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15120117CITY OF CUPERTINO BUILDING PIERMIT BUILDING ADDRESS: 1210 RUPPELL PL CONTRACTOR: AG CONSTRUCTION & REMODELING, OWNER'S NAME: PERUVEMBA PRAKASH K AND PRAKASH PRE 5292 AMELIA DR OWNER'S PHONE: 4087484683 LICENSED CONTRACTOR'S DECLARATION [1he,eby nse Class Lic. # O `�j ractors affirm that I am licensed under the provisions of Chapter 9 mencing with Section 7000) of Division 3 of the Business & Professions and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: and will maintain a certificate of consent to self - insure for Worker's 'Comp nsation, 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. 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. SAN JOSE, CA 95118 PERMIT NO: 15120117 DATE ISSUED: 12/15/2015 PHONE NO: (408) 838 -2872 JOB DESCRIPTION: RESIDENTIAL COMMERCIAL - REMOVE (E) WINDOW WINDOW AND SKYLIGHT; ENLARGE (1) IN (E) REAR BEDROOM; CONVERT (E) DINING ROOM TO BATHROOM AND HALLWAY (102 SF). Sq. Ft Floor Area: --Fv—,iatio,. $50000 APN Number: 36230041.00 PERMIT EXPIRES IF WO WITHIN 180 F PEI 180 D ROM A. �sued9 JEEpancy Type: NOT STARTED ISSUANCE OR SLED INSPECTION.` ZI t � // Nigna Date — , '�� RE- ROOFS. f " 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 rI OWNER- BUILDER DECLARATION inspection. tI hereby affirm that I am exempt from the Contractor's License Law for one of he 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 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. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &Safety Code, Sections 2? %�3a and 25534------ Owner or authorized a Date.7... ISI 1< 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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 90300 TORRE AVENUE • CUPERTiINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 - building n cueertina Ora ALTERATION / i Z iC �-L)PPFLam.. PL OWNER NAME f2RAKA&H k- STREET ADDRESS 6Zl kV Pr IF LL PL CONTACT NAME _ Iq S A AS ovG G— STREET ADDRESS /DEFERRED �APN e) A PHON4,0 T •_ S X4` g 2 E -MAH CITY, STATE, ZIP ! V Gu P ART J4 Gl� al sb ► PHONE E -MAIL CITY, STATE, ZIP _FAX FAX EJ OWNER ❑ OWI\rER- BUILDER ❑OWNER AGENT ❑CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TEN CONTRACTOR NAME ANT LICENSE NMER � ^ U rM �L LICENSE TYPE BUS. LIC # COMPANY NAME t'2 T q E -MAIL STREET ADDRESS � FAX CITY, STATE, ZIP ARCHITECT/ENGEQEERNRME !�'� `ID� _ ©Zj 2 �'� ��c� � t "�"� LICENSE NUMBER �2 2�j COMPANY NAME �� � ✓"` J (fin), ' E -MAIL // �. Zf STREET ADDRESS CITY, STATE, ZIP HONE DESCRIPTION OF WORK , M•1'Gf �L_ i O ( �y b �4X CW Mn �3, t psi o 1,4.E c ►uDOcv GV P NDC`s CUS X11 �} • j V R A,6, , EXISTG AREA BATHROOM REMODEL AREA PORCH AREA # DWELLINr3In�r, NEW FLOOR DEMO AREA AREA PRE - APPLICATION YES PLANNING APPL # r-I N[l REMODEL AREA IS A SECOND UNIT ❑ YE BEING ADDED? ONO IF YES, PROVIDE COPY OF PLANNING APPROVAL LETTER TOTAL NET AREA REMODELAREA(02 ADDITION? `-' V V ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? r l NO USE I TYPE I OCC. SQ.FT. I VALUATION ($) By my signature below, I certify to each of the following: I am the property application and the information I have provided is c I have . �� v® C) ® . 06 Property owner's behalf. 71- . read he Des Description of Work and verify it s accurate. ordinances and state laws rela ' to building construe . I authorize representatives of Cupertino I have read this I agree to comply with all applicable local to enter the above - identified Signature of Applicant/Agent: Age Date: property for inspection p purposes. SUPPLEMENTAL INFORMATION REQUIRED New SFD Or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required to issuance PLAN CHECK TYPE ❑ OVER THE ROUTING SLIP prior of building permit for new building. - - COUNTER BUILDING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ PLANNING PLAN REVIEW form if any Hazardous Materials are being used as part of this project. ❑EXPRESS STANDARD ❑ PUBLIC WORKS Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. ❑ LARGE ❑ FIRE DEPT ❑ MAJOR ❑ SANITARY SEWER DISTRICT ❑ B1d9App_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 1210 Ruppell Place DATE: 12/14/2015 REVIEWED BY: Phuong APN: 362 30 041 BP #: `VALUATION: $50,000 °PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair USE: SFD or Duplex PENTAMATION PERMIT TYPE: 1 R3SFDREM WORK Remove e window and sk li ht; Enlar e 1 j window in e rear bedroom Convert e dining room to SCOPE bathroom and hallway (102 SF). be NOTE This estimate does not include fees due to other -Departments i.e. Plannmg Public etc.. These ees are based District, School on the preliminary ITEMS (Fee Resolution] Ff information available t am e. ontact the De t info. Work Without Permit? QTY/FEE MISC ITEMS .Plan Check Fee: $0.00 102 s.f. Remodel, Advanced Planning Fee: Other Suppl. PC Fee: Reg. OT 0.0 firs $0.00 $431.00 IREMREso7'H PME Plan Check: � $0.00 �L J # Window /Sliding Glass Door Permit Fee: $0.00 $431.00 1WINRBP Replacement Suppl. Insp. Fee: Reg. Q OT 0 0 firs $0.00 Bldg Stds Commission Fee: PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTAL FEE: $$70.50 Work Without Permit? C) Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Q Building or Structure Strong Motion Fc.c,. 1BSEISMICR $6.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $8.50 $862.00 TOTAL FEE: $$70.50 Revised: 10/01/2015 c Building Department City Of Cupertino 10300 Torre Avenue LM Cupertino, CA 95014 -3255 Telephone: 408 - 777 -3228 C U P E RT I N O Fax: 408 - 777 -3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: `Z. I 0 r— !_ PERMIT # 2 O l OWNER'S NAME: T ,!� S PHONE # t Lf C>8 6 Z GENERAL CONTRACTOR:. S��zo_rc c7C2o BUSINESS LICENSE # Z LAS ADDRESS: 52g 2 .� tit t=l.�1s �� , ��� '' o�T� CITY /ZIPCODE: \\,a *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical �- Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile zzI Dal CALGREEN RESIDENTIAL CHECKLIST — MANDATORY ITEMS 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 - buildinq cupe no.orq The'2013 CalGreen Code applies to all newly constructed hotels, motels, lodging houses, dwellings, dormitories, condominiums, shelters, congregate residences, employee housing, factory -built housing and other types of swellings with sleeping accommodations and new accessory buildings associated with such uses. Existing site and landscaping improvements that are not otherwise disturbed are not subject to the requirements of CALGreen. Project Name: Project Address: Project Description: Peruvemba Residence 1210 Ruppell Place Cupertino, CA Interior Remodel Instructions: 1. The Owner or the Owner's agent shall employ a licensed professional ex . r enced with the California Green Buildin Standards Codes to verify and assure that all required wo 4crcrk is properly planned and implemented in the project. 2. The licensed professional, in collaboration with the owner and the design professional shall initial Column 2 of this checklist, sign and date Section 1 - Design Verification 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 professi8 all complete Column 3 and sign and date Section 2 - Implemen,�aliatn Verification at the end of this checklist and submit the r Y � � r, completed form to the Building Inspector -1 Y Rte, MANDATORY FEATURE OR MEASURE 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. 4.146.3 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. Column 2 Column 3 Project Verification ,-auirements Page 1 of 5 CalGreen-2014.doc •revised 01/15/14 General 4.201.1 Low -rise residential buildings shall meet or exceed the minimum ( ®� standard design required by the California Energy Standards. Indoor Water Use 4.303.1 Water conserving plumbing fixtures 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, and shall meet the applicable standards referenced in Table 1401.1 of the California Plumbing Code. Page 2 of 5 CalGreefl 2014.doc revised 01115114 Outdoor Water Use 4.304.1 Irrigation 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. ❑ 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 Durability and Reduced Maintenance 4.406.1 Rodent proofing. Annular spaces around pipes, electric cables, conduits, or other openings in plates at exterior walls shall be protected against the passage of rodents by closing such openings with cement mortar, concrete masonry or similar method acceptable to the enforcing agency. Construction Waste Reduction, Disposal and Recycling 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. Building Maintenance and Operation 4.410.1 Operation and maintenance manual. At the time of final inspection, an operation and maintenance manual shall be provided to the building occupant or owner. Fireplaces 4.503.1 General. Install only a direct -vent sealed- combustion gas or sealed wood - burning fireplace, or a sealed woodstove. Pollutant Control 4.504.1 Covering of duct openings and protection of mechanical equipment during construction. Duct openings and other related air distribution component openings shall be covered during construction. 4.504.2.1 Adhesives, sealants and caulks. Adhesives, sealants and caulks shall be compliant with VOC and other toxic compound limits. 4.504.2.2 Paints and coatings. Paints, stains and other coatings shall be compliant with VOC limits. 4.504.2.3 Aerosol paints and coatings. Aerosol paints and other coatings shall be compliant with product weighted MIR Limits for ROC and other toxic compounds. Page 3 of 5 �N! M CalGYeen 2014.doc revised 01115114 4.504.2.4 Verification. Documentation shall be provided to verify that compliant VOC limit finish materials have been used. ILN 4.504.3 Carpet Systems. Carpet and carpet systems shall be compliant with VOC limits. M 4.504.4 Resilient flooring 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) Law - emitting VN 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 LU comply with low formaldehyde emission standards. Interior Moisture Control 4.505.2 Concrete slab foundation. Required vapor retarders and capillary breaks are also required to comply with CalGreen Section 4.505.2.1. UN 4.505.3 Moisture content of building materials. Moisture content of building materials used in floor framing wall and is checked before enclosure. Indoor Air Quality and Exhaust 4.506.1 Bathroom exhaust fans. Exhaust fans which terminate outside the building in are provided every bathroom. Environmental Comfort 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. INSTALLER, AND; SPECIAL INSP �CT E R QU° ° (qualifications 702.1 Installer training. HVAC system installers are trained and certified in the installation HVAC proper of systems. 702.2 Special inspection. The Licensed Professional responsible to verify CALGreen compliance is qualified and able to demonstrate competence in the UU discipline they inspect and verify. Verifications 703.1 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 CalGreen_2014.doe revised 01115114 CALGREEN SIGNATURE DECLARATIONS Project Name: Peruvemba Residence Project Address: 1210 Ruppell Place Cupertino, CA Project Description: Interior Remodel SECTION 1 — DESIGN VERIFICATION 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. Owner's Signature t KA 5 #t Owner's Name (Please Print) Design Professional's Signature Desig�ssion 's Name (Please Print) Signature of License Professional responsible for CalGreen compliance Eric Kirk Name of License Professional responsible for CalGreen compliance (Please Print) eric @builders - energy.net Email Address for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION Date Date 12/14/2015 Date 408 - 806 -9901 Phone 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 01115114 , CUPERTINO STATEMENT OF SPECIAL INSPECTIONS, 2013-CBC COMMUNITY DEVELOPMENT DEPARTMENT '• BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.Q., BUILDING .OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777-3228 • FAX (408) 777 -3333 • bulldina0 upertino.orq SITE ADDRESS 1.2- it) 1LU P ft � � LA • APN _ BP# Owner d 5&s. 4 ............ ............................... .. Rt?.P E .I AINJ....... FPA.. Contractor.. 09 �F........ RQ.ST N ............................... Address.J.24 .... K?,raa L ..... ...Dj -... ...... ..... a s4 t.. zip- OtS.A1y ...... . Address ........................................................ . .................... I .............. I.......... . C• ty /st .................................................. Zp ................... Phone ........................ Applicant.. PM -t- J.H.1......... ................. Engineer /Architect. yt > �' •�d. � �yt# Add ress.l.- i......� P.F. k� ........%...... City /st..W...1 ll`�flf A... zip..q. R.l. `{ Pho i' 's4' Address ..1.�.7(,y..�Al:!'i`.j.L -1 &).....�%1.�'�-NVA. ''��� �� p3 - AlPhon .WK . � glib•' tom• s�1r^kf'�.. .��. P • es� -� City /St.. .e....... zi PROJECT DESCRIPTION: " d �, uS' L ;0'40 jD 1;'L j A*9y ­ 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 ❑ "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 pfo n a fpro d i R' a ns, this statement and CBC Sections 1704, 1705, 1706,1707, and 17�T: nt frm orks 11 u , fitted to ur i cial a 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. RE C E I Vi • Correction of discrepancies noted in inspections. ED 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 far 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. SpeCkdnspect10nF0?7? 2012.doc revised 09106112 t i t 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 p ibalist duties. Special Inspection agency's listed on this form must be pre - approved and listed on Cupertino's approved Special Inspector's Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the califomia Council of Testin4and Inspection Agenciess. 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. rE tim- (except for Firm. -_ ..Addr. . 1. Special Inspection ( pt .......................... ............................... ..................... State .....................Zip ...................... geotechnicai) City ......................................................................... ............................... Telephone.... ............................... Fax............ ............................... Email ......... ......................... 1 Testing Firm. .......................... Addr.......................................................... ............................... 2. Mateda ........... ............................... .State .......................Zip ...................... Telephone.... ............................... Fax....... ............................... Email.......................... ............................... 3. Geotechnical inspections Finn ............................................................. --- Addr ......................................................... .......... ............................... City......................... ............................... '.......... ............................... Email ...................................... Fax.. ............ 4. Other: Ftrrrr ............................................................. . .... ... Addr........................................................ ............................... Telephone.. ............................... Fax ......... ............................... Email�..� ................. ..... ..'p....................... "Ali 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 1706.3.6) Description of seismiafonce- resisting system and designated seismic systems subject to special inspections as per Section 1705.3: The extent of the seismicforoe- resisting system is defined in more detail in the construction documents. 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. SpechdhspecdonForm 2012.doc revised 09105112 SCHEDULE OF SPECIAL INSPECTION PROJECT DESCRIPTION: Noiation Used in Tabte: Column headers: C indicates continuous inspection is required. P Indicates periodic inspections are required. The notes and /or contract documents should clarify Box entries: ro date column to denote either "C" continuous or "P" periodic inspections . x is placed in the app p Denotes an activity that is either a one -time activity or one whose frequency is defined in some other manner. Additional detail regarding inspections and tests are provided in the project specificationF's or ER notes on the drawings. IRC REFERENCE VERIFICATION AND INSPECTION C I P INSPECTION OF FABRICATORS 1. ❑ Inspect fabricator's fabrication and quality control r _. procedures. INSPECTION OF STEEL 1. Material verification of high - strength bolts, nuts and washers. AISC 360, ❑ Identification marking to conform to ASTM stds Section A3.3 and specified in the approved construction documents. x applicable ASTM ._...4-047! r-tondarrl ❑ Inspect fabricator's fabrication and quality control _ x --- procedures. 2. Inspection of high- strength bolting: x ❑ Snug -tight joints. ❑ Pretensioned and slip - critical joints using turn -of -nut x with matchmarking, twist -off bolt or direct tension RISC 360, indicator methods of installation. Section M2.5 p Pretensioned and slip - critical joints using turn.4 -nut x - -- wrench methods without matchmarking or calibrated of installation. 3. Material verification of structural steel and cold formed steel deck• AISC 360, ❑ For structural steel, identification markings to conform x Section M2.5 to AISC 360. [3 For other steel, identification markings to conform to x ASTM standards specified in the approved Applicable ASTM material standards construction documents. Manufacturer's certified test reports. ❑ x 1704.3 1704:3:3 SpecialnspectianForm 2012.doc revised 09106112 VERIFICATION AND INSPECTION C P STANDARD REFEREPUA 4. Material verification of weld filler materials: AISC 364, ❑ Identification marking to conform to AWS specification X Section A3.5 and _. in the approved construction documents. -- applicable AWS A5 documents 13 Manufacturer's certificate of compliance required. _r X 5. inspection of welding: a. Structural steel and cold formed steel deck: ❑ Complete and partial joint penetration groove welds. X © Multipass fillet welds. X AWS D1.1 1704.3.1 [I Single•pass fillet welds > 5116» 113 K Plug and slot welds. -- X [3 Single-pass fillet welds <= 5116° X AWS D1.3 E2 Floor and roof deck welds. b. Reinforcing steel: ❑ Verification of weidability of reinforcing steel other than X ASTM A 706. U3 Reinforcing steel resisting flexural and axial forces in and special moment frames, X 1$: _. � AWSect intermediate boundary elements o special walls a# on 3 51 .2 concrete and shear reinforcement. X ❑ Shear reinforcement. -- X ❑ other reinforcing steel. 6. Inspection of steel frame joints details for compliance: ❑ Details such as bracing and stiffening. X 1704.3.2 X ❑ Member locations. X ❑ Application of joint details at each connection. --' VERIFICATION AND INSPECTION C REFERENCED IBC P STANDARD REFERENCE INSPECTION OF WELDING 1 ❑ Welded studs when used for structural diaphragms. ""- X 1704.3 2. [3 Welding of cold-formed steel framing members. --� X 3. ❑ Welding of stairs and railing systems. X Spee1 rm M$Peeti0nF0 2012.doc revised 09106112 VERIFICATION AND INSPECTION C P INSPECTION OF CONCRETE 1. ❑ inspection of reinforcing steel, including prestressing X tendons and placement. 2. 13 Inspection of reinforcing steel welding in accordance with Table 1704.3 Item 5b. 3. ❑ Inspection of bobs to be installed in concrete prior to and during placement of concrete where allowable x loads have been increased or where strength design is used. 4. ❑ Inspection of anchors installed in hardened concrete. --- x 5. ❑ Verifying use of required design mix. X 6. ❑ At time fresh concrete is sampled to fabricate specimens for strength tests, perform slump and air content tests and determine the temperature of the concrete. 7. ❑ Inspection of concrete and shotcrete placement for proper application techniques. 8. ❑ Inspection for maintenance of specified curing temperature and techniques. 9. Inspection of prestressed concrete: ❑ Appiicatiori of prestressing forces. ❑ Grouting of bonded prestressing tendons in the seismic force - resisting system. 10. ❑ Erection of precast concrete members. 11. ❑ Verification of in -situ concrete strength, prior to stressing of tendons in posttensioned concrete and prior to removal of shores and forms from beams and structural slabs. 12. ❑ Inspect formwork for shape, location, and dimensions of the concrete member being formed. 13. ❑ Bolts Installed in Existing Masonry or Concrete EODirect tension testing of existing anchorsDirect tension testing of new bolts. ❑ To testing of new bolts. CI Prequalification test for bolts and other types of anchors. 14.13 Other: ®= ACI 318: 3.5,7.1-7.7 1913.4 A DI A ACI 318: _- 3.5.2 ACI 318: 8.1.3, ! 1911.5,1912.1 21.2.8 I ACI 318: 1912.1 1904.2.2,1913.2, ACI 318: 1913.3 ASTM C 172 ASTM C 31 1913.10 ACI 318: 5.6, 5.8 1913.6,1913.7, X _ -_ ACI 318: 5.9, 5.10 1913.8 X ACI 318: 5.11 -5.13 1913.9 X -- ACI 318:18.20 X ACI 318:18.18.4 -- X ACI 318: Ch. 16 --- X 1 ACi 318: 6.2 X ACI 318: 6.6.1 — --- X X See ICC ES Reports form special x inspection requirements for proprietary products --- X a $ 4, f Ca�-- '�'� SpecialnspecdanForm 2012.d9c revised 0910611.2 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 4021ACI TMS 4021ACIi 15301ASCE6 SECTION 5301ASCE 5 INSPECTION OF LEVEL 1 MASONRY 1. ❑ Compliance with required inspection provisions of Art. 1.5 the construction documents and the approved --- X --- submittals shall be verified. 2. ❑ Verification of f,,, and f aac prior to construction — X __ __ Art. 1.413 except where specifically exempted by this code. 3. ❑ Verification of slump flow and VSI as delivered to X -, __ — Art.1.5B.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.3.313 a Location of reinforcement, connectors, — X _. Art. 3.4, 3.6A prestressing tendons, and anchorages. ❑ Prestressing technique. --- X --- -- Ark 3.68 ❑ Grade and size of prestressing tendons and X _r __ Art, 2,413, 2AH anchorages. 5. During construction the inspection program shall verify: ❑ Size and location of structural elements. --- X — -- Art. 3.3F ❑ 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, X -�- Sec. 1.15 Art. 2.4, 3.4 anchor bolts, prestressing tendons and --- anchorages. ❑ Welding of reinforcing bars. X --- -'° 13 Preparation, Preparation, construction and protection of masonry during cold weather (temperature below X Sec. 2104.3, Art. 1.8C,1.80 40 degrees F) or hot weather (temperature above 2104.4 80 degrees F). ❑ Application and measurement of prestressing X ___ — w Art. 3.613 force. 6. Prior to grouting the following shall be verified to ensure compliance: ❑ Grout space is clean. — X --- — Art. 3.2D R 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. 2.66 prestressing grout for bonded tendons. 11 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. SpecfalnspeclionFOM 2612.doc revised 09 106112 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 4021AC1 TMS 4021AC1 SECTION 5301ASCE 5 5301ASCE 6 8. ❑ Preparation of any required grout specimens, Sec. X 2105.2.2, --- Art. 1.4 mortar specimens, and/or prisms shall be --- observed. 2105.3 INSPECTION OF LEVEL 2 MASONRY 1. ❑ Compliance with required inspection provisions Art 1.5 of the construction documents and the approved --- X --- - — submittals. 2. ❑ Verification of fm and f AAc prior to construction Art. 1.413 X ___ and for every 5,000 square feet during --- -" construction. 3. ❑ Verification of proportions of materials in Art 1.513 X premixed or preblended mortar and grout as --- delivered to the site. 4. ❑ Verification of slump flow and VS1 as delivered to X _ Art. 1.613.1.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. 3.21) 13 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, X - -- Sec. 1.15 Art. 2.4, 3.4 anchor bolts, prestressing tendons and --- 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 w X Sec. 2104.3, Art. 1.8C, 1.81) 40 degrees 1=) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing X w __ Art. 3.6B force. 6. ❑ Preparation of any required grout specimens, Sec. Art. 1.4 mortar specimens, and /or prisms shall be X -- 2105.2.2, --- observed. 2105.3 SpecialnspectionForm 2012.doc revised 09106112 VERIFICATION AND INSPECTION I C I P 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. �- 1744.6.1 C] 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 restraint1bracing 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 M X achieve the desired bearing capacity. 2. ❑ Verify excavations are extended to proper depth and _ X have reached proper material. 3. ❑ Perform classification and testing of compacted fill X Table 1704.7 materials. 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 X and verify that site has been prepared properly. REQUIRED VERIFICATION AND INSPECTION OF DEEP DRIVEN FOUNDATION ELEMENTS 1. ❑ Verify element materials, sizes and lengths comply X with the requirements_ 2. 17 Determine capacities of test elements and conduct X p_ 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 M accordance with Section 1744.3. 6. ❑ For concrete elements and concrete filled elements, perform additional inspections in accordance with --- --- Section 1704.4. SpecialkspectionForm 2012.doc revised 09106112