B-2017-0272CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0272
11018 SYCAMORE DR CUPERTINO, CA 95014-6562 (342 56 028)
F W H ACQUISITION
CO LLC
BOTHELL, WA 98011
OWNER'S NAME: TAMBLYN WILLIAM JAND PATTYA TRUSTEE
DATE ISSUED: 02/16/2017
OWNER'S PHONE: 650-996-4207
PHONE NO: (425) 636-7078
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C36 Lic. #987398
Contractor F W H ACQUISITION CO LLC 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:
REPLACE 50 GAL WATER HEATER (GARAGE)
I hereby affirm under penalty of perjury one of the following two declarations:
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.
�
' . /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: $1733.00
APPLICANT 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 authorize
342 56 028
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.
Additionally, the applicant understands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM L ECT
Signature �.� Date 02/16/2017
V
Issued by: AMES
OWNER -B UDER DECLARATION
Date: 02/16/2017
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
r. 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)
a 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: 02/16/2017
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
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 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 Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
1.
be deemed revoked.
Owner or authorized agent: _. 1
APPLICANT CERTIFICATION
Date: 02/16/2017
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.
1 understand my plans shall be used as public records.
Licensed
SiSignature Date 02/16/2017
9
Professional
02/07/2017 TUB 6-'59 FAX Fat5t water H*atOr 0002/012
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COMMUNITY DEVELOPMENT DEPARTMENT & BUILDING DIVISION
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By try signature below, I cerdry to each of tht followhig, I am the property owner or authotizBd agent to act on the property owner's bebaLlf. I have read this
RpOication and the information I have provided Is corrmt, I have read the DeacriPtion of Work and verify It Is accurate, I agree to comply with all applicable local
ordinances and state laws mIating to building eptietuction, I authorize representativea of Cupertino to anter the 0ove-identifled property for 146pection purposes,
Signature of ApplIcanYA80tit.' Date:
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MEPN1baAppj01 Woo i*"Ind 06121111
SMOKE / CARBON MONOXIDE A,l.%lR
OWNER:C:ERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
I! 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO(408) 777-3228 •FAX (408) 777-3333 • building
(aD-cupertino.org
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
Existhag 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:
c AREA
SMOKE ALARM
CO ALARM',_ 1
_
I Outside of each separate sleeping area in the immediate vicinity of the
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bedrooms) — (Smoke alarms shall not be located within 3 feet of bathroom door)
On everylevel of a dwelling unit including basemenfs and habitable attics
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Within each sleeving room _
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Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burnuzg appliances azld 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.
h -L 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 fetishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section 8314 and CBC Sections 907.2.11.4 and 420..6.2.1 n electrical permit is .required for
alarms ivhich 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: /to/
S ` CA4444A L --'t? A.
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Permit No. $" No.. Z" ®z'? 2"'
Specify Number of Alarms: � # Smoke Alarms: # Carbon Monoxide Detectors: FT -1
rrl nri7f nnc of this etatamant
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Own/�er (or Owner Agen ` ) Name:
all ay o �� vv,,.p,, ............ ...._ _.._ __.._.-_. _.
............................................................ Date:.....�.....
Signature .••........
Contractor Name:
Signature.................................................................. Lic.# ......................................Date:..................
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Smoke and COf01777.doc remised 01/10/1017
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
CVR'ERTtN€7 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
/ (408) 777-3228 • FAX (408) 777-3333 a building(a)cupertino.org 0 �-� 07-74
Owner Name INry 14ce"I �%r!9�►e.6t,� Permit No.
Address /1011 ,S40C4-" o AE -� A,. dam j j n E _ C'4 =J5t�
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.
9 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?
❑ 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 fora and sign bottom of form.
J� 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.
X No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
XNo 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..
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 pluinbing fixtures throughout the building. On or before January 1, 2017, all non-
compliant plumbing fixtures shall be replaced with water-conseiving 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 age.
Owner or Owner Agent's Signature: Date: ya/7
Unon comnletina and sinning this Certificate, pfease return it to the Building Division in order to final your building pennit.
SB407 2015. doe revised 08/26/15