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14110001I CITY OF CUPERTINO BUILDING PERMIT I I BUILDING ADDRESS: 10466 ANSON AVE I CONTRACTOR: JENNECKY HOMES I PERMIT NO: 14110001 1 OWNER'S NAME: CHAUDHURI SAMIT AND MOUSUMI DAS TRU 14273 MULBERRY AVE I DATE ISSUED: 02/12/2015 OW'NER'S PHONE: 4082457561 I LOS GATOS, CA 95023 I PHONE NO: (408)314 -9297 I ❑ LICENSED CONTRACTOR'S DECLARATION License Class r__ Lic. # 9 7 02.5 --1 / Contractor 1a 11 A e .} T S r- Lk t L Date 2_-1,2-16 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: 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. 1 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. 1 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. _ Date 0?5u—/ ❑ OWNER - BUILDER DECLARATION 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 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. 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, 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 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ CONSTRUCT FIRST STORY ADDITION (65.5 SQ FT); FRONT COVERED PORCH (72 SQ FT); SECOND STORY ADDITION (336 SQ FT); RE -ROOF (1900 SQ FT); REMOVE SIDING Sq. Ft Floor Area: I Valuation: $148000 I APN Number: 32641059.00 I Occupancy Type: I PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROI T�ALLED INSPECTION. Issued by: Date: b"Id l6 RE- ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date:,' -/,? - I CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO N U *► •J COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE ^ CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • build ing CD-cupertno.orq V AlnlTInN 1 AITF.RATION /TI I inl REVISIC N / DEFF.RRF.D 0 ORfGINAI. PERMIT N Vv C�¢� y(�✓I7�° L �3 �IL to BldgApp_201 l.doc revised 06 12111 l V PROJECT ADDRESS / ® a'� i4N5-o Aj Aug APN N 0 OWNER NAME 1 I V( PHO E a�J �e E -MAIL STREET ADDRES$ o �q CIT_Y, ST TE, ZIP �S Y/ .�S 60 6 l.:J.'PnAH°ONFee FAX y CONTACT N ;� B E-MAIL ,-6®lJ+-6,a ,b / ® ®. STREETA ®DRrS � CITY ,STATE ,6P"- 7'0 � �® FAX ❑ OWNER ❑ OWNTER- BUILDER ❑ OWNER AGENT tW CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTR. NAME LICE1� NUMBER LICEj�[SE TYPE BUS. LIC H FOR i/ �C� COMPANYNAI�,E E -MAIL o FAX STREET ADDRE.,$S�A Is I/ A 7 6 CITE Y�S�TAi E, ZIP �� Gam. a..zicr� P ;ONE- 7 6C�S_ ARCm�3a6:T /ENGINEER NAME� LI ANSENUMBER �D ',,,,,,,,. BUS. LICK COMPANYNAN ' �( a VA, —U E -MAIL FAX STREET ADDRESS CIT STATE, ZIP �7 PHONE DESCRIPTION OF WORK sn �J D. % r9 ° EXISTING USE PROPOSED USE CONSTR. TYPE N STORIES ONEW'FLOOR G� I USE TYPE OCC. SQ.FT.I VALUATION ($) EXTSTG DEMO TOTAL AREA A� I NET AREA U BATHROOM KITCHEN OTHER REMODEL AREA f REMODEL AREA REMODEL ARE PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: U DETACH ❑ ATTACH H DWELLING UNITS IS A SECOND UNIT ❑ YES SECOND STORY ES BEING ADDED? 0 ADDITION? NO PRE-APPLICATION DUFS IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ Y -EIV AL. VALUATION: PLANNING APPLH NO PLANNING APPROVAL LETTER EICI I LER HONE? !��t �0, ®�� By my signature below, I certify to each of the following: I am the property owner or authorize agent to act I have Te a application and the information I have provided is correct. I have read the Description of Work and verify it is curate agree to comply with all applicable local ordinances and state laws relating to uilding ConstnlCtion. I authorize representatives of Cupertino to enter t e ab -identified property for inspection purposes. Signature of Applicant/Agent Date: l© ° Ira SUPPLEMENTAL INFORMATION REQUI D PLAN CIIECKTYPE ROUTING SLIP ❑ OVER -THE- COUNTER ❑ BUILDING PLAN REVIEW New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. 0 EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bid-s: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. '❑ LARGE ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting With Planning prior to El MAJOR ❑ SANITARY SEWER DISTRICT Submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH Vv C�¢� y(�✓I7�° L �3 �IL to BldgApp_201 l.doc revised 06 12111 l V 0TY OF CUP EI TRNO FEE ]ESTIMATOR - BUI LMN(C DRVISRON ADDRESS: 10466 ANSON AVE DATE: 11/03/2014 REVIEWED BY: MEI -ISSA APN: 326 41 059 RP #: *VALUATION: 1$148,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex 2nd Unit? 0 Yes ,o No PENTAMATION 1R3SFDADD USE: OTC. 0 Yes GNo PERMIT TYPE WORK ADD 336 S.F. TO 2ND ADD N MASTER BATH & EXTEND E MASTER BEDROOM. ADD 65 S.F. SCOPE TO CREATE (N) ENTRY & CONVERT BEDRM TO OFFICE. RE -ROOF 19 SQ'S. RE- STUCCO 500 OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA I s.f. PC FEES PC ]FEE ID BP ]FEES BP ]FEE ID R -3 (Custom) II- B,111- B,IV,V -B 401 $1,626.00 IADDPLCK $1,323.00 IADDINSP 01 hii !; . Suppl. Insp. Fee :Q Reg. ® OT 0.0 hrs $0.00 7900 s.f. Re -roof $323.00 1REROOFRES PME Unit Fee: $0.00 PME Permit Fee: $0.00 # Window 4.51iding Glass Door $859.00 1WINMEWSTR New (Shearwall /Masonry) C0vs1;'ucti,-)17 Tds: Aclmit;i.,trcrtiti'c Fee: O E) Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee: IPLLONGR $56.14 Select a Non - Residential Q Building or Structure d TOTALS: 401 $1,626.00 $19.24 $1,323.00 Bldg Stds Commission Fee: IBCBSC MEC1H[, HOURLY © Yes D No IP1LUI' I]B, HOURLY (")Yes Q No ]E1L]EC, HOURLY Q Yes Q No Uecl/ Plan (.heck l'looll). Mon Che•c! /'lan Check a/ea /;. 1'erwli1 Fee: l'ha�r: /�. Permit /'ec Oec l'ernfit Llilr'lch. m 1 rch. lnp. Other I'lurnh Ins; Ciax r h 1,.� - Ins /�. hlsp. I'ece: Pl70Nlr. hisp. Fee: 01 hii !; . NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt ah- ) Thorn feet nro hacod an tho nrefiminary infnrniatian avaitahte and ore nniv an vctimate_ Contact the Dent for addn't info. FEE ITEMS (Fee Resolution II -053 a.'7111131 FEE QTY/FEE MISC I'T'EMS Plan Check Fee: $1,626.00 1 # Close Existing Openings $503.00 ICLOSOPA7N Interior Wall Suppl. PC Fee: Q Reg. 0 OT Q hrs $0.00 PME Plan Check: $0.00 500 s.f. Restucco $539.00 ISTUCOAPP Permit Fee: $1,323.00 Suppl. Insp. Fee :Q Reg. ® OT 0.0 hrs $0.00 7900 s.f. Re -roof $323.00 1REROOFRES PME Unit Fee: $0.00 PME Permit Fee: $0.00 # Window 4.51iding Glass Door $859.00 1WINMEWSTR New (Shearwall /Masonry) C0vs1;'ucti,-)17 Tds: Aclmit;i.,trcrtiti'c Fee: O E) Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee: IPLLONGR $56.14 Select a Non - Residential Q Building or Structure d Tru�'el Dr,r;,cnz�'�2talir,n Fe S: Strong Motion Fee: IBSEISMICR $19.24 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $6.00 SUBTOTALS. $3,030.38 $2,224.00 TOTAL FEE: 1 $5,254.38 Revised: 10101/2014 DACK DIEVELOPMEN7 AND EHG�NIZEKUNG 39870 PJtuirn Sbreet Yremonl, ACA 94536 (510) 993 -1130 ph/fox May 15, 2015 Building Inspection Services 10300 Torre Avenue Cupertino, CA RE Special Inspection of seismic shearwall system @ SFD Chaudhuri Residence at 10466 Anson Avenue, Cupertino, CA 95014 To whom it may concern: As the engineer of record, I was requested to do the special inspection of the seismic shearwall system installation for the addition/remodel at the above address, which was permitted from the City of Cupertino. IL I observed the satisfactory completion of the shear walls throughout including ply nailing, anchor connection, and holddowns_ At the upper story holddown strapping, a couple of places had to be modified from the plans, due to existing framing conditions. This work was performed per my direction. As of this date, and by this letter, I have verified that the installation and materials used appear to have been performed in conformance with the plans and specifications for this job. No corrective actions are necessary. If you should have any other questions, please let me know. I can be reached at 510 793 -1130 Sincerely, Thomas M. Dack, P.E., C036326 DACK DEVELOPMENT AND 1ENGINEIERENG (e-11)(560 38870 Ap uim Sweet IFuremont, ACA 94536 (510) 793 -100 ph/fax � —L4r?- April 21, 2015 Building Inspection Services 10300 Torre Avenue Cupertino, CA RE: Special Inspection of epoxy of anchor bolts and holddowns @ SFD Chaudhuri Residence at 10466 Anson Avenue, Cupertino, CA 95014 To whom it may concern: As the engineer of record, I was requested to do the special inspection of the epoxy anchor bolts and holddowns into the existing foundation at the above address, which was permitted from the City of Cupertino. As of this date, and by this letter, I have verified that the installation and materials used appear to have been performed in conformance with the plans and specifications for this job. I observed the satisfactory the installation of the anchor bolts and holddowns. No corrective actions are necessary. If you should have any other questions, please let me know. I can be reached at 510 793 -1130 Sincerely, Thomas M. Dack, P.E., C036326 1• 44 STATEMENT OF SIrL UAL NSPEC I1 MS, 2013 CBC COMMUNITY DEVELOPMENT DEPARTMENT " BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL CUPERTINO 10300 TORRE AVENUE " CUPERTINO, CA 95014 -3255 (408) 777 -3228 " FAX (408) 777 -3333 o building cupertino.oro SITE ADDRESS l0Y6 ,{ Vc `:^ APIV��i9 s Owner............................................................................... ......:........................ Contractor .......... �� i ?` ........ I ........................................................ ....... Address............................................................................ ............................... Address............................................................................ ............................... City/ St .............. ............:.................. Zip........................... Phone..................... City/ St.................. ..:..:......................... Zip .................. .Phone ... .:::................... Applicant.... —e—p ........... . .... .:...::.................. Engineer/ Architect....... AM1.6........... ....... Address ... . q. 9,7.2..'........ � �..�.���....>�.�r.......... .. Address........ . .......................................... .......................:....... City /St�Q. -S ...CATC- �...... Zip. :+ti.�..�... Phone." ... � � Zi y _91.7 .......................... p ............... Phone ...;................. PROJECT DESCRIPTION: P 0/� "�' 09 b Si natu Lic.# .., .................. e I This "STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This form is structured after and used by permission from the Structural En in led of North (ONC) mode statement of Special Inspections. Also, included with this form is the folf 4x �j( ❑ "LIST OF SPECIAL INSPECTION AGENCIES (page 2). A lis f e' f cies an8uthMr'�p p n� s that will be retained to conduct the tests and inspections for this project -a ❑ "SCHEDULE OF SPECIAL INSPECTION" (page 3 - 6). The e,...&f e ps� ti ummarizes the Special Inspections and tests required. Special Inspectors will refer t p a and sn3 ationspfor detailed special inspection requirements. Any additional tests and inspections �re�gVuiired�b them ��©sE COMPLIANCE Decifi ti ns shall also be performed. UQ UUFFii E' ��r,� Special Inspections and Testing will be performed in accordance with the approvedrp?ans?9ngtpecifi'cat an , thi/ sfatteFnent and CBC Sections 1704, 1705, 1706, 1707, and 1708. Interim reports will be submitted to the Building Official and the Registered Design Professional in Responsible Charge in accordance with CBC Section 1704.1.2. A Final Report of Special Inspections documenting required Special Inspections, testing and correction of any discrepancies noted in the inspections shall be submitted prior to issuance of a Certificate of Use and Occupancy (Section 1704.1.2). The Final Report will document: Required special inspections. • • Correction of discrepancies noted in inspections. GFIRCE 0 The Owner recognizes his or her obligation to ensure that the construction complies with the approved permit documents and to implement this program of special inspections. In partial fulfillment of these obligations, the Owner will retain and directly pay for the Special Inspections as required in CBC Section 1704.1. This plan has been developed with the understanding that the Building Official will: • Review and approve the qualifications of the Special Inspectors who will perform the inspections. • Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and are performing their duties as called for in this Statement of Special Inspection. • Review submitted inspection reports. • Perform inspections as required by the local building code. I have read and agree to comply with the terms and conditions of this statement Prepared By: Project ❑ Engineer ')& Architect �� s�9y 77 s Registered Design Professional in Char a Signature Lic.# ..fC.. /...�. ...�..... Date: :vo.°® Owner Name: ���% �.'i.. ..)... Date: Owners Authorization Signature ...... �/... i� �. ,9,U.K -U.. .. .�i ......... Inspection Agency/ Inspector Name: P 0/� "�' 09 b Si natu Lic.# .., .................. Building Official or design Signature.... .......................................................... ............................... Date:.......................... SpecialnspectionForm_2012.doc remised 09106112 r LIST OF SPECIAL INSPECTION AGENCIES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and special inspector shall be recognized by the Building Official prior to performing any duties. Special Inspection agency's listed on this form must be pre- approved and listed on Cupertino's approved Special Inspector's list. Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall - follow the criteria set by the California Council of Testing and Inspection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a "Stop Work Order' and possible permit revocation. To -be . pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout. Please allow -two weeks to complete the application process. The following are the testing and special tnat win oe retalnea to conauci tests and Inspecuon on this *All agencies specified on this form must be pre- approved and listed on the Uity of Gupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic - force- resisting system and designated seismic systems subject to special inspections as per Section 1705.3: t.i The extent of the seismic - force- resisting system is defined in more detail in the construction documents. WIND KtUUIKtMtN IS (section vuaa.1l Description of main wind- force - resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind - force- resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionForm_2012.doc revised 09106112 EXPERTISE FIRM I INSPECTOR INFORMATION * -' 1. Special Inspection (except for Firm.... .......................... ........................................... Addr ........... ....................................... ...... ........ ...................... geotechnical) City ................: ........................... ... ....................... ............................... State ..:....:...............Zip ...................... Telephone....... ............................... Fax ...................... ...................... Email.. ....................... . ......................... ........ .2. Material Testing Firm ............. .................................... ....... ............. Addr .................................. I...................................................... City..................... . ............................................................. I.,..................... State .......................Zip ...................... Telephone... .................................... Fax ............ ........................ ...... Email ......................................... I............... 3. Geotechnical Inspections Firm ................ ...................... .... ................. . ......... Addr .... ............ ................................................... ...................... City........................................................................... ............................... State .......................Zip ..........:...I.... W.. Telephone....... ............................... Fax............. ............................... Email.......................... ............................... 4. Other: Firm ..................................................................... Addr...................................................... .... ...................... ...... ... City........................................................................... ............................... State .......................Zip ...................... Telephone....... ............................... Fax............. ............................... Email.......................... ............................... *All agencies specified on this form must be pre- approved and listed on the Uity of Gupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic - force- resisting system and designated seismic systems subject to special inspections as per Section 1705.3: t.i The extent of the seismic - force- resisting system is defined in more detail in the construction documents. WIND KtUUIKtMtN IS (section vuaa.1l Description of main wind- force - resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind - force- resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionForm_2012.doc revised 09106112 CUPERTINO REC®GNMED SPEMLL, 9NSPECTM AGENCY( UST 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 ^ buildino(a.cupertino.org The following list of Special Inspection Agencies and their special inspectors are approved by the City of Cupertino to provide specific inspection in their respective held until the expiration date listed. Agency Name, Address and expiration date Special Inspectors Special Inspection Field RC PC SM SW H FP s W CG Achievement Engineering Corp. 434 Camille Cir. #13 San Jose, CA 95134 Tel: (800) 653 -1397 Fax: (408) 852 -0331 Expires: 07/22/2015 Firouz'aei, Arash X X X X Hooshdar, Sina X X X X Khodadadi, Mohammad X Safaian, Farshad Applied Materials & Engineering, Inc. 980 41st Street Oakland, CA 94608 Tel: (510) 420 -8190 Fax: (510) 420 -8186 Expires: 12/19/2014 Email: info(abappmateng.com Aaron Hardy X X X Anthony Klarich X X X X X Armen Ta'irian, RE, X Jackson X X —Bryan David Jackson X X X X X Diego Bertolino X X X Harold Walrath X X X X Ken Maloney X X Michael Knowles X X X X Oswaldo Dominguez X X X X Sean Guches X X X Bagg Engineers 847 West Maude Ave. Sunnyvale, CA 94085 -2911 Tel: (650) 852 -9133 Fax: (650) 852 -9138 Expires: 7/16/2015 www.baggengineers.com Brown, Christian X X X X X Cole, Michael Hepper, John X X X Knudsen, Steven J. McManus, Alvin X X X Norris, David L. X X X X O'Driscoll, Alan Salceda, Francisco Sciortino, Brandon Smith, Louis Steinbrueck, Bryan Thai, Minh Umeki, Takashi RC = Reinforced Concrete SW = Steel 8 Welding S =Soils PC = Pre - stressed /Post- tensioned Concrete HB = High - Strength Bolding W= Wood SM= Structural Masonry FP = Spray - Applied Fireproofing CG = CalGreen Code SpeciallnspectionList.doc revised 02101114 6- SCHEDULE OF SPECIAL INSPECTION SITE APN BP# ADDRESS PROJECT DESCRIPTION: Notation Used in Table: Column headers: - -C Indicates continuous inspection is required. P Indicates periodic inspections are required. The notes and /or contract documents should clarify. Box entries: _ X Is placed in the appropriate column to denote either "C" continuous or - "P" periodic inspections. - -- Denotes an activity that is either a one -time activity or one whose frequency is defined in some Other- manner. - 4dditional detail regarding inspections and tests are provided in the project specifications or notes on the drawings. VERIFICATION AND INSPECTION C p REFERENCED IBC REFERENCE STANDARD INSPECTION OF FABRICATORS 1. ❑ Inspect fabricator's fabrication and quality control 1704.3 procedures. INSPECTION OF STEEL 1. Material verification of high- strength bolts, nuts and washers. ❑ Identification marking to conform to ASTM stds AISC 360, specified in the approved construction documents. - -- X Section A3.3 and applicable ASTM material standards ❑ Inspect fabricator's fabrication and quality control procedures. 2. Inspection of high- strength bolting: • Snug -tight joints. - -- X • Pretensioned and slip - critical joints using turn -of -nut with matchmarking, twist -off bolt or direct tension - -- X AISC 360, indicator methods of installation. 1704.3.3 Section M2.5 ❑ Pretensioned and slip - critical joints using turn -of -nut without matchmarking or calibrated wrench methods X - -- of installation. 3. Material verification of structural steel and cold- formed steel deck. ❑ For structural steel, identification markings to conform X AISC 360, to AISC 360. Section M2.5 ❑ For other steel, identification markings to conform to Applicable ASTM ASTM standards specified in the approved --- X material standards construction documents. ❑ Manufacturer's certified test reports. ___ X Specia(nspectionForm_2012.doc revised 09106112 VERIFICATION AND INSPECTION C P REFERENCED STANDARD IBC REFERENCE 4. Material verification of weld filler materials: • Identification marking to conform to AWS specification in the approved construction documents. _ - -- X AISC 360, Section A3.5 and applicable AWS A5 documents 1704.3 • Manufacturer's certificate of compliance required. - -- X - -- - -- 5. Inspection of welding: a. Structural steel and cold- formed steel deck: ❑ Complete and partial joint penetration groove welds. X --- AWS D1.1 1704.3.1 13 Multipass fillet welds. X --- [I Single -pass fillet welds > 5/16" X - -- ❑ Plug and slot welds. X -- Single -pass fillet welds <= 5/16" - -- X ❑ Floor and roof deck welds. - -- X AWS D1.3 b. Reinforcing steel: • Verification of weldability of reinforcing steel other than ASTM A 706. __- X AWS D1.4 ACI 318: Section 3.5.2 • Reinforcing steel resisting flexural and axial forces in intermediate and special moment frames, and boundary elements of special structural walls of concrete and shear reinforcement. X ___ ❑ Shear reinforcement. X - -- ❑ Other reinforcing steel. -- X 6. Inspection of steel frame joints details for compliance: • Details such as bracing and stiffening. - -- X - -- 1704.3.2 • Member locations. - -- X • Application of joint details at each connection. - -- X VERIFICATION AND INSPECTION C P REFERENCED STANDARD IBC REFERENCE INSPECTION OF WELDING 1. ❑ Welded studs when used for structural diaphragms. - -- X - -- 1704.3 2. ❑ Welding of cold- formed steel framing members. - -- X r3. ❑ Welding of stairs and railing systems. - -- X SpecialnspectionForm_2012.doc revised 09106112 VERIFICATION AND INSPECTION C P REFERENCED TIBC STANDARD IREFERENCE INSPECTION OF CONCRETE 1. ❑ Inspection of reinforcing steel, including prestressing X ACL.3.18: 3.5, 7.1-7.7 _-1.913.4 tendons and placement. _ .. 2. ❑ Inspection of reinforcing steel welding in accordance AWS D1.4 ACI 318: with Table 1704.3 Item 5b. = .. _ -__ 3.5.2 - -- 3. ❑ Inspection of bolts to be installed in concrete prior to and during placement of concrete where allowable X ACI 318: 8.1.3, 1911.5, 1912.1 loads have been increased or where strength design 21.2.8 is used. 4. ❑ Inspection of anchors installed -in hardened concrete. - -- X ACI 318: 1912A 5. ❑ Verifying use of required design mix. 1904.2.2,1913.2, X ACI 318: 1913.3 6. ❑ At time fresh concrete is sampled to fabricate ASTM C 172 specimens for strength tests, perform slump and air X - -- ASTM C 31 1913.10 content tests and determine the temperature of the concrete. ACI 318: 5.6, 5.8 7. ❑ Inspection of concrete and shotcrete placement for X - -- ACI 318: 5.9, 5.10 1913.6, 1913.7, proper application techniques. 1913.8 8. ❑ Inspection for maintenance of specified curing - -_ X ACI 318: 5.11 -5.13 1913.9 temperature and techniques. 9. Inspection of prestressed concrete: ❑ Application of prestressing forces. X - -- ACI 318:18.20 ❑ Grouting of bonded prestressing tendons in the X - -- ACI 318: 18.18.4 seismic force - resisting system. 10. ❑ Erection of precast concrete members. - -- X ACI 318: Ch. 16 - -- 11. ❑ Verification of in -situ concrete strength, prior to stressing of tendons in posttensioned concrete and ___ X ACI 318: 6.2 - -- prior to removal of shores and forms from beams and structural slabs. 12. ❑ Inspect formwork for shape, location, and dimensions X ACI 318: 6.6.1 - -- of the concrete member being formed, 13. ❑ Bolts Installed in Existing Masonry or Concrete ❑ Direct tension testing of existing anchors. - -- X X See ICC ES Reports form special X inspection requirements for proprietary ❑ Direct tension testing of new bolts. - -- • Torque testing of new bolts. _ -- products • Prequalification test for bolts and other types of anchors. -_- X 14. ❑ Other: SpecialnspectionFonn_2012.doc revised 09106112 SpecialnspeclionForm_7012.doc revised 09106112 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402IACI -rmS 4021ACI SECTION! 5301ASCE 5 5301ASCE 6 INSPECTION OF LEVEL 1 MASONRY 1. ❑ Compliance with required inspection provisions of - the construction documents and the approved - -- X -- - -- Art. 1.5 submittals shall be verified. 2. ❑ Verification of fm and f nnc prior to construction ___ X - -- - -- Art. 1.46 except where specifically exempted by this code. 3. 0 Verification of slump flow and VSI as delivered to X - -- - -- - -- Art. 1.56.1.b.3 - the site for self consolidating grout. 4. As masonry construction begins, the following shall be verified to ensure compliance: • Proportions of site - prepared mortar. - -- X - -- - -- Art. 2.6A • Construction of mortar joints. - -- X - -- - -- Art.3.31B • Location of reinforcement, connectors, - -- X - -- - -- Art. 3.4, 3.6A prestressing tendons, and anchorages. • Prestressing technique. - -- X - -- - -- Art. 3.613 • Grade and size of prestressing tendons and ___ X - -- - -- Art. 2.48, 2.4H anchorages. 5. During construction the inspection program shall verify: • Size and location of structural elements. - -- X - -- - -- Art. 3.31F • Type, size, and location of anchors, including Sec. 1.2.2(e), other details of anchorage of masonry to - -- X 1.16.1 _ structural members, frames or other construction. • Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and - -- X - -- Sec. 1.15 Art. 2.4, 3.4 anchorages. • Welding of reinforcing bars. X - -- - -- -- ❑ Preparation, construction and protection of masonry during cold weather (temperature below ___ X Sec. 2104.3, _ -_ Art. 1.8C, 1.8D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). • Application and measurement of prestressing X - -- - -- - -- Art. 3.613 force. 6. Prior to grouting the following shall be verified to ensure compliance: • Grout space is clean. - -- X - -- - -- Art. 3.2D • Placement of reinforcement and connectors and X - -- Sec. 1.3 Art. 3.4 prestressing tendons and anchorages. • Proportions of site - prepared grout and X - -- -- Art. 2.613 prestressing grout for bonded tendons. • Construction of mortar joints. - -- X - -- - -- Art. 3.313 7. Grout placement: ❑ Grout placement shall be verified ensure X - -_ ___ ___ Art. 3.5 compliance. ❑ Observe grouting of prestressing bonded X _ -- ___ ___ Art 3.6C tendons. SpecialnspeclionForm_7012.doc revised 09106112 SpecialnspectionFonn _2012.doc revised 09106112 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 4021ACI TMS 402 /ACI SECTION 530fASCE 5 530 /ASCE 6 8. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and /or prisms shall be - -- X 2105.2.2, - -- Art. 1.4 observed.. _ _- 2105.3 INSPECTION OF LEVEL 2 MASONRY 1. El Compliance with required inspection provisions of the construction documents and the approved - -- X - -- - -- Art. 1.5 submittals. 2. ❑ Verification of fm and fAAc prior to construction and for every 5,000 square feet during - -- X - -- - -- Art. 1.413 construction. 3. ❑ Verification of proportions o.f. materials in _ ._,_. ...._ premixed or preblended mortar and grout as - -- X _ - -- - -- Art. 1.513 delivered to the site. 4. ❑ Verification of slump flow and VSI as delivered to X ___ __- ___ Art. 1.513.1.b.3 the site for self consolidating rout. 5. The following shall be verified to ensure compliance: • Proportions of site - prepared mortar, grout, and X - -- - -- Art. 2.6A prestressing grout for bonded tendons. • Placement of masonry units and construction of - -- X - -- - -- Art. 3.313 mortar joints. • Placement of reinforcement, connectors and - -- X - -- Sec. 1.15 Art. 3.4, 3.6A prestressing tendons and anchorages. • Grout space prior to grouting. X - -- - -- - -- Art. 3.21D • Placement of grout. X - -- - -- - -- Art. 3.5 ❑ Placement of prestressing grout. X - -- - -- - -- Art. 3.6C • Size and location of structural elements. - -- X - -- - -- Art. 3.3F • Type, size, and location of anchors, including other details of anchorage of masonry to X __- ___ Sec. 1.2.2(e) -- structural members, frames and other construction. • Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and - -- X - -- Sec. 1.15 Art. 2.4, 3.4 anchorages. • Welding of reinforcing bars. X - -- Sec. 2.1.9.7.2, - -- 3.3.3.4 (b) ❑ Preparation, construction, and protection of masonry during cold weather (temperature below X Sec. 2104.3, 40 degrees F) or hot weather (temperature above ___ 2104.4 Art. 1.8C, 1.8D 90 degrees F). ❑ Application and measurement of prestressing force. X - "' - "" ___ Art. 3.66 6. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and /or prisms shall be X - -- 2105.2.2, - -- Art. 1.4 observed. 2105.3 SpecialnspectionFonn _2012.doc revised 09106112 VERIFICATION AND INSPECTION C P REFERENCED IBC STANDARD IREFERENCE INSPECTION OF WOOD 1. ❑ Inspect prefabricated wood structural elements.and assemblies in accordance with Section 1704.2. 1704.6 2. ❑ Inspect site built assemblies. - -- - -- 3. Inspect high -load diaphragms: ❑ Verify grade and thickness of sheathing. - -- --- ❑ Verify nominal size of framing members at adjoining panel edges. - -- 1704.6.1 • Verify nail or staple diameter and length, - -- --- ❑ Verify number of fastener lines, - -- --- ❑ Verify spacing between fasteners in each line and at edge margins. - -- - -- 4. ❑ Metal- plate- connected wood trusses spanning 60 feet or greater: Verify temporary installation restraint/bracing and the permanent individual truss - -- X - -- 1704.6.2 member bracing are installed in accordance with the approved truss submittal package. REQUIRED VERIFICATION AND INSPECTION OF SOIL 1. ❑ Verify materials below footings are adequate to achieve the desired bearing capacity. - X 2. ❑ Verify excavations are extended to proper depth and have reached proper material. - -- X 3. ❑ Perform classification and testing of compacted fill materials. _ _ X - -- Table 1704.7 4. ❑ Verify use of proper materials, densities and lift thicknesses during placement and compaction of X - -- compacted fill. 5. ❑ Prior to placement of compacted fill, observe subgrade and verify that site has been prepared properly. - - X REQUIRED VERIFICATION AND INSPECTION OF DEEP DRIVEN FOUNDATION ELEMENTS 1. ❑ Verify element materials, sizes and lengths comply X with the requirements. 2. ❑ Determine capacities of test elements and conduct X additional load tests, as required. 3. ❑ Observe driving operations and maintain complete X and accurate records for each element. 4. ❑ Verify locations of piles and their plumbness, confirm type and size of hammer, record number of blows per -- Table 1704.8 foot of penetration, determine required penetrations to X - -- achieve design capacity, record tip and butt elevations and document any damage to foundation element. 5. ❑ For steel elements, perform additional inspections in accordance with Section 1704.3. - -- _- 6. ❑ For concrete elements and concrete filled elements, perform additional inspections in accordance with - -- - -- Section 1704.4. SpecialnspectionFoirn_2012.doc revised 09106112 VERIFICATION AND INSPECTION C P REFERENCED IBC STANDARD REFERENCE 7. ❑ For specialty piles, perform additional inspections as 1704.10 tip elevations, final depth, final installation torque. determined by the registered.design professional in - -- - -- - -- Table 1704.8 = responsible charge. 1. Condition of substrates. ❑ Inspect surface for accordance with the approved fire - REQUIRED VERIFICATION AND INSPECTION OF CAST -IN -PLACE DEEP FOUNDATION ELEMENTS 1 ❑ Observe drilling operations and maintain complete and X - - - -- accurate records for each element. ' written instructions. 2. ❑ . Verify placement locations and plumbness, confirm ❑ Verify minimum ambient temperature before and after element diameters, bell diameters (if applicable), application. - X lengths, embedment into bedrock (if applicable), and X - -- - -- Table 1704.9 adequate end - bearing strata. capacity. Record Section 1704.12.4. S - -- --- concrete or grout volumes. 1704.12.1 3. ❑ Verify density of material for conformance with the r3. ❑ For concrete elements, perform additional inspections - -- - -- i n accordance with Section1 704.4. Section 1704.12.5) HELICAL PILE FOUNDATIONS 1. ❑ Record installation equipment used, pile dimensions, X - -- - -- 1704.10 tip elevations, final depth, final installation torque. SPRAYED FIRE- RESISTANT MATERIALS Physical and visual tests 1. Condition of substrates. ❑ Inspect surface for accordance with the approved fire - resistance design and the approved manufacturer's - -- - -- written instructions. ❑ Verify minimum ambient temperature before and after application. - X ❑ Verify ventilation of area during and after application. - -- X 2. ❑ Measure average thickness per ASTM E605 and Section 1704.12.4. S - -- --- - -- 1704.12.1 3. ❑ Verify density of material for conformance with the approved fire- resistant design and ASTM E605. (Ref. - -- - -- Section 1704.12.5) 4. ❑ Test cohesive /adhesive bond strength per Section 1704.12.6, - -- - -- 5. ❑ Condition of finished application. MISCELLANEOUS 1. Mastic and Intumescent Fire - Resistant Coating. - -- - -- - -- 1704.13 2. Exterior Insulation and Finish Systems (EIFS). Water - resistive barrier coating when installed over a sheathing - -- - -- - -- 1704.14 substrate. 3. Special Cases - -- - -- - -- 1704.15 4. Smoke Control System - -- - -- - -- 1704.16 5. Seismic Resistance ❑ Suspended ceiling systems and their anchorage. - -- - -- - -- 1705.3 [4.3] SpeciahupectionFonn 2012.doc revised 09106112 ,d VERIFICATION ARID INSPECTION C P REFERENCED IBC STANDARD REFERENCE 6. Wind Resistance • Roof cladding and roof framing connections. - -- - -- --- ❑ Wall connections to roof and floor diaphragms and framing. - ❑ Roof and floor diaphragm systems, including collectors, drag struts and boundary elements. ❑ Vertical wind - force - resisting systems, including braced frames, moment frames, and shear walls. ❑ Wind- force - resisting system connections to the foundation. ❑ Fabrication and installation of systems or components required to meet the impact resistance requirements - -- - -- - -- of Section 1609.1.2. SPECIAL INSPECTION FOR NAND REQUIREMENTS 1. Structural Wood • Inspect field gluing operations of elements of the main X wind - force - resisting system. - -- 1706.2 • Inspect nailing, bolting, anchoring, and other fastening of components within the main windforce- resisting -� X system, including wood shear walls, wood diaphragms, drag struts, braces and hold- downs. 2. Cold- Formed Steel Framing • Welding of elements of the main wind- force - resisting X system. • Inspection of screw attachments, bolting, anchoring, and other fastening of components within the main 1706.3 wind - force - resisting system including shear walls, - -- X braces, diaphragms, collectors (drag struts) and hold - downs. 3. Wind- resisting components ❑ Roof cladding. - -- X - -- 1706.4 ❑ Wall cladding. - -- X SPECIAL INSPECTIONS FOR SEISMIC RESISTANCE 1. ❑ Special inspection for welding in accordance with the X - -- 1707.2 quality assurance plan requirements of AISC 341. 2. Structural Wood ❑ Inspect field gluing operations of elements of the X seismic - force - resisting system. ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the seismic - force - resisting 1707.3 system, including wood shear walls, wood - -- X diaphragms, drag struts, braces, shear panels and hold- downs. 3. Cold- Formed steel light -frame construction ❑ Welding of elements of the seismic - force - resisting _ _ X 1707.4 system. SpecialnspectionFonn_2012.doc revised 09106112 ❑ Inspection of screw attachments, bolting, anchoring, and other fastening of components within the seismic- X force - resisting system including shear walls, braces, _ diaphragms, collectors (drag struts) and hold- downs. 4. Storage racks and access floors ❑ Anchorage of storage racks 8 feet or greater in height X 1707.5 and access floors. 5. Architectural components - ❑ Inspect erection and fastening of exterior cladding weighing more than 5 psf and higher than 30 feet - -- X above grade or walking surface. ❑ Inspect erection and fastening of veneer weighing more than 5 psf.and higher than 30 feet above grade - -- X - or walking surface. - -- 1707.6 ❑ Inspect erection and fastening of all exterior non- bearing walls higher than 30 feet above grade or - -- X walking surface. ❑ Inspect erection and fastening of all interior non- bearing walls weighing more than 15 psf and higher - -- X than 30 feet above grade or walking surface. 6. Mechanical and Electrical Components • Inspect anchorage of electrical equipment for emergency or stand -by power systems. X • Inspect anchorage of non - emergency electrical equipment. X • Inspect installation of piping systems and associated mechanical units carrying flammable, combustible, or - -- X - -- 1707.7 highly toxic contents. • Inspect installation of HVAC ductwork that contains X hazardous materials. • Inspect installation of vibration isolation systems where required by Section 1707.7. _ X 7. ❑ Verify that the equipment label and anchorage or mounting conforms to the certificate of compliance when mechanical and electrical equipment must be - -- -_- -__ 1707.8 seismically qualified. 8. ❑ Seismic isolation system: Inspection of isolation - -- X ___ 1707.9 system per ASCE 7 — Section 17.2.4.8 9. ❑ Obtain mill certificates for reinforcing steel, verify compliance with approved construction documents, - -- - -- - -- 1708.2 and verify steel supplied corresponds to certificate. 10. ❑ Structural Steel: Invoke the QAP Quality Assurance requirements in AISC 341. - -- -- ___ 1708.3 11. ❑ Obtain certificate that equipment has been seismically qualified. - -- _ -" ___ 1708.4 12. ❑ Obtain system tests as required by ASCE 7 Section 17.8. - -- - -- - -- 1708.5 SpecialnspectionFa-m_2012. doe revised 09106112 P. 11t3 STATEMENT OF SPEM L N SPEC TIOM3, 2013 CBC COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION - 1 ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL l!%�,j; / QDfPEf�il DGV® 10300 TORRE AVENUE . CUPERTINO, CA 95014 -3255 C (408) 777 -3228 - FAX (408) 777 -3333 o buildingdcupertino.org r rr GJ SITE b wS a �4PW ..................................... ............................... Lic.# ........ ............................... j Date:........).! ...`....I. Owner.. .. �. ...Y'�r 4'2A, �V 1g.el ...................... Contractor .... - 1 ..... r ....Q^7 / G �s f .................... Address °f ®.. ��?.....(^..... ....:. ....... Address........................................................................... ..................................................................................... ............................... Date:.......................... . ............................... Zip. .5..5 %11X . .... Phoed`tt�•�S� City /st .......................... D)—wV, I 11,./ ............. ....... .......... ............ Lic.#... ...... ............................... ........... Zip................. ..Phone........................ Applicant .. ....... ............................... nngiee r rchitect..... .T�. ....`.V ..-. .tI .- .0 . A �....� ..... Address... z&ie.. 1� .... 17R ............................... Add re ss 3.J City /St,'o �..� ®rte...��. ...... ZipJ� er..... honed' / .................................... .... . ... .......... eNy �, ��yy��-- // % D City /St..' .................. . Zip.d.�:63.4 Phone. PROJECT DESCRIPTION: This "STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This form is structured after and used by permission from the Structural Engineer Association of Northern California's (SEAONC) mode statement of Special Inspections. Also, included with this form is the following: ❑ "LIST OF SPECIAL INSPECTION AGENCIES (page 2). A list of testing agencies and other special inspectors that will be retained to conduct the tests and inspections for this project p ❑ "SCHEDULE OF SPECIAL INSPECTION" (page 3 — 6). The Schedul , Inspections �� ll al Inspections and tests required. Special Inspectors will refer to the ap eve and specie! j jd�ett lbWecial inspection requirements. Any additional tests and inspections requir proved plans anp►it I also be performed. FM fl) 9 20is Special Inspections and Testing will be performed in accordance with the approvRt �A �stecifcations, this statement and CBC Sections 1704, 1705, 1706, 1707, and 1708. Interim reports will be submitted to the uil�in '®ffiL���j�tHS�rt Professional in Responsible Charge in accordance with CBC Section 1704.1.2. Reviewed E3y. <9y A Final Report of Special Inspections documenting required Special Inspections, testing and correction of any discrepancies ted in the inspections shall be submitted prior to issuance of a Certificate of Use and Occupancy (Section 1704.1.2). The Final Report will document: Co Required special inspectio ; 1 l��-') /1 UUU •I�, o Correction of discrepancies n d i Fin p Li � The Owner recognizes his or her obligation to ensure that the construction complies with the approved permit 6n)p� and to implement this program of special inspections. In partial fulfillment of these obligations, the O ner will retain and direct! / the �. Special Inspections as required in CBC Section 1704.1. This plan has been developed with the understanding that the Building Official will: • Review and approve the qualifications of the Special Inspectors who will perform the inspections. • Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and A�pe ming their duties as called for in this Statement of Special Inspection. • Review submitted inspection reports. • Perform inspections as required by the local building code. / have read and a ree to comply with the terms and co ditions of this statement Prepared By: /� 0 E Project Engineer ❑ Architect Registered Design Professional in Charge Si nature ..................................... ............................... Lic.# ........ ............................... j Date:........).! ...`....I. Owner Name: Owner's Authorization Signature ..................................................................................... ............................... Date:.......................... Inspection Agency / Inspector Name: Dt !v— Signature D)—wV, I 11,./ ............. ....... .......... ............ Lic.#... ...... l Date: .......�.�.....Q.. Building Official or designee: Si nure .. . ............................... Date: �...... SpecialnspectionForm_2012.doc revised 09106112 � il{•'E f. t IrJ��� sTmLfivU Ew Ofd SPC MAL IINSPEC7IIONS, 2013 C o C COMMUNITY DEVELOPMENT DEPARTMENT a BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE a CUPERTINO, CA 95014 -3255 (408) 777 -3228 o FAX (408) 777 -3333 - buildingg cupertino.org SITE a 00(0 �S,) n L pPR BP# ADDRESS I Signature .......................................... ..........................Lic.# ........ ............................... Date:........... /............ Owner ........ ....... ................................................... ........... _ .. ................... .......... Contractor .. .....................•......... ...................................... ............................... Address............................................................................ ............................... Address............................................................................ ............................... City/ St ............................................. Zip ........... ................ Phone ..................... City/St ................................................. Zip. .................. Phone ........................ Applicant ...... 5. !. !... .....k1�!..A. .0 ... 14 .v . ...... ............................... ngineer rchitect. 7 ... ........ ............................... b Address........ .. s ... . ... .. . . .. . ��.. .....R City/St ..... C'.. 1A .1�.,« Zip..... .5.5AIS .... Phone i 600� !o 9.D9� — .. .. ........ City /St..... 5 7-Z6 PROJECT DESCRIPTION: This "STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This form is structured after and used by permission from the Structural Engineer Association of Northern Califomfa's (SEAONC) mode statement of Special Inspections. Also, included with this form is the following: ❑ `LIST OF SPECIAL INSPECTION AGENCIES (page 2). A list of testing agencies and other special inspectors that will be retained to conduct the tests and inspections for this project ❑ "SCHEDULE OF SPECIAL INSPECTION" (page 3 — 6). The Schedule of Special Inspections summarizes the Special Inspections and tests required. Special Inspectors will refer to the approved plans and specifications for detailed special inspection requirements. Any additional tests and inspections required by the approved plans and specifications shall also be performed. Special Inspections and Testing will be performed in accordance with the approved plans and specifications, this statement and CBC Sections 1704, 1705, 1706, 1707, and 1708. Interim reports will be submitted to the Building Official and the Registered Design Professional in Responsible Charge in accordance with CBC Section 1704.1.2. A Final Report of Special Inspections documenting required Special Inspections, testing and correction of any discrepancies noted in the inspections shall be submitted prior to issuance of a Certificate of Use and Occupancy (Section 1704.1.2). The Final Report will document: • Required special inspections. • Correction of discrepancies noted in inspections. The Owner recognizes his or her obligation to ensure that the construction complies with the approved permit documents and to implement this program of special inspections. In partial fulfillment of these obligations, the Owner will retain and directly pay for the Special Inspections as required in CBC Section 1704.1. This plan has been developed with the understanding that the Building Official will: • Review and approve the qualifications of the Special Inspectors who will perform the inspections. • Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and are performing their duties as called for in this Statement of Special Inspection. • Review submitted inspection reports. • Perform inspections as required by the local building code. I have read and agree to comply with the tei7ns and conditions of this statement Prepared By: Project Engineer L3 Architect ('� � 6��- Registered Design Professional in Charge Signature .......................................... ..........................Lic.# ........ ............................... Date:........... /............ Owner Name: n!,` Owner's Authorization Si nature ..........., .................................................................... ............................... Date:.......................... Inspection Agency / Inspector Name: Sinature .......................................... ..........................Lic.# ........ ............................... Date:.......................... Building Official or designee: Signature..................................................................................... ............................... Date:...................... 2012.doc revised 09106112 Z, .. e U37 OF SPECIAL 1INSPEC7110M AeEMES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and special inspector shall be recognized by the Building Official prior to performing any duties. Special Inspection agency's listed on this form must be pre- approved and listed on Cupertino's approved Special Inspector's list. Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the California Council of Testing and Inspection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a "Stop Work Order" and possible permit revocation. To be pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout. Please allow two weeks to complete the application process. The following are the testing and special inspection agencies that will be retained to conduct tests and inspection on this project: EXPERTISE FIRM / INSPECTOR Ih1FORMATIORI 1. Special Inspection (except for Firm .................................................. ................... Addr ...... ............. geotechnical) City ............... ............................... ..... ............................... ................... State .......................Z.- ip ................. ..... Telephone....... ............................... Fax............ ............................ Email.......................... ............................... 2. Material Testing Firm ..................... ............................... ............... Addr......................................................................................... City......... ............................... ............................... ............................... State .......................Zip ...................... Telephone.................. .................. Fax............. ............................... Email.......................... ............................... 3. Geotechnical Inspections Firm ............. ..................................................... Addr.......................................................... ............................... City.. ..................................................................... ......................I........ State .......................Zip ...................... ephone....... ............................... Fax............. ............................... Email.......................... ............................... 4. Other: Firm ..................................................................... Addr.......................................................... ............................... City........................................................................... ............................... State .......................Zip ...................... Telephone....... ............................... Fax............. ............................... Email.......................... ............................... "All agencies specified on this form must be pre- approved and listed on the City of Cupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic-force-resisting system and designated seismic systems subject to special inspections as per Section 1705.3: The extent of the seismic-force-resisting system is defined in more detail in the construction documents. 1700.4. Description of main wind- force- resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind- force - resisting system and wind resisting components is defined in more detail in the construction documents. 2.doc revised 09106112 VERIFICATION AMD INSPECTIOM C P REFERENCED ZFERENCE STANDARD INSPECTION OF CONCRETE 1. ❑ Inspection of reinforcing steel, including prestressing X ACI 318: 3.5, 7.1 -7.7 1913.4 tendons and placement. 2. ❑ Inspection of reinforcing steel welding in accordance AWS D1.4 ACI 318: with Table 1704.3 Item 5b. 3.5.2 3. ❑ Inspection of bolts to be installed in concrete prior to and during placement of concrete where allowable X _° ACI 318: 8.1.3, 1911.5, 1912.1 loads have been increased or where strength design 21.2.8 is used. 4. ❑ Inspection of anchors installed in hardened concrete. - -- X ACI 318: 1912.1 5. ❑ Verifying use of required design mix. 1904.2.2,1913.2, X ACI 318: 1913.3 6. ❑ At time fresh concrete is sampled to fabricate ASTM C 172 specimens for strength tests, perform slump and air X __ ASTM C 31 1913.10 content tests and determine the temperature of the concrete. ACI 318: 5.6, 5.8 7. ❑. Inspection of concrete and shotcrete placement for X -° ACI 318: 5 .9, 5.10 1913.6, 1913.7, proper application techniques. 1913.8 8. ❑ Inspection for maintenance of specified curing - -- X ACI 318: 5.11 -5.13 1913.9 temperature and techniques. 9. Inspection of prestressed concrete: ❑ Application of prestressing forces. X - -- ACI 318:18.20 ❑ Grouting of bonded prestressing tendons in the X _ -- ACI 318: 18.18.4 ° seismic force - resisting system. 10. ❑ Erection of precast concrete members. - -- X ACI 318: Ch. 16 - -- 11. ❑ Verification of in -situ concrete strength, prior to stressing of tendons in posttensioned concrete and X ACI 318: 6.2 -- prior to removal of shores and forms from beams and structural slabs. 12. ❑ Inspect formwork for shape, location, and dimensions _ -- X ACI 318: 6.6.1 - -- of the concrete member being formed. 13. 9 Bolts Installed in Existing Masonry or Concrete • Direct tension testing of existing anchors. -- X See ICC ES Reports form special inspection requirements for proprietary • Direct tension testing of new bolts. --- X • Torque testing of new bolts. X products • Prequalification test for bolts and other types of -_- X anchors. 14.6( Other: �� ®.%i v-)LA,0&- SpeciabwpectionForm_2012.doc revised 09106112 t t ffEMS COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE o CUPERTINO, CA 95014 -3255 (408) 777 -3228 ^ FAX (408) 777 -3333 ^ building@cuoertino.org The 2013 CalGreen Code applies to additions or alterations of existing residential buildings where the addition or alteration increases the building's conditioned area, volume, or size and also applies to all new low -rise residential buildings, high -rise residential buildings, or both. Existing site and landscaping improvements that are not otherwise disturbed are not subject to the requirements of CALGreen. Project Name: ,(ate za Project Address: Z O Y 66 Q112 Project Description: �.,g/ sad,76—_,14 6, Instructions: 1. The Owner or the Owner's agent shall employ a licensed professional experienced with the California Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. 2. The licensed professional, in collaboration with the owner and the design professional shall initial Coiummn 2 of this checklist, sign and date Section 9 - Design Veltificadon at the end of this checklist and have the checklist printed on the approved plans for the project. 3. Prior to final inspection by the Building Department, the licensed professional shall complete Wummn 3 and sign and date Section 2 - Implementation Veo lification at the end oft is C c bmit the completed form to the Building Inspector. (OFMCE O MANDATORY FEATURE OR MEASURE progact ` alffication Reauirernents Planning and Design -Site Development 4.106.2 Storm water drainage and retention during construction. A plan is developed and implemented to manage storm water drainage during construction. 4.106.3 Grading and paving. The site shall be planned and developed to keep surface water away from buildings. Construction plans shall indicate how site grading or a drainage system will manage all surface water flows. E (CUIPERT MO F Building Departmw 'j FEB 0 9 203 Page 1 of REVIEWED FOR CUnE Co fAPLIAHCL Reviewed By: �� /7Av;�/ CalGreen 2014.doc revised 11104114 A4.2 ENERGY EFFICIENCY General 4.201.1 Low -rise residential buildings shall meet or exceed the minimum C� standard design required by the California Energy Standards. A4.3 WATER AND CONSERVATION Indoor Water Use 4.303.1 Water conserving plumbing futures and fittings. Plumbing fixtures (water closets and urinals) and fittings (faucets and showerheads) shall comply with the following: ® 4.303.1.3.2 Water Closets. The effective flush volume of all water closets shall not exceed 1.28 gallons per flush. Tank -type water closets shall be certified to the performance criteria of the U.S. EPA WaterSense Specifications for Tank -type Toilets. ® 4.303.1.3.2 Urinals. The effective flush volume of urinals shall not exceed 0.5 gallons per flush. ® 4.303.1.3.1 Single Showerheads. Showerheads shall have a maximum flow rate of not more than 2.0 gallons per minute at 80 psi. Showerheads shall be certified to the performance criteria of the U.S. EPA WaterSense Specification for showerheads. ® 4.303.1.3.2 Multiple Showerheads serving one shower. When a shower is served by more than one showerhead, the combined flow rate of all showerheads and /or other shower outlets controlled by a single valve shall not exceed 2.0 gallons per minute at 80 psi, or the shower shall be [ ❑❑ designed to allow only one shower outlet to be in operation at a time. ® 4.303.1.4.1 Residential lavatory faucets. The maximum flow rate of residential lavatory faucets shall not exceed 1.5 gallons per minute at 60 psi. The minimum flow rate of residential lavatory faucets shall not be less than 0.8 gallons per minute at 20 psi. ® 4.303.1.3.2 Lavatory faucets In common and public use areas. The maximum flow rate of lavatory faucets installed in common and public use areas (outside of dwellings or sleeping units) in residential buildings shall not exceed 0.5 gallons per minute at 60 psi. ® 4.303.1.4.3 Metering faucets. Metering faucets when installed in residential buildings shall not deliver more than 0.25 gallons per cycle. ® 4.303.1.4.4 Kitchen Faucets. The maximum flow rate of kitchen faucets shall not exceed 1.8 gallons per minute at 60 psi. Kitchen faucets may temporarily increase the flow above the maximum rate, but not to exceed 2.2 gallons per minute at 60 psi, and must default to a maximum flow rate of 1.8 gallons per minute at 60 psi. 4.303.2 Standards for plumbing fixtures and fittings. Plumbing fixtures / and fittings shall be installed in accordance with the California Plumbing Code,�J/ and shall meet the applicable standards referenced in Table 1401.1 of the California Plumbing Code. Page 2 of 5 CalGreen 2014.doc revised 11104114 Outd ow �ffaftr Use 4.304.1 lrrigatlon controllers. Automatic irrigation systems installed at the time of final inspection shall be weather- based. ® 4.304.1.1 Controllers shall be weather- or soil moisture -based controllers that automatically adjust irrigation in response to changes in plants' needs as weather conditions change. 0 ® 4.304.1.2 Weather -based controllers without integral rain sensors or communication systems that account for local rainfall shall have a separate wired or wireless rain sensor which connects or communicated with the controller(s). Soil moisture -based controllers are not required to have rain sensor input. Enhanced DuPabilft and Reduced NaMenance 4.406.1 Rodent proofing. Annular spaces around pipes, electric cables, conduits, or other openings in plates at exterior walls shall be protected [Ell the passage of rodents by closing such openings with cement mortar, concrete masonry or similar method acceptable to the enforcing agency. ConztP6 cUan Gffa]ste RedludloOn, Mopoeaal and Re6`} cfing 4.408.2 Construction waste management plan. Where a local jurisdiction does not have a construction and demolition waste management ordinance, a construction waste management plan shall be submitted for approval to the enforcing agency. B OOdIIng vv @ Menance and apavaiden 4.410.1 Operation and maintenance manual. At the time of final inspection, an operation and maintenance manual shall be provided to the building 2r, Cl occupant or owner. °n gal �lPe�ia�c�e� 4.303.1 General. Install only a direct -vent sealed- combustion gas or sealed wood- buming fireplace, or a sealed woodstove. Pollutant 6ontroi 4.504.1 Covering off dud openings and protection off mechanical equipment during constriction. Duct openings and other related air C ❑0 distribution component openings shall be covered during construction. 4.504.2.1 Adhesives, sealants and coughs. Adhesives, sealants and caulks Ell C� shall be compliant with VOC and other toxic compound limits. 4.504.2.2 Points and coatings. Paints, stains and other coatings shall be uuulll �l u compliant with VOC limits. 4.504.2.3 aerosol paints and coatings. Aerosol paints and other coatings shall be compliant with product weighted HAIR Limits for ROC and other toxic � 0 compounds. Page 3 of 5 CalGreen_2014.doc revised 11104114 r 4.504.2.4 Veriflics0on. Documentation shall be provided to verify that C� compliant VOC limit finish materials have been used. 4.504.3 Carpet Systems. Carpet and carpet systems shall be compliant with CL� VOC limits. 4.504.4 Resilient f➢oorIng systems. Eighty (80) percent of floor area receiving resilient flooring shall comply with the VOC- emission limits defined in the Collaborative for High Performance Schools (CHPS) Low- emiiiing ❑❑ Materials List or be certified under the Resilient Floor Covering Institute (RCFI) FloorScore program. 4.504.5 Composite wood products. Particleboard, medium density fiberboard (MDF), and hardwood plywood used in interior finish systems shall � ❑ comply with low formaldehyde emission standards. Ila erlJor Mdeauve Conavd 4.505.2 Concrete slab foundation. Required vapor retarders and capillary FE] C breaks are also required to comply with CalGreen Section 4.505.2.1. 4.505.3 Noisture content of building mmateNalls. Moisture content of building materials used in wall and floor framing is checked before enclosure. [Indoor NV' QQ U -SORY and EN(r U22 4.505.9 Bathroom exhaust fans. Exhaust fans which terminate outside the building are provided in every bathroom. Enw roruPl7 enf l C®r1711Voutt 4.507.2. Duct systems are sized and designed and equipment is selected using the following methods: 1. Establish heat loss and heat gain values according to ACCA Manual J or equivalent. 2. Size duct systems according to ACCA 29 -D (Manual D) or equivalent. 3. Select heating and cooling equipment according to ACCA 36 -S (Manual S) or equivalent. Qtn�lu�ac��uoDi11�4 702.9 lnstallev trainIng. HVAC system installers are trained and certified in the proper installation of HVAC systems. 702.2 Special 6nspectlon. The Licensed Professional responsible to verify CALGreen compliance is qualified and able to demonstrate competence in the [� discipline they inspect and verify. Mc�rif�ca4ir�a�� 703.9 Documentation. Verification of compliance with CALGreen may include construction documents, plans, specifications, builder or installer certification, inspection reports, or other methods acceptable to the enforcing agency which show substantial conformance. Implementation verification shall be submitted to the Building Department after implementation of all required measures and prior to final inspection approval. Page 4 of 5 Ca[Green_2014.doc revised 11104114 Project fume: Project Address: Project Description: CALGREEN 9110MATURE DECLARAONS Complete all lines of Section 1 —"Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as adopted by the City of Cupertino. 1,,� cd, It Owners Signature Date 5111MII AUbI -Qv0� Owners Name (Please Print) Desi Professional's Signatuie Date Design Professional's Name (Please Print (Zo ((> k�� e -c— S CUAJ—T L Sig re of License Professional responsible for CalGreen compliance Date KaAL_i _,� dj&L:� Name of License Professional responsible CalGreen compliance (Please Print) Phone Email Address for License Professional responsible for CalGreen compliance SEC70M 2 - NPLENEWG° YM MCG°30f;=0CAMM Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2013 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone Email Address for License Professional responsible for CalGreen compliance Page 5 of 5 CalGreen 2014.doc revised 11104114