B-2017-0115CITY OF CUPERTINO BUILDING PERMIT,
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0115
23594 OAK VALLEY RD CUPERTINO, CA 95014-6552 (342 57 019)
VALLEY
GREENSCAPES
SAN JOSE, CA 95173
OWNER'S NAME: NEVEITT WILLIAM T TRUSTEE & ET AL
DATE', ISSUED: 01/23/2017
OWNER'S PHONE:
PHONE NO: (408) 564-2251
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-53 Lic. #939661
Contractor VALLEY GREENSCAPES Date 10/31/2017
X BLDG —ELECT X 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:
INSTALL NEW FIRE PIT; NEW 1 1/2" POLY GAS LINE - FIRE PIT
I hereby affirm under penalty of perjury one of the following two declarations:
(200,000 BTU)
have and will maintain a certificate of consent to self-insure for Worker's
ff�C mpensation, as provided for by Section 3700 of the Labor Code, for the
r `
p ormance of the work for which this permit is issued.
ave 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:
Valuation: $10000.00
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
342 57 019
representatives of this city to enter upon the above mentioned property for
inspection purposes. e) agree to save indemnify and keep harmless the
City of Cupertino agai st liabilities, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue a ainst s id City in conseque�he granting of this permit.
Additionally, th appli ant understaad�d will comply with all non-point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulati s p ppeffino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signatur '" Date 1/23/2017
Issued by: AbbyAyende
Date: 01/23/2017
I hereby of arm that I in exempt from the Contractor's License Law for one of the
following two reason :
RE ROOFS:
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: 1/23/2017
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
z. 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
is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit
s. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 255) should I store o andle hazardous
material. Additionally, should I use eq went or de ' s. hich emit hazardous
shall not employ any person in any manner so as to become subject to the
UtyManagement District I
air contaminants as defined by theeBay,R25505,
Worker's Compensation laws of California. If, after making this certificate of
�y� maintain compliance wit the nicipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health &Safety 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: 1/23/2017
1 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
CONSTRUCTION N
I hereby affirm that there is a construcfi n lending agency for the performance
this
of w905%r which this permit is issued ec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of city
N me
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's
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
ARCHITECT'S DECLARN
ATI
Code, Section 9.18.
I understand my plans shall be used as public records.
Licensed
Signature Date 112$/2012
Professional
CUPERTINO I
NKEW CONSTRUCTION
�-Ioq -Ms
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - building(a)cupertino.org
❑ ADDITION El ALTERATION/TI El REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS
6r
APN # (A
OWNER NAME W L) 74,
PHONE
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP at E, M #D :
FAX
CONTACT NAME OC?
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PHO(t4o 0 ) �4+ AVZ4F JAIL 1
STREET ADDRESS
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STATE, , r
CITY, STATE zip 4iw So s—
0 OWNER 0 OWNER -BUILDER 0 OWNERAGENT 0 CONTRACTOR 13 CONTRACTOR AGENT 11 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME .1Z Me\-fZ-Z,4 ]
LICENSE NUMBER tj �5(p 1
'01
LICENSE TYPE
BUS. LIC # 3U 4 ZT
COMPANY NAME k /
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E-MAILVA ULC-) - &F,664? S
FAX
STREET ADDRESS 'P
Box -73 v5--, 2-
STATE, ZIP
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CITY, 5t- t-A-�Cj5113
•
PHON
Ope')
ARCHITECT/FNGINEERNAME
LICENSE NUMBER
BUS. LIC 9
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
EXISTING USE
PROPOSED USE CONSIR-TYPE
II STORIES
USE
TYPE
OCC.
SQYT.
VALUATION
EXISTG
AREA
NEW FLOOR
I
I AREA
DEMO
AREA
I
TOTAL
NET AREA
I
BATHROOM KITCHEN
REMODEL AREA REMODEL AREA
OTHER
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH
GARAGE AREA: []DETACH
0 ATTACH
#DWELLINGuNrrs:
IS A SECOND UNIT El YES
BEINGADDED? []NO
SECONDSTORY EIYES
ADDITION? nNO
PRE -APPLICATION nYES IF YES, PROVIDE COPY OF
PLANNINGAPPLff E]NO PLANNING APPROVAVTTER
IS THE BLDG AN [3 ylis
EICHLER HOME? E] NO I
y
n&
TJ).TAL VALUATION:
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By my signature below, I certify ealp,ofthefo wing: I am the property owner or authorized agent to At on the property owner's behalf. I have r1ad this
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I ha- provided is T-rect. I have read the Description of and verify it is accurate. I agree to comply with all applicable local
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Tn'tio . to =s
on
application and the intbi relating
ordinances and state laws relating to tion. I authorize representatives of Cupertino to enter the above-ifentified ion purposes.
ng to t -operty for inspect
Signature of Applicant/ ut. Date: ol
-Si4RQL�EMENTAL I FORMATION REQUIRED
New SFD or Mulrif�amielli gs: Apply for demolition permit for
ti TH, 'Ili
existing building(s). Demolition permit is required prior to issuance of building
permit for now building.
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
Ton—n if any Hazardous Materials are being used as part of this project.
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
PLAN CHECKTYPE
ROUTING SLIP
OVER-THE-COUNTER
0 EXPRESS
El STANDARD
0 LARGE
El MAJOR
❑ BUILDING PLAN REVIEW
El PLANNJNG PLAN REVIEW
1:1 PUBLIC WORKS
El FIRE DEPT
El SANITARY SLIVVERDISTRICT
❑ ENyrRONMENTALREALTH
BldgApp_M Ldoc revised 06121111
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CUPERTINO
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 • buildingQcupertino.org
PERMIT CANNOT BE FINNALED UNTIL: THIS CERTIFICATE IIAS BEEN:.., ;
COMPLETED. N_,jED AND RUT11Ml) TO THE BUILDING DIVISION
PURPOSE
This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2016 CRC Section R314, R315, 2016 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, R315, 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:
e AREA
SMOKE ALARM
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the
X
X
bedroom(s) - (Smoke alarms shall not be located within 3 feet of bathroom door)
;
On every level of a dwelling unit including basements and habitable attics
X
X
I Within each sleeping room
X
J
Carbork NIonoxide 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.
Address:
Permit No. 6 — -zd t 6I if q,
Specify Number of Alarms: # Smoke Alarms: FF71 # Carbon Monoxide Detectors: r?,
I have read and naree to comnly with the terms and conditions of this statement
Owner or OTer Agent's) Name:7
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71
Signature ................................................................................................................. Dater ../...''.....
Contractor Name:
Signature...................................................................... Lic.#........................................ Date:...................
Smoke and COform.doc revised 01/1012017
CUPERTINO
Owner Name
Address d 3519 � (Da
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building2cupertino.orcl
01
1. Is your real property a registered historical site?
❑l Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
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.
XJSkip the rest of the form and sign bottom of form.
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.
% No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
YJ No My real property is built and available for use or occupancyafter 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:
❑ 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-conselving 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. _ 1 , to n - �
I/
Owner or Owner Agent's Signature: 1)A ,4Vl f CL?9td�, Date: uidtiA
Upon completing and signing this Certificate, please return it to the Building Division in order to final your building permit.p
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