B-2016-3172 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3172
10981 NORTHSKY SQ CUPERTINO,CA 95014-0538(316 40 043) THRASHER TERMITE
&PEST CONTROL
17427 FARLEY RD
WEST
OWNER'S NAME: WALKER KATHRYN M DATE ISSUED;11/28/2016
OWNER'S PHONE:408-255-9095 PHONE NO:408-354-9944
I IR. t,t, I t' I i. r.4. I. BUILDING PERMIT INFO:
License Class Lic.#PR5009
Contractor THRASHER TERMITE&PEST CONTROL Date X BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
—MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
FRONT/ABOVE GARAGE;REPAIR BALCONY TERMITE/DRY ROT
I hereby affirm under penalty of perjury one of the following two declarations: DAMAGE(36 S.F.)
1. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
2. ,?I have and will maintain Worker's Compensation Insurance,as provided for by
ex�✓Section 3700 of the Labor Code,for the performance of the work for which this
" permit is issued. Sq.Ft Floor Area: Valuation:$2280.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 40 043
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant Gnderstands and will comply with all non-point
source regulations,perthJJI)0' /)AI9€&
iupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
�=
Signature I Date 11/28/2016 Issued by:„/1,— '`��� ��'��_
d ✓` ' Date:11/28/2016
OWNER-BUILDER CLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: .
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. . I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:11/28/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3.. I certify that in the performance of the work for which this permit is issued,.I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino A unicipal Code Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections i 505,255 .,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall /
be deemed revoked.
Owner or authorized agent - l I� �1I,1�
Date:11/28/2016 w i r" / r
APPLICANT CERTIFICATION
h.
I certify that I have read this application and state that the above information is i x Y: di -
correct.I agree to comply with all'city and county ordinances and state laws I hereby affirm that there is a construct on lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 11/28/2016 Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISIONB
s.rsx 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinq(a�cupertino.orq
CUPERTINO
❑NEW CONSTRUCTION El ADDITION ❑ ALTERATION I TI ❑ REVISION/DEFIERRED ORIGINAL PERMIT#
PROJECT ADDRESS 1,0424
A1�i �F7f►`, .ss 1A}?Jcco APN# V U — D
OWNER NAME
c/u YFPH0 a01 S5 (o KT\bulgy vf� v7 �7J4 ,®),a---i-
,
STREET ADDRESS �� A� p CITY,STATE/ZI�P,/4„��J 1,0A4. /y('� / FAX
1Sr {”"� i 4(/1/l i4 y7,e�(�
'I .
CONTACT NAME �-Nu% PHONE E M �L
STREET ADDRESS I/t �l/ L>'2o d /+ CITY,STATE,ZIP J � ��� FAX L` {� ^7�a�
I O� TUz /`J�/ 6-f/ 07,,-40 (�O-.39,c-/ /
El OWNER ❑ OWNER-BUILDER ❑OWNER AGENT J�'{CONTRACTOR D CONTRACTOR AnPnrr 0 ARCHITECT ❑ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME• 1+12.' r � LICENSE EP LIC N T BUS.LIC#
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COMPANY NAME E M+** 5T,j-77204.
STREET ADDRESS CITY,STAT ,ZIP PH p �,/
�� �tlr�'t. ��, tij/O.�°�' LAI i�C( Ba 1°i/4' lis �c>U , jgc-7^47"P / r
ARCHITECT/ENGINEER NAME LICENSE NUMBER , BUS.LIC# --
COMPANY NAME E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK /� be
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EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN - OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑DETACH
❑ATTACH
DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES - - "--
BEING ADDED? ❑NO ADDITION? NO r
r'
klier
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑ iE +•m'�';, ® TOTAL VALUATIO
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PLANNING ADPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? L'•s:� ,---'77,3:,:r4- : pry ,
i
/hy�. s r � ��
By my signature below,l certify to each of the following: I am the property owner or authorized agent to act on the property owner's beh. ;. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to dl construction. I utho ' pr sentatives off Cu�]pertino to enter the above-identifierd property for inspection purposes.
Signature of Applicant/Agent: Ac,`f1 _ G� t Date: C 1 c� r (Cd
SUPPLEMEN AL INFORMATION REQUIRED
PLANCHECK•TYPE „l.v,_. fl�JT�N• SLIP.'
New SFD or Multifamily dwellings: Apply for demolition permit for
❑'&[LR`IIIE-COIINTEk ❑ BUILDING PLAN.REYiELV
existing building(s). Demolition permit is required prior to issuance ofbuilding
permit for new building. ❑ EXPRESS ❑, TANNING Pi ANI2EVTEw
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ P Lrc WOB1CS
form if any Hazardous Materials are being used as part of this project. '
0 I EnxGE ❑..FIRE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to -
submittal of Building Permit application.
❑ _MAJOR 0 SA�VTTAAY SEW▪ER DISTRICT,
'ENVIRONNIENTAL`HEALTR
BldgApp 2011.doc revised 06/21/11
SMOKE / ALARMS iwz
N
IDE
(..0 OWNER C RRBO ATE OFXCOMPLIANCE •
r6
�yT,ts� COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTINO10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinqa,cupertino.orq
PFRMIT NNO lE FIN ZED UNTIL THIS GERTIEICATE'HAS„BEN
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4-40 Y my ED,isterNmaxa ®� 9 Qj i T D1rWiDF O1
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00,CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon.
Monoxide Alarms be installed in the following locations:
AREA • SMOKE ALARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of 7C X
the bedrooin(s)
On every level of a dwelling unit including basements X X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke_ alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply:In dwelling units with no commercial power supply,alarm(s)may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl
space.Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2.An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above-referenced property,I hereby certify that the alarm(s)referenced aboue has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms specified below have been tested and are operational, as of the
date signed below.
Address: 1 9 / Ad/C7r- 5 if S L?Q t--epee,'- 7 Permit No. 173— OI 3/ 7X,
Specify Number of Alarms: #Smoke Alarms: #Carbon Monoxide Detectors: A I
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name: ke L` � p
,t/,A I,y t !� Siati gnature l Date:
Contractor Name:
Signature Lic.# Date:
Smoke and CO forr.doc revised 09/27/16
\\I 7 WATER-CONSERV1NG PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE Lc WS
ki23
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE 0 CUPERTINO,CA 95014-3255
(408)777-3228 FAX(408)777-3333.buildincacuaertirta.arg
Owner Name r Wei,ffe..0.--r- Permit No o[6. /7
AddreiSIU / 0 7 6/ .41 0-7/-i-h. 2 14-e-r-7'7'n
1. Is your real property a registered historical site?
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
[j] Cfj,,Piro Go to Question 2
•
2. Does your real property have a licensed plumber certifying that,due to the age or configuration of the property or its
plumbing,installation of water-conserving plumbing fixtures is not technically feasible?
ID Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
0 The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
CW110171\To Go to Question 3.
•
3. Is water service permanently disconnected for your building?
11 Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the formand sign bottom of form.
C7:41:a/Ro Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
El No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
Yes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign
bottom of form..
5. Please check ONE of the following:
(7.17_A/My property is a sittgle-family residential real property. See Civil Code Section 1101.4.
Orr and after January 1,2014,building alterations,or improvements shall require all non-compliant plumbing fixtures
to be replaced with water-conserving plumbing fixtures throughout the building.On or before January 1,2017,all non-
compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
CI My property is a multifamily residential real property. See Civil Code Section 1101.5.
On arid after January 1,2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conServing plumbing fixtures.
On or before January 1,2019;all non-compliant plumbing fixtures shall be replaced with water-
conserving plumbing fixtures throughout the building(regardless of whether property undergoes alterations or
improvements).
CI Myproperty is a commercial real property. See Civil Code Section 1101.5.
On and after January 1,2014,specifiedbuitcling alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing,fixtures throughout the building(regardless of whether property undergoes alterations or improvements).
I,as the owner or owner's agent of this property,certify under penalty of perjury that non-compliant plumbing fixtures will be
replaced prior to date specified above with water-conserving plumbing fixtures in accordance with Civil Code Sections 1101.1
through 1101.8,the current California Plumbing Code and California Green Building Standards Code,and manufacturer's
installation requirements,and,that the water-conserving plumbing fixtures comply with the requirements as indicated in the
table on the following page
7
Owner or Owner Agent's, / - -I- -/ 4 h&c-leplaio
e-4- q r /'/'/
Upon completing and signing this:Certificate,please return it to the Building Division in order to final your building permit.
SRO'?20115.doc revised 08/26/15