B-2017-03210
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0321
10334 JUDYAVE CUPERTINO, CA 95014-3525 (375 10 008)
OWNER/BUILDER
OWNER'S NAME: SCHERP RALPH S
DATE ISSUED: 02/28/2017
OWNER'S PHONE: 408-838-9194
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OWNER/BUILDER Date
X BLDG X 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:
PANEL UPGRADE (200 AMP)
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
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. Ft Floor Area:
Valuation: $3000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
"N 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
375 10 008
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 the granting this permit.
Additionally, the applicant understands and willl comply with all ll non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 2-28-2017
Issued by: Kim Dunbar
Date: 02/28/2017
OWNER--B-ER DECLARATION
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
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: 2-28-2017
I hereby affirm under penalty of perjury one of the following three declarations:ALL
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
ROOF COVERINGS TO BE CLASS "A" OR BETTER
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 505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
ffi 1/)
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
Date: 2-28-2017
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
Signature Date 2-28-2017
�.
Professional
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT * BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 * building2cupertino.org
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PROJECT ADDRESS 1013�j tTOD,
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APN #
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OWNERNAME-
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PHONE " _8-3-9-9/5q
I E MAR W&VP 666ACA5T,
STREET ADDRESS
CITY, STATE, ZIP CUP6-RDA00; 9Z
FAX
CONTACT NAME
PHONE
E-MAIL
I
STREET ADDRESS
crry, STATE, zip
I FAX
C3 OWNER 0 OWNER -BUILDER 0 OWNERAGFNT
13 CONTRACTOR 13 coNTRAcToR AGENT 13 ARCHITECT 0 ENGINEER 13 DEVELOPER 0 TENANT
CONTRACTORNAMELICENSE
AMM IRLSLAI-T
NUMBER
LICENSE TYPE
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BUS. LIC #
COMPANY NAME
ARP CLEM)C
E-MAIL
AHW-n32(RA]EQET-
FAX
STREETADDRESS oAi
CITY, -9K EK ZIP
IP09: CA
PHONE
ARCHITECVENGINEERNAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF 4jrsFD or DuPLFx E3 MULTI -FAMILY
BUILDING b COMMERCIAL
PROJECT IN WILDLAND 0 YES
I URBAN INTERFACE AREA 0 NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ No
IS THE BLDG AN ❑ YES
I EICHLER HOME? ❑ No
DESCRIPTION OF WORK t� OCLRICAC
'AA)a U962 -ADE EEM IM -T-6 2W AMPS
Ll
TOTAL VALUATI*
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on tIfe property owner's behalf. 1have read this
application and the information I have provid( is 0 1 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 bull I T!Pope representatives of Cupertino to enter the above -identified property for inspection purposes,
Signature of Applicant/Agent Date: .2017. &A�?—
SUPtLEMENTAL INFO TION TION REQUIRED
10IFFICEVS9 ONLY
0
MAMARD
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MEPMiscApp_201 1. doe revised 06/21111
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildingP-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:
SITE ADDRESS __ nA 7APN
7.4y- 10_ 0C)S
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77t,20
-4 C)32
OWNER NA .,
OWNER ADDRESS D P��—
DESCRIPTION OF WORK: CA -S�
TWE lei 06 t 2 e P
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 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.)
1. 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. 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.
OL2. 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.
�6 3. 1 understand as an "Owner -Builder" l am the responsible party of record on the 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. .
J_i!� 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. I understand if I 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.
-6. I 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 abide by these laws may subject
me to serious financial risk.
7. 1 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 building Contractor.
C 8. I 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.
0wnerBuiZderFor7n 2010.doc revised 04114110
f4� 9. 1 understand I may obtain more information regarding my obligations as an "employe" 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-CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
%L10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
Taj —1 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, 1 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 any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be 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 not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
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 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 accept le to the city may be required to be presented when the permit is issued
to verify the property owner's signat� >)'/ -
--
----
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------------------------------------------------------------------------------ ----------------------------------=-------------------
(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 file 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:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. 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
signature.
Property Owner's Signature:
Date:
OwneYBuilderForn4 2010.doc revised 04114110
CUPERTINO
SMOKE I 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 - building (a)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, 8315, 2016 CBC Sections 420.6 and 907.2.11.2 where no ulterior access
for inspections are required.
GENERAL INFORMATION
Existing siingle-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, 8315, 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) — (Smoke -alarms shall not be located within 3 feet of bathroom door)
X
X
On every level of a dwelling unit including basements and habitable attics
X
X
Within each sleeping room.
X
Carbon Monoxide alarms are not required in dwellings wl- ch do not contain fuel -burning appliances and that
do iot have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply S�Titln
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, alarms) 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 pen -nit is required for
alarms «Tlnich 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
hnstalled in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms specified below leave been tested and are operational, as of the
date signed below.
Address: jo33� L �% ii -i° ` l��C `J ( d C i5 C Permit No. `3Zr�t -0 1
r Smoke Alarms: ! ! r Carbon Monoxide Detectors:
Specify Number of Alarms:
r have read and aurae to rmmnly with th:b terms and.conditions of this statement
Owner (or Owner Agent's) me:
%SfA
� SN
p
Signature .............. ................................... Date: .iG
...........................,�flLP
ContractorName:
f
Signature.................................................................. L1c.# ......................................Date:..................
S»zoke mrd COfor7n.doc remised 01/1012017
CUPERTINO
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
S
ut,..
�f� G
(408)77 -3 FAX (408) 777-3333 - building(a.cugertino.org
`
Owner Name AL H S � Permit No. 2t �` -0 32.1
Address (0331 ' `TRIVY A)6_ CUP 6-R71-1 k) C' Ck 51011A
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.
ANo Go to Question 2.
2. Does your real properly 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.
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?
❑ No My real property �s built and available for use or occupancy after January 1, 1994.
Civil Code Secti'ns 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
s� Yes My real property�s 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.. I
Please check ONE of the fo11'owir
My property is a single f4mily
On and after January 1, X014
to be replaced with water -con
compliant plumbing fixtures
property undergoes alteration:
❑ My property is a multifamily 7
On and after January 1, 2014,
plumbing fixtures to be replac
On or before January 1, 2019,
conserving plumbing fixtures
improvements).
❑ My property is a commercial
On and after January 1, 2014,
plumbing fixtures to be replac
On or before January 1, 20
plumbing fixtures throughout
residential real property: See Civil Code Section 1101.4.
building alterations or improvements shall require all non-compliant plumbing fixtures
erving plumbing fixtures throughout the building. On or before January 1, 2017, all non -
shall be replaced with water -conserving plumbing fixtures (regardless of whether
or improvements).
?sidential real property. See Civil Code Section 1101.5.
specified building alterations or improvements shall require non- compliant
-d with water -conserving plumbing fixtures.
all non-compliant plumbing fixtures shall be replaced with water-
:hroughout the building (regardless of whether property undergoes alterations or
-al property. See Civil Code Section 1101.5.
specified building alterations or improvements shall require non- compliant
;d with water -conserving plumbing fixtures.
9, all non-compliant plumbing fixtures shall be replaced with water- conserving
he building (regardless of whether property undergoes alterations or improvements).
I, as the owner or owner's agent f 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-conser g'plur ing fixtures comply with the requirements as indicated in the
table on the following page. A/� ,/
FOwner or Owner Agent's Signature: -�-� � 4 Date: ;40 f-f-,/0`IId ,._
Upon completing and signing this Certrfica e, please return it to the Building Division in order to final your building permit.
SB407 2015.doc J•evised 08126/15