B-2016-3279CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS:
CONTRACTOR:
PERMI NO: B-2016-3279
21035 LAURETTA DR CUPERTINO, CA 95014-1655 (326 55 004)
OWNER/BUILDER
OWNER'S NAME: SALVADORAVELINAA TRUSTEE
DATE ISUED: 12/16/2016
OWNER'S PHONE: 408-996-3871
PHONE P 10:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERNIIT INFO:
License Class Lie. #
Contractor OWNER/BUILDER Date
X BLDG _ ELECT X PLUM B
X MECH X RESIDENTIAL COMMERCL&L
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:
(I) 50'. GAL WATER HEATER REPLACE FURNACE (SAME
I hereby affirm under penalty of perjury one of the following two declarations:
LOCATION)
i. 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
Section 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuatio : $6200.00
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
A'N Number:
Occupat cy Type:
and state laws relating to building construction, and hereby authorize
326 55 004
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 EXPIRESi 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 understands and will comply with all non-point
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 12-16-2016
Issued by: Kim Dunbar
Date: 12/16/2016
"
OWNER-BUILDER DECLARATION'
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior tc any roofing material being installed. If a roof is
following two reasons.
1. I, as owner of the property, or my employees with wages as their sole
installed without first obtaining ani ispection, 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)
I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
5�.
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 12-16-2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINTO 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
maintain compliance with the Cu ertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 5532(a) should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I se equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by tb e 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 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: 12-16-2016
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
T r ION LENDING AGENCY
I hereby affirm that there is co slending agency for the performance
relating to building construction, and hereby authorize representatives of this city
ued ( (Sec. 3097, Civ C.)
of work's for which this permit is issued
to enter upon thabove mentioned property for inspection purposes. (We) agree
e
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
'CTIS DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal
I understand my plans shall be sed as public records.
Code, Section 9.18.
/�_��
Signature Date 12-16-2016
Licensed
Professional
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CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • building cDcupertino.org ; .z 7 --3279
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❑ NEW CONSTRUCTION ❑ ADDITION
tvi ALTERATTnN / TT ❑ RRVTCT0N / n-P.PP.RRRTI Ri( TMAT RFRnaTT tI
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OWNERNAMEy v (A w A Loh P Cyf—
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❑ OWNER ❑ OWNER -BUILDER /OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT d
ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK �i, 0 p _ „� A
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EXISTING USE
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PROPOSED USE CONST
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USE
'TYPE
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SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA.
AREA
AREA
NETAREA
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
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RE D .
TOTAL VALUATION:
PLANNING APPL # r-1NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
tlowner's
read
By my signature below, I certify to each of the following: I am the property owner or authorize gent to act on the property
behalf.lII h(aavvef 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 Iding construction. f ` representatives of Cupertino to enter the above-iden%ti
ed property for inspection purposes.
�aujthoriz
Signature of Appheant/Agent: U' Date: �i
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
OYER -TIME -COUNTER
❑ BUILDING PLAN REVIEW -
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑" FIRE DEPT "
Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY SEWERDISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BIdgApp_2011.doc revised 06121111
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OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as th builder of the property
improvements specified at:
SITE ADDRESS-__' •�°
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APN 3 0) C _ �� r � ®
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OWNER NA E���
OWNERADDRES4 AC!®v r° 1 a*,
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DESCRIPTION OF WORK:
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We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your r ame as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of Bach provision, signed, and
returned this form to us at our official address indicated. An. agent of the owner canr of execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
Wt° 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
&� 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility
3. 1 understand as an "Owner -Builder' I am the responsible party of record on th permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
IV 4. 1 understand Contractors are required by law to be licensed and bonded in C lifornia and to list their license
numbers on permits and contracts.
p�
ri1 � 5. 1 understand if I employ or otherwise engage any persons., other than Californ a licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer' under state and federal law.
IV 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to ab de by these laws may subject
me to serious financial risk.
�t
1 7. 1 understand under California Contractors' State License Law, an Owner-Builc er who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, u less all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
�s 8. 1 understand as an Owner -Builder if I sell the property for which this permit is ssued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
2010.doc revised 04114110
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9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department artment of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more inforrr ation about licensed
contractors.
IT/ 10. 1 am aware, of and consent to an Owner -Builder building permit applied for in
am the party legally and financially responsible for proposed construction activity at tF
A311. 1 agree that, as the party legally and financially responsible for this proposed
by all applicable laws and requirements that govern Owner -Builders as well as emplo,
K12. 1 agree to notify the issuer of this form immediately of any additions, deletion
information I have provided on this form. Licensed contractors are regulated by laws c
you contract with someone who does not have a license, the Contractors' State Licen
assist you with any financial loss you may sustain as a result of a complaint. Your onl
Contractors may be in civil court. It is also important for you to understand that if an u
employee of that individual or firm is injured while working on your property, you may
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be respor
those Contractors are properly licensed and the status of their workers' compensatior
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the
(Sec 3097 Civ.)
Lender Name: Lender Address:
y name, and understand that I
site address listed above.
ction activity, I will abide
, or changes to any of the
ssigned to protect the public. If
e_Board may be unable to
remedy against unlicensed
licensed Contractor or
e held liable for damages. If
;ible for verifying whether or not
insurance coverage.
for which this permit is issued
Before a building permit can be issued, this form must be completed and signed by
the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the propelty
owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presen
�ed when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: 0 C, 4kt_ajZeUL
Date: /e . /'6A4
----------------------------------------------------------------- --------------------------------
(NOTE: The following Authorization Form is required to be completed by the property ovi
agent of the property owner to apply for a construction permit for the Owner -Builder).
TTOACT ON
Excluding the Notice to Property Owner, the execution of which I understand is my pei
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the d
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work)(
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
--------------------------------
only when designating an
responsibility, I hereby
:nts necessary to obtain an p
I declare under penalty of perjury that I am the property owner for the address listed abov and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's li ense, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
1 z� r �� -C �Lr f �-/ �f 6
Property Owner's Signature:'' e �r Date: ��
2010. doe revised 04114110
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building0cupertino.org
PERMIT CANNOT BE FINALE UNTIL THIS CERTIFICATE HAS BEEN
COMPLETED, ,SIG 1 f , ,:AND. RETCTR"NFD "TQ THE BUILDING DIVISIO
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
the bedroom(s)
X
X
On every level of a dwellmi 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.
ei
Address: (..A-yfZ-1-t -rT ��'' Permit No -9,61 � L7
Specify Number of Alarms: # Smoke Alarms: (7, # Carbon Monoxide Detectors:
1 have read and agree to comply with the terms and conditions of this statement
Ow��n�err (or Owner Agent's) Name:
y A
ate:
1 C / J �I�C i�
Signature..........1�.'1�9�J........................?.....:............................I.................� .t
......................... j l
Contractor Name:
Signature.................................................................. Lic.#...................................... Date:
Smoke and CO form.doc revised 09/27/16
STATE OF CALIFORNIA
ALTERATIONS - HVAC
CEC-CF1R-ALT-03-E Revised 03/15 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF1R-ALT-03-E
Alterations-HVAC CZ 1,3 to 7 and 16(formerly CF-IR-ALT-HVAC) (Page 1 of 1)
Site Address: Enforcement Agency: Date Pre�ared: Permit#: �
�/�r.�`�`✓ �.��i�l��_tl i �� ji �. • I^i '' /r f'' U i.-�" I ���� �-6: —j' 't'�.-r`�� - �.'G' i��
Equipment Type Equipment Efficiency New:Ducting,Plenums,Lineset Conditioned Thermostat
Required R-value Floor Area(sq ft)
❑Packaged System ❑Evaporator Coil AFUE ��P ❑R-6 (CZ 1,3-7)Ducts Served by system Setback
❑Split System ❑Condensing Unit SEER ❑R-8' (CZ 16)Ducts Sq ft (If not already
HSPF ❑ R-6(all CZ's)Plenums present,must
Furnace ❑ Lineset EER ❑ R-5 or R7.5 Lineset3 be installed)
HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this
form is allowed to be filled out by hand. For final inspection all forms are to be registered(no hand filled forms allowed)and a copy left on site.
� 1.HVAC Changeout/Repair Required Compliance Documents to be left on site for Final:
Can include new ducting
All Equipment, CF1R-ALT-02-E
Condenser Unit,Evaporator Coil, CF2R:MECH-01,MECH-20-HERS
Air Handler/Furnace CF3R:MECH-20-HERS
Installer Requirement:Duct leakage(<15°/a or,<10%to outside,or seal all accessible leaks)
Exempted from duct leakage testing if:
❑1.Duct system registered with HERS provider as previously sealed,0�2.There is less than 40 linear feet of duct in unconditioned
space,or ❑3.Existing duct systems are constructed,insulated or sealed with asbestos(list manufacture date of building_�
❑ 2.New HVAC System Required Compliance Documents to be left on site for Final:
All new equipment and All New DuctsZ CF1R-ALT-02-E
CF2R-MECH-01, MECH-20-HERS,MECH-22-HERS,MECH-(23 or 24)-HERS
CF3R-MECH-20-HERS,MECH-22-HERS,MECH-(23 or 24)-HERSZ
Installer Requirement:Duct leakage<6%,Fan Efficacy(.58W/CFM),Air Flow>_350 CFM/ton(or Standards Table 150.0-C/D alternative)
❑3.All New Ducts with Replacement Required Compliance Documents to be left on site for Final:
Includes replacing or installing All New CF1R-ALT-02-E
DuctsZ and one or more of the following: CF2R-MECH-Ol, MECH-20-HERS,MECH-(23 or 24)-HERS
Condenser Unit,Evaporator Coil,Furnace CF3R-MECH-20-HERS,MECH-(23 or 24)-HERS
Installer Requirement:Duct leakage<6%a,Air Flow>_350 CFM/ton(or Standards Table 150.0-C/D alternative)
❑ Exempted from duct leakage testing I existing duct systems are constructed,insulated or sealed with asbestos.
❑4.New Ducting over 40 feet Required Compliance Documents to be left on site for Final:
Adding or replacing ducts in unconditioned CF1R-ALT-02-E
space but less than All New DuctsZ CF2R:MECH-20-HERS
CF3R:MECH-20-HERS
Installer Required to:Duct leakage(<15%or,<10%to outside,or seal all accessible leaks)
❑ Exempted from duct leakage testing I existing duct systems are constructed,insulated or sealed with asbestos.
'All new ducting R-8 required when more than 40 ft installed and R-6 when less than 40 ft installed. This includes in walls,between floors etc.
Z A New Duct system is when the duct system is constructed of at least 75 percent new duct material,and up to 25 percent may consist of reused
parts from the dwelling unit's existing duct system(e.g.,registers,grilles,boots,air handler,plenums,duct material.
3 R-5(1"thick insulation)for linesets 1"and less. R-7.5(1.5"thick insulation)for linesets over 1 inch. Most mfg will require Suction line Diameter
with insulation as the following 1.5-2T-2%",2.5-3T-2%",3.5 to 4T-2%",5T-4%"
Contractor(Documentation Author's/Responsible Designer's Declaration Statement)
I certify the following under penalty of perjury,under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct.
2. I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the information on this document.
3. That the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the
requirements of Title 24,Parts 1 and 6 of the California Code of Regulations(CCR).
4. That the energy features and performance specifications,materials,components,and manufactured devices for the building design or
system design identified on this Certificate of Compliance conform to the requirements of Title 24,Part 1 and Part 6 of the CCR.
5. The building design features or system design features identified on this Certificate of Compliance are consistent with the information
provided on other applicable compliance documents,worksheets,calculations,plans and specifications submitted to the enforcement
agency for approval with this building permit application.
Responsible Designer Na Respo i le Designer Signature:� � Date Signed: License:
�;;`�:;,�.� ����.��J� r�f� , �'�-;��;- ������,�_� ��-,.--; �i
;.
Company: Ad ess: City/State/Zip: Phone:
For assistance or questions regarding the Energy Standards,contact the Energy Hotline at:1-800-772-3300
F
ETA 0 HA ZWKIIA :4 N1 a LN -11 9 :N01 &Rrej Ji I . I .
M F-1 I ffil �
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
�� (408) 77 J 2,2 U01(408),777-3333 • buildinm&cupertino.orgOwner Name NA �V Permit No. y
Address Ii� p W)F-t i A 99- ' N � ir4o e CA �1 G01 '
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.
,JZ 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.
11t No Go to Question 3.
3'. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
u�X 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.
+ z 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..
Please check ONE of the following:
�d 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 property 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 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. I A , a ! A
I Owner or Owner Agent's Signature: I A 10 WOQl —Lyf Date: (I (1 b
Unoll combletina and sienna this Ce ficate, please return it to the Building Division in order to final your building permit.
SB407 2015. doc revised 08126115
PERMIT FEE RECEIPT
Case # B-2016-3279
Date Printed: 12/16/2016
CUPERTIhtO
CITY OF CUPERTINO - FEES RECEIPT
Case Number: B-2016-3279 Permit No:
Project Valuation: 6200.00 Date Submitted: 12/16/2016
Permit Type: Building
Address/APN: 21035 LAURETTA DR CUPERTINO,CA
95014-1655(326 55 004) Receipt#: 209758
Scope of Work: (N)50 GAL WATER HEATER-REPLACE FURNACE(SAME LOCATION)
, Contact Type: Applicant
Full Name: SALVADOR AVELINA A TRUSTEE
Address: 21035 LAURETTA DR CUPERTINO,CA 95014-'
Contact Type: Property Owner
Full Name: SALVADOR AVELINA A TRUSTEE
Address: 21035 LAURETTA DR CUPERTINO,CA 95014-'
Fee Information Amount
Bldg Stds Commission Fee $1.00
Mechanical Furnace,Forced-Air Fee $147.91
Permit Issuance Fee $36.98
Plumbing Water Heater Fee $36.98
PME Mechanical Permit Fee $49.30
PME Plumbing Permit Fee $50.29
Strong Motion Category 1 $0.81
Travel and Documentation Fee $50.29
Payment Information Payment Date Patron Payment Type Amount
Plumbing Water Heater Fee 12/16/2016 AVELINA SALVADOR CheCk $36.98
Mechanical Furnace,Forced-Air Fee 12/16/2016 AVELINA SALVADOR CheCk $147.91
Strong Motion Category 1 12/16/2016 AVELINA SALVADOR Check $0.81
Bldg Stds Commission Fee 12/16/2016 AVELINA SALVADOR CheCk $1.00
Travel and Documentation Fee 12/16/2016 AVELINA SALVADOR Check $50.29
Permit Issuance Fee 12/16/2016 AVELINA SALVADOR Check $36.98
PME Mechanical Permit Fee 12/16/2016 AVELINA SALVADOR Check $49.30
PME Plumbing Permit Fee 12/16/2016 AVELINA SALVADOR CheCk $50.29
FEE TOTAL $373.56
AMOUNT PAID $373.56
BALANCE DUE $0.00
12/1 612016-7:49:14 AM-Generated by:kimd
1/1
CTI'Y OF CUPII2TIN0 BUII,DING PII2MfI'INSPECTION CARD
BUII.DINGADDRESS
21035 LAURETTA DR CONTRACI'OR P�r NO
C[JPIItTINO,CA 950141655 B-20163279
OWNFR'S NA11� 21035 LAUREITA DRCCJPFRTINO,CA 950141655 P���S�'
SALUADORAVFIINA A TRUSTFE 1?J16/2016
OWNIIt'S PHONE PHONENO:
JOB DFSCRIl'TION:
(I�50 GAL W ATII2 HEt1TFR-RFPLACE FI.JRNACE(SAME LOCATIOI�
TYPE INSPECI'OR DATE
PLUMBING
iINDERGROLIND GAS PIPWG
UNDEItQZOTJND WATQt
LINDERGROUND SEWIIt
UNDERFLOOR
ROiK,II PLUMBING
SHOWEIL PAN �
WA7'ER HEATE[t
WATER SERV[CE
GAS PRESSURE TEST
GAS METER RII.EASE
PROPERTY LINE CLEANOLTI'
PLLJMBING FINAI.
ELECI'RICAL
�� TO ARRANC�INSPF]CI'ION
���o� Ca11777-3228 bet�eeu 7:30 am and 3:30 pn Monday through�-iday,at least 24 hours before required
inspection.Jobaddress andPermitNumbers are needed�tren requesting an inspecbon.
[7t�IDERFLooR
CUPII2TIlV0 SA�VIi'ARYDISTRICI'
Ro�Jc�i e�"c'rt�C'�`" C7os ed circuit tideo inspeclion of property line cleanout,point of connection
T��ivoRNtY PovlIIt Po[.E and street lateral required�ior to passing NINAL CITYPLUMBING
INSPECTION.Call the District(408-253-7071)for an appoinUnent
SERV[CE UPGRADE
�Ecr�c n�r�aII.FqsE NO BUII DINGFINALS INSP�CI'IONS UNTIL ALL R�QUII2ID
Bi1SIlVESS LICINSFS AREOBTAINID
FT FCTRIC FINAI.
t�;cxntv[Cpi, PII2MIT II�IRFS IF WORK IS NOT STARTID WII'HIN 180 DAYS OF PII2MlT
��� ISSUANCEOR 180 DAYS bROMLAST CAI.LID INSP�CITON.
RotlGl[IvtECW,MCAt Il�9PORTANT When a per�rt has e�pred,a charge totaling one-half the fees to ohtain a newpernit
FtrnrtnxCE must be paid in order to reactivate the permit If a per�rrit has been eaqired for more
than one year,a charge totaling the fiill fees to ot�tain a new pervit must be paid
AIF2 CONDTTIONER t0 reactiVate the permit
HOOAS
ngcrurncni,Fwn[. NOTES:
T-BAR
PLUMF3ING
ELECTICAI.
MECEIANICAL
BUQ.DA'G
FIRE
SWIIILM[NG POOL
R:iII�'FORCEMEKi'
�P/M/E
Fr FrTRICAL BONDING
ROOFY�,'G
PRE AlSPECTION
TEAR OFF
NAQ.A'Ci
BATTINS
TYPE INSPECI'OR D.1TE TYPE IIVSPECTOR DATE TYPE IIVSPECTOR DATE
FOU!VDATION PL[J�IBIIG SAhTTARY IirSPECt'IONS
FOOTINGS SHOWER PAN UNDERQ20UND
UFER WATER HEATII2 '� � �: - ROFLUSH
PIIILS WATER SERV[CE
GRADE BEAMS GAS TFST PUBLIC WORKS
RIQ-1T OF WAY
GARAGE SLAB GAS Iv�.7'ER RII.EASE
GROi71VD/STI'E WORK ���'
UNDERGROUND FJ.ECTRICAL FT.FCl'RICAT REl'AINING WAT I.
UNDERGROiJND GAS PIl'ING TIINP POWER POLE
UNDIItGROtJND WATII2 SERVICE UPGRADE �'�E��ng'�
UNDERGROLII�ID SEWE[t PV SYSTEM SITE COMPI_iANCE
SITE WALIS FIItE MAIN SYSTEMS
EV SYSTEM
FOOTING FIItE SPR�rci�te-ROUGFI
MASONRY REBAR ME��� FIRE SPRINIQ.IIt-FINAL
DRAINAGE FU2NANCE � �J '. £IItE ALARM FINAL
CMU WALLS BOII.EIt STANDPIPE SYSTFMS
U�DFRFf'OOR AIR CONDTCIONIIt ENGINEQiEA FIl2E PR07'ECTION SYSTEM
UNDERFLOOIt PLUMBING
HOOAS FIItE LIFE SAFEI'Y
UNDERFLOOR MECHANICAL
DiJ(:T WRAP
UNDERFLOOIt ELECTRICAL
➢OCUh1EM'ATION
UNDERFIAOIt FRAMIIJG �.i.$� ���� � PADlSEI'BACK CERTIFICATION
UNDERFiAOit INSULATiON PLiJMBING TRUSSFS
F��'G ELECi'iCAL SPECIAi.,INSPECI'iON REPORTS
FLOOR NAiUSHEATHING SMOKF/CARBON MON07TDE CERT OF
MECIIANICAL
ROUGH PLUMBING COMPLIANCE
BUQDING WATER FIXTURE CERT OF COMPI.,IANCE
ROUGf{MECHANICAL
F� ENERGY COMPLIANCE FORMS
ROU(3H II.ECTRICAL
CALGREEN MANDATORY ITEMS CHECKI.iST
ROiJGII FRAMING SVVA9�IIL\G POOL
WfERIOR SIIFAR RIINFORCQdINC
DEPARTh1ENC FINAI.,S
EXTERIOR SIIFAR P/M/E PI.ANNING-CALI.7773308
WALI,INSULATION II.E(:TRICAL BONDING PUBL[C WORKS-CALL 777-3354
CIII.ING INSULATION DFMOLTf ION FIRE-CALS,378-0010
ROOF NAII�ING BACI�'II.L f]EAI,TH-CALL 408-91&3400
II11'ERIOR FL�IISHES
SANIT'ARY-CALL 253-0071
SI IEETROCK ROOFING
TIL.E BACI�R iJNDERLAYNSQ�*I' PRE INSPFLTION
BDII�DING FIl`IALS
TII.E BACI�R TEAR OFF PLiJbffiING
WI'ERIOR LATH G II,g�1•RI�pi,
F.XfERIOR F[HISHES BATTINS
IvfF.CI�AN[CAL
EXTERIOR LATH
TIIdPORARY OCCUPANCY
SCRATCH COAT �
BUILDING � � , �� �� �
SIDING