B-2016-1258CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
6541 CLIFFORD DR CUPERTINO, CA 95014-4555 (369 26 003)
CONTRACTOR:
OWNER/BUILDER
PERMIT NO: B-2016-1258
OWNER'S NAME: WAIBEL RONALD M
DATE ISSUED: 01126(2016
OWNER'S PHONE: 408-253-1244
PRONE No:
LICENSED CONTRACTDRIS DE, CLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OW NERIBU IL D ER Date
X BLDG _ELECT _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:
I hereby affirm under penalty of perjury one of the following two declarations:
REPLACE (E) SLIMING GLASS DOOR IN LIVING ROOM, SAME SIZE
2. 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 permit is issued.
Sq.I Ft FloorArea:
Valuation: $3200.00
APP WANT CERTIFICATION
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
369 26 003
authorize 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
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will
WITHIN 1,80 DAYS OF PERMIT ISSUANCE OR
comply with all non-point source regulations per the Cupertino Municipal
180 DAYS`ROM LL CALLED INSPECTION.
Code, Section 9.18.
Signature Date
s
Date:
RE-ROOFS:
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 to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, i agree to remove all new materials for
1. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Scc,7044, Business & Professions Code)
Signature of Applicapt:
�2. I, as owner of the property, am exclusively contracting with licensed
Date:
contractors to construct the project (See.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOD 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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
?W1s. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
sial[ not employ any person in any manner so as to become subject to the
air contaminants a!s defined by the Bay Arca 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
the Health & Safety Code, Sections 25505, 25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
Owner or aufhorixed agent:
be deemed revoked.
Date, '
APPLICANT CERTIFICATION
t f CONSTRUCTION FENDING ACT NCY
I certify that I have read this application and state that the above information Is
I hereby affirm that'there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec, 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
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
ARCHITECT'S DECLARATIOl�
understands and will comply with all non-point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Code, Section 9.18.
Signature l �(�
Licensed
professional
4,1J Date 2
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CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE < CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • buildinci@cupertino,org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SrrE ESS
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OWNER ME�SB
OWNERADI
DESCRIPTION OF WORK:
We are providing you with an Owner -Builder Ackhowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, 'initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot 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)
I. I 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, 1, 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.
R W 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.
U 3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. l 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,
VU A.1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
RW 5. 1 understand if [ employ or otherwise engage any persons, other than California 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.
is 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 faxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand'my failure to abide by these laws may subject
me to serious financial risk.
gL�_7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless 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 bulid Ing Contractor.
F-0 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, 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.
OwnerEuiderForrn 2010.doc revised 04/14110
W9.1 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 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-CSL.B (2752) or www,cslb,ca.gov for more information about licensed
contractors.
Kw 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that
am the party legally and financially responsible for proposed construction activity at the site address listed above.
11.1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information -I have•provided on this form. Licensed contractors are regulated by.�laws designed to protect the -public. If .
you contract with -someone who does not have a license, the Contractors' State License Board may be unable to
assist you with ahy financial loss you may sustain as a result of a complaint,.Your only remedy against unlicensed
Contractors maybe in civil court. It is also -important-for. you -to understand that if an unlicensed Contractor or
employee of that individual or firm is injured .while working on your property, you may be held liable for damages. If
you obtain a permit. as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or note
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following constructloh lending agency information,)
I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
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 property owner's driver's license,
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 s4qaaLture.
Property Owner's Signature: Date: ] 29 6
--------------------------------------------------------- ------------------------ -----------------------------------------------------------
(NOTE, The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and fife the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or [Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that 1 am the property owner for the address listed above and l personally filled out the
above information and certify its accuracy. Note: A copy of the property owners driver's license, 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.
Property Owner's Signature:
Date:
OwnerBuilderForm 2010.doc revised 04114110
RONMOKE VCARBON MONOXIDE AL4RMB
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 -, FAX (408) 777-3333 - buildingacuperfino.ong
PER
TMIT CAN
TN OT BE F INAixm AND COMPLETED UNTIL THIS CE, RTIFICATE
HASBB EN & AND ,Wj$W TO 1% BUILDING DIWS10 N,
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:
F19
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 includin 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 Sect -ion R314 and CBC Sections 907.2.11.4 and- 420.6.2. -Ari electrical permit is required for
alarins which, must be connected to the building wiring.
As owner of the above -referenced. property, I hereby certify that the al-ar m(s) referenced above has/have been
im6taRed in. accordance with the mna.rtufact utrier's instructions and in caimplia-nice with the California Building
and CaRonrda Residential Codes. The alarms have been tested and are operation -all, as of the date signed
below.
t have read and, agree- la cam,: w4thh the, tbmf s, anal, conditions of this statemw ani,
41,
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.......................... .......
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Sigiaalure ..................... ......... ............. Licif.......... ...... ...................
Smoke and'CO-fornz.libc revised.-031P817.,*4
FEE MW
WATER -CON ERS NG PLUMBING FIXTURES ->
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO CA 95014-3255
CUPERTINO I
(40,8) 7 7-3228 - FAX (408) 777-3333 - building&uPertirio.orn
Owner Nam ,# vco k i Permit N -20 12
Address 0— K911
1- Is your real property a registered historical site?
F] Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
K No Go to Question 2.
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?
EJ Yes Civil Code Sections 1101.1 through 1101.8 donot apply.
0 The licensed plumber's certification has been provided to the, Building Division.
Skip the rest of the form and sign bottom of form.
No Go to Question 3.
3. Is water service permanently disconnected for your building.?
11 Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
@ P� No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1,1994?
0 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.
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).
0 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).
F1 My property is a commercial Teal 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).
1, 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.
Owner or Owner Agent's Signat C, 2�L Date; ]l
UreT
I ELM;
Upon completing and signing this Certificate, please return It to the JJUII(ung JJIVISIUIJ III t)ILICI LU u11ai )1VU1 VW UL11r, Fw
SB407 2015. doc revised 08126115