B-2016-3295 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: - CONTRACTOR: PERMIT NO:B-2016-3295
19854 BAYWOOD DR CUPERTINO,CA 95014-2316(316 31 013) SAMSCAPING INC
MOUNTAIN VIEW,CA
94043
OWNER'S NAME: PUTHIYAPURAYIL RIYAZ V AND ASLAM SHAH1N TRU DATE ISSUED:12/19/2016
OWNER'S PHONE:408-775-1985 PHONE O:(650)965-9150
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C27 Lic.#654593
Contractor SAMSCAPING INC Date 07/31/2018 X BLDG _ELECT X PLUMB
MECH X RESIDENTIAL_I 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:
REPLACE MAIN WATER L FROM METER TO FOUNDATION
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
7` Compensation,as provided for by Section 3700 of the Labor Code,for the
r^l
performance of the work for which this permit is issued.
Imo'j.,t,� 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: Valuatio I:$500.00
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: Occupa cy Type:
and state laws relating to building construction,and hereby authorize ' 316 31 013
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 bF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations pe Cupertin unicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur es Date 12/19/2016 Issued by: vl Vilinallilliiiiicr Date: 12/19/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the 1 •
•
following two reasons: All roofs shall be inspected prior to.•y 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:12/19/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 2 532(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 Municipal ode,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cod ,Sect1Q 5505, . 33, n. 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall %/ �` r
be deemed revoked. Owner or authorized agegtt �1`f L
APPLICANT CERTIFICATION Date:12/19/2016
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 consction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is is ued(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, Lender's Address
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 .II IT'_ 1
Code,Section 9.18. I understand my plans shall be us-d as public records.
Licensed
Signature Date 12/19/2016 Professional
GENERAL PERMIT APPLICATION MEP
i
iii,„,k COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
<rJ, 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinq(7a.cupertino.o_rq
CUPERTINOMIS C
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EIPLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
j PROJECT ADDRESS '77, APN#
/9 4 7 4(4-2o06.1" /De .-..
OWNER NAME S'/ e ' F 64`Y' ����7 ` PHONE 547 j 7/}r:mr- E-MAIL
STREET ADDRESS CITY,STATE,ZIP
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CONTACT NAME , ry PHONE y
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STREET ADDRESS 9J Z �,7 « G i CITY,STATE ZIP f, e A �� FAX f f"
❑OWNER 0 OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR ❑�CONNTRACTTOR AGENT c❑.��ARCHTTECT_s�Z❑'I ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME ceamtejLICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME �.... E-MAIL FAX
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STREET ADDRESS !(" 4j 4 d 9 CITY,STAB TE p -e� CW 9/e� PHONE osoT f gli o
ARCHITECT/ENGINEER NAME 3 D �j� /�/LLIICeENSE NUMBER �� BUS.LIIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF 0 SFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILDLAND 0 YES PROJECT IN 0 YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE 0 NO EICHLER HOME? 0 NO
DESCRIPTION OF WORK
/,op/G.-ce (e) AA ,,,,) 47a // 4-0,4,
MaL--....6-1. 7/D I' i I Al ai- L,941..0-1-- ...____
TOTAL VALUATION: kri, C3 RECEIVEDD B '
By my signature below,I certify to each of the following: I am the property owner or authorized a_;i to a •• . �: :••.If: I have readout _
application and the information I have prow'+ed is correct. I have read the Description of Work and verify it is acc -: -e o comply with all applicable local
ordinances and state laws relating to b '.V r g constru .on. . •orize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent l Date: /2—ir~`
SUPPLEMENTAL INFO• ATION REQUIRED
( OFFICE USE ONLY
( VER-TRE-COUNTER
❑ EXPRESS
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0 STANDARD
0 LARGE
0 MAJOR
MEPMiscApp_2011.doc revised 06/21/11
,.,:i,,,,`ri"' SMOKE /CARBON MONOXIDE ALARMS ,�W
IN) OWNER CERTIFICATE OF COMPLIANCE, 4n:
QST •9rs,,_ COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION b Gni ,II
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO
(408)777-3228•FAX(408)777-3333•building( cupertino.orq
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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 COALARM _
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 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 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. a n�`
Address: I5T RA t/W OO U PE R T/N Q Permit No. S"LO (Q J2RS-
Specify Number of Alarms: #Smoke Alarms: 15- i • #Carbon Monoxide Detectors: I 1
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
Signature Date:12j1ii 4
Contractor Name:
Signature Lic.# Date:
Smoke and CO form.doc revised 09/27/16