B-2016-3198CITY OF CUPERTINO BUILDING PERMIT
BUHMINGADDRESS:
10792 ALDERBROOK LN CUPERTINO, CA 9501411604 (369 20 041)
CONTRACTOR:
PETERSEN-DEAN INC
PERMIT NO: B-2016-3198
FREMONT, CA 94538
OWNER'S NAME: ANDERES STEPHEN C AND DEBORAH M TRUSTEE
DATE ISSUED: 12/02/2016
OWNER'S PHONE: 408-252-7153
PHONE NO: (510) 371-6500
LICENSED CONTRACTOR'S DEC141RAITON
BUILDING PERMIT INFO:
License Class C10. C46 Lic. #468117
Contractor PETERSEN-DEANINC Date 91/31/2017
X BLDG ELECT _ PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MEECH 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:
1h ereby affirm under penalty of perjury one of the following. two declarations:
(I) 18 PANEL (3 ARRAYS) ROOF MOUNTED PV SYSTEM (5.13kW)
1. I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
/I have and will maintain Worker's Compensation Insurance, as provided for by
'/Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Sq. Ft Floor Area:
Valuation: $21799.00
APPLICANT ANT RTIFI ATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
369 20 041
representatives of this city to enter upon the above mentioned property for
inspection purposes, (We) agree to save indemnify and keep harmless the
City of Cupertino against liabilities, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Munici al Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature ate 12/02/2016
Issued by:;MELI
Date: 12/0 6
OWNER-BUILDERDECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RF 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. 1, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 12/02/2016
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
s. 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
Worker's Compensation laws of California. If, after making this certificate of
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
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 12/02/2016
1 certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. i agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ C.)
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Signature Date 12/02/2016
r
Licensed
Professional '
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CUPERTINO
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 buildingOcupertino org
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PROJECT ADDRESS
APN #
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT '�CO RACTOR ❑ CON'TRACTORAGENT
❑ ARCHITECT ❑. ENGINEER ❑ DEVELOPER ❑ TENANT
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COMPANY NAME
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USE OF ❑ SFD Or Duplex ❑ Multi -Family
PROJECT IN WILDLAND
PROJECTIN
STRUCTURE: ❑ Commercial
URBAN INTERFACE AREA ❑ Yes
❑ NIO
FLOOD ZONE ❑ Yes ❑ No
SOLAR PANELS
❑ ELECTRIC VEHICLE CHARGING STATION
❑ SOLAR WATER HEATING
ElOTHER:
FOR SOLAR PANELS: NUMBER OF PANELS/UNITS:
KILOWATTSLCOMMERCIAAL ONLY):
TOTAL VALUATION:
DESCRIPTIONT OF WORK
A l
By my signature below, I certify to each of the following: I am the propertyowner or authorized ag t to act on the pro e have read this
application and the information I have provided is correct. I have read the Description of Work and ven s accurate. I agree to comply with all applicable local
ordinances and state laws relating to b� construction. I authoriz rese trves of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: / _ Date: / ,- / e� 71
AL INFORMATION REQUIRED
PV4pp_2011.doc revised 03/16/11
CUPERTINO
- SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
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
the bedroom(s)
X
X
On every level of a dwelling unit including basements
X
X
Within each sleeping room
X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with -
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
hz 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 fuiishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and.420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms specified below have been tested and are operational, as of the
date signed below. ,,
Address: `1 q1— I Lel AoA t -A) Permit No.
Specify Number of Alarms: # Smoke Alarms: # Carbon Monoxide Detectors: 1 9 1
I ha„A rAart and anraa to rmmnty with the terms and conditions of this statement
Owner (or Owner Agent's) Name:
Date:
Signature ... ..,
....................................................................................
Contractor Name:
Signature.................................................................. Lic.# ......................................Date:
Smoke Mid COfbign.doe revised 09/27/16
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
CUP RTINO I 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 77-3 8 . FAX (408) 777-3333 , buildinq(alcupertino.org yy , 916
Owner Name �Q�t�► pJ e/ e15 Pen -nit No. G�
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Address �' a Py f r®!�
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1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the'fonn and sign bottom of form.
U/No - _ Go to Question 2.
Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its
plumbing, installation of water -conserving plumbing fixtures is not technically feasible?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
IR /No Go to Question 3.
3. Is water service permanently disconnected for your building?
❑l y,�s Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
R' No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ 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.
Q'xles 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. Ple- se check ONE of the following:
My property is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non-
compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
❑ My property is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water -
conserving plumbing fixtures throughout the building (regardless of whether properly undergoes alterations or
improvements).
❑ My property is a commercial real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements).
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 vrith water -conserving plumbing fixtures in accordance with Civil Code Sections 110 1. 1
through 110 1.8, the current California Plumbing Code and California Green Building Standards Code; and manufacturer's
installation requirements, and that the water -conserving plumbing fixtures comply with the requirements as indicated in the
table on the following page.
Owner or Owner Agent's Signature: C_Date: — A
Upon completing and signing tlus c:ertirrcate, prease reiurn it to Me bu11u711g LiviZ11v11 111 vl-- w ii+ yvu -'--111,--'
SB407 2015.doc revised 08/26/15