C lil i�o /"i d N e s a ...g....... , .. ..Date:
Contractor Name: ...
Signature .......... Lic# . � .f .......Date:
Smoke and CO forin.doe revised 09•%27116
WATER-CONSERVING PLUM' BING FIXTURES
2 OWNER CERTIFICATE OF COMPLIANCE NCE I L
E
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION r k)
U1' I Tt!`Jt? `ttl3 0 TORRE AVENUE-Ci1PERT1NO,CA 95014-3255
J408)777-3228-FAX(408)777-3333-buildinaCa�pertiroo ona
OwnerNamot—McLAVIn Me� Permit N:o� .( 9-
Address fly e- Ln Cu 2
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.
j 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 11`01.1 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.
No Go to Question 3.
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.
No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
11 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 January1, 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:
C1 K Myproperty 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. 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 willbe-
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 &411,k D r` '
Upon completing and signing this Ce ficate,please return it to the Building Division in order to final your building permit.
S&4072015"doe revised 08126115