B-2017-0328CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0328
10174 RIEDEL PL CUPERTINO, CA 95014-2337 (316 21 056)
APOLLO TB
ELECTRIC
SAN JOSE, CA 95159-
8001
OWNER'S NAME: SCOTT FRANK
DATE ISSUED: 02/28/2017
OWNER'S PHONE: 408-252-7464
PHONE NO: (408) 275-0880
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Q --IQ Lic. #884168
Contractor APOLLO TB ELECTRIC Date 09/30/2018
X BLDG X ELECT _PLUM
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 (1) ELECTRICAL OUTLET - (50 AMP CIRCUIT)
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
N performance of the work for which this permit is issued.
l 2. 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: $950.00
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
316 21 056
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.
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.
Signatur! ' Date 2-28-2017
Issued by: Kim Dunbar
Date: 02/28/2017
OWNER -BUILDER 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 sball 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 (See.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
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
material. Additionally, should I use 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 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 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agele.\
APPLICANT CERTIFICATION
Date: 2-28-2017
I certify that I have read this application and state that the above information is
CONSTRUCTION I NDINAGENCY
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
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
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 2-28-2017
Professional
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPE� �� (408) 777-3228 • FAX (408) 777-3333 • building--)cupertino.m
In I-1— MISC
❑ PLUMBING ❑ MECHANICAL LECTRICAL ❑ MISCELLANEOUS
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT IONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE �NUMBER 6
LICENSCE TYPE
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ARCHITECT/ENGINEER NAME
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BUS. LIC #
COMPANY NAME
E-MAIL
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STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ sFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WJLDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YESr1BCHLER
FLOOD ZONE ❑ NO
THE BLDG AN ❑ YES
HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION:
RECEI BX:
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read 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 buildin ,constiwtio I authorize representatives of Cupertino to enter the above -identified pro 'erty for inspection purposes.
Signature of Applicant/AgentDate: 'Z 2-7 17?
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
❑ OVERTRE-COUNTER
❑ EXPRESS .
❑ STANDARD
❑ LARGE
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❑- MAJOR
MEPMiscApp_201 I. doe revised 06/21/11
CUPERTINO
SMOKE l CARBON MONOXIDE ALARMS
OWNER..CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE_- CUPERTINO, CA 55014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingO cupertino.ora
.hr
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 interior access
for inspections are required.
GENERAL INFORMATION
Existing single-family and multi -family dwellings shall be provided with Smoke Alarm and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section 8314, 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:
ARFA
SMOKE ALARM
CO ALAR2il I
_
utside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
-- (Smoke alarms shall not bel located within 3 feet of bathroom door)
Ori every level of a dwelling aunt including basements and habitable attics+
Within each sleepinoom. _—
X
i X
j
Carbon Monoxide -alarms are not required in dwellings ivhich do not contain fuel -burning appliances and that
do not have an attached garage. Carbon moa :.oxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Pourer Supply: Inn dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
111 existing dwelling units, alarms are.permitted to be solely battery operated where repairs or alterations do
not result it the removal of wall and ceiling finishes 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. Ali electrical permit is required for
alarms ivIicln must be connected to the building wiring.
As ojh7lner 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. Thee alarms specified below have been tested and are operational, as of the
date sighed below. e� _
Address: _ /,,0 f� i / � r ��� ��. ��� � 5 � � � Permit No.04«`011
Specify Number of Alarms: T Smoke Alarm t Carbon Monoxide Detectors: 2-
1 have read and agree to comply with the terms and conditions of this statement
Owner (or Owner Agent's) Nam:
5 Fra-
2',/1 A-7
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Signature. ...................................................................................
Date:
Contractor Name:
Signature.. ................................................................
Lica ......................................Date:..................
Smoke and CO form. doc remised 01/10/2017
CUPERTINO
Owner Name 5C.4
i
WATER CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORREi AVENUE • CUPERTINO, CA 95014-3255
408) 7�7�„7-3228 •FAX (408) 777-3333 • buildinaCa-cupertino.ora
`f,`� ice-- I Permit No.
— � -� 4'0
Address /0/ _7tj 9S;-0/
f
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.
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 form 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 donot apply. Skip the rest of the form and sign bottom of form.
0 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 110 1. 1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
Q 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:
M 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 followine -Daae.
I Owner or Owner Agent's Signature: 4 )"1 C / Date: '/ t / ! /
Upon completing and signing this Certificate, please return it to the Building Division in order to sinal your building permit.
SB4072015.doc rtvised 08126/15