B-2016-3248 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3248
10255 ANTHONY PL CUPERTINO,CA 95014-5646(342 12 072) FIDELITY HOME
ENERGY INC
SAN LEANDRO,CA
94577
OWNER'S NAME: TROLLMAN JOHN H AND HELEN S TRUSTEE DATE ISSUED:12/09/2016
OWNER'S PHONE:408-9730130 PHONE NO:(510)957-2220
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class jJ Lic.#790709
Contractor FIDELITY HOME ENERGY INC Date 01/31/2017 • X BLDG _ELECT _PLUMB
MECH X RESIDENTIAL COMMERCIAL
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. JOB DESCRIPTION:
(N)5 PANEL ROOF MOUNTED PV SYSTEM (1.5 KW)
I hereby affirm under penalty of perjury one of the following two declarations:
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.
Wi. 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:$5000.00
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 342 12 072
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 s-id City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the a .:r- t understands and will comply with all non-point
source reg�ul ti per e Cupertin• ,rici.al Code,S- • :. - 180 DAYS FROM LAST CALLED INSPECTION.
Signature rf J Date 12.9.16 Issued by:AbbyAyende
Date: 12/09/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). ' Date:12.9.16
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 equipm-, or devices which emit hazardous
air contaminants as defined by the : • :' Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with t,.C 4 •,r,Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety, o , ,,ns 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall . _._.
be deemed revoked. Owner or authorized age :,
APPLICANT CERTIFICATION Date:12.9.16
I 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. I understand my plans shall;be used as public records.
Licensed '
Signature Date 12.9.16 Professional
116104 '''" ?..Lii
ALTERNATIVE ENERGY PERMIT APPLIC• TION ,- A E
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISI'N
9
,�,t.Iss�;.: 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
. 40 (408)777-3228•FAX(408)777-3333•buildings icupertino.orq -
CUPERTINO /
PROJECT ADDRESS 55
Af Ili C/Lj 0 L, APN# /42 1 2 011
OWNER NAME t " Gln/ PHO $7,0JJl) E-MAIL
STREET ADD'''SS �y/� , ` CIT STATE,ZI f FAX
CONTACT NAME6 I
( PHONE '75— o/2 E-MAIL
STREET ADDRESS1.y^ CITY,S/I,E t/,.¢y 0 6,17 FAX
❑OWNER 0 OWNER-BUILDER 0 OWNER AGENT Di CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR N�fl 41 Q LICEI�TSi �E � LICEI�'S�TYPE BUS.LIC# L.l�b
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COMPANY NAME /,---,i_eC
E-MAIL FAX
STREET ADDRESS .- 00 La zyd cet_ TY,STAT IP PH
,c41 I) (f_i(lko Z4
ARCHITECT/ENGIIIEER NAME / LICENSE NUMBER 0 0 9 BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF 0 SFD or Duplex 0 Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: 0 CommercialURBAN INTERFACE AREA 0 Yes 0 No. FLOOD ZONE 0 Yes 0 No
SOLAR PANELS 0 ELECTRIC VEHICLE CHARGING STATION 0 SOLAR WATER HEATING 0 OTHER:
FOR SOLAR PANELS: NUMBER OF PANELS/UNI KILOWATTS(COMMER sJAL ONLY): TOTAL VAL TION:
DESCRIPTION OF WORK4cO4. S f(,.5 / 5 A-14j
RECEIVED BY'
By my signature below,I certify to each of,.following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I hay- .. .ed 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 o. ....' 'onstructio I,...i.= - .-.resentatives of Cupertino to enter the above-identifi d property for inspection purposes.
Signature of Applicant/Agent: // Date: h=24-/‘
'PPL' ENTAL INFORMATION REQUIRED OFFICE USE ONLY:. :. ':'
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(�{ ❑ OVER-THE-COUNTER
- l�t\U
❑ EXPRESS
.- 0. STANDARD
a 0 _LARGE
0.MAJOR .
PVApp_2011.doc revised 03/16/11
No i WATER-CONSERVING PLUMBING FIXTURES ,
rev/ OWNER CERTIFICATE OF COMPLIANCE �i k 1
�n,rs: COMMUNITY DEVELOPMENT DEPARTMENT a BUILDING DivistON
CUR Nth 10300 TORRE AVENUE e CUPERTINO,CA 95014-3255
(408)777-3224a FAX(408)777-3333.bui.in• • u.ertino.or.
Owner Name* fes/ / Lj ` 74e2 i, 3.: „.(1.,,,�►'
Permit No - -- -
Address ,()71` , 1( -
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
•,, [11/No Go to Question 2. I
!
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.
INo Go to Question 3.
3. Is water service permanently disconnected for your building?
El yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
17,1. No Go to Question 4.
. r
4. Is your real property built and available for use or occupancy on or before January 1, 994?
II 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 ofte form and sign bottom of form.
1.1
es 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. Pl9aSe check ONE of the following:
IV
MY property is a sinSgleamilY 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 (regardlessl of whether
property undergoes alterations or improvements).
El My property is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant':
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1,2019,all non-compliant plumbing fixtures shall be replaced with water-
conserving plumbing fixtures throughout the building(regardless of whether property undergoes alterations or
improvements).
El 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 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-con -rving plumbing fixtures comply with the requirements as indicated in the
table on the following Pago• _. /
Owner or Owner Agents Signature:< 1 � -' `° ' 1 / Date,:J/ 20
Upon completing and signing this Certificate,plea e return it to the Building Division in order to final your building permit.
SB4072015.doc revised 08/26/15
EIL
y; SMOKE I CARBON MONOXIDE ALARMS
iif OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE CUPERTINO;CA 95014-3255 ,
(408)777-3228• FAX(408)777.3333 buildinqApupertino.orci
' • , - ,
RIZISTETk-CANN laREINALEDVIMTERS CERTIFICATE:RAS BKW
c4 444 tlsi;-AV:lsC9riaEZETEMST et: '149,vEreisumpiNaps zisiolvivc
t4"4.4400, W,47,10*0:674;ZZAtt;`-''tZ34,g144'7A1U:
FURPOSE
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 4204 end 907211,2 where no;interior access for
inspections are required.
GBNBRAL INFORMATION
Existing single-family and maid-family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuadon of additions,alterations,or repairs to existing dwelling units exceeds
$1000.00,CRC Section R.314 and CDC Sections 907.2.11.5 and 4204 reqnire that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA SMOKE ALARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of X X
the bedroom(s)
On every level of a dwelling unit including basements ' I X — X
Within each sleging 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.
rower Supply:In dwelling units with no commercial power supply,alarm(s)may be solely battery operated.
In existing dwelling units,alarms axe 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 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.
\ 2- -
Address: 41'0'4 Permit No.
N.1 'P _
„f7
Specify Number qf Alarms: #Smoke Alarms: Carbon Monoxide Detectors:
(have react react and=agree ,.tssi:)/pRfy witiaVerms-and conditions of this statement
Owner (or*Owneagg,V)Name:
S9rtueV7 • RA4*.4", • •.•.. ....•• . ..••.•..•.... . ......Dae: Ow/kmor,
Contractor Name:
Signature..... .....„..... ........... ...Lio.# ... ... ..... .......„..—Pate:
Okal cq-fomm=,remised PP/2