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B-2017-0427CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0427 21572 COLUMBUS AVE CUPERTINO, CA 95014-4781 (356 18 056) TRENCHFREE INC SAN JOSE, CA 95151 OWNER'S NAME: FUJIKAWA BRUCE Y AND KATHLYN Y TRUSTEE DATE ISSUED: 03/15/2017 OWNER'S PHONE: 408-252-6248 PHONE NO: (408) 726-7926 LICENSED CONT-RACTORIS pEcIAgATION BUILDING PERMIT INFO: License Class C -12:C -3&C-42 Lia #971016 Contractor TRENCH FREE INC Date 03/31/2018 I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 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 tcompensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ty 12., .Q I have and will maintain Worker's Compensation Insurance, as provided for by X5* Section 3700 of the Labor Code, for the performance of the work for which this 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 and state laws relating to building construction, and hereby 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 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 th ertino Municipal Code, Section 9.18. Signature - Date 3/15/2017 OWNER -BUILDER DER D A_R TION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 2. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. s. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the - Worker's Compensation laws of California. If, after making this certificate of 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 be deemed revoked. 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 and state laws relating to building construction, and hereby 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 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 Code, Section 9.18. Date 3/15/2017 BLDG —ELECT X PLUMB MECH X RESIDENTIAL _ COMMERCIAL DESCRIPTION: ACE WATER MAIN SERVICE Sq. Ft Floor Area: J Valuation: $4950.00 "N Number: Occupancy Type: 356 18 056 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Abby A ey nde Date: 03/15/2017 RFS All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: 3/15/2017 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Se 'on 25533, and 25534. Owner or authorized ag Date: 3/15/2017 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional [*(F GENERAL PERMIT APPLICATION RA, E P COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(?7cupertino.org EN PLUMBING ❑ MECHANICAL ❑ EL ❑ MISCELL Tw MEPMiscApp 2011.doc revised 06121111 ANEOUS PROJECT ADDRESS I V` APN # ® 1� l rC �_ OWNER NAME ge�� 4 6o G� v L l PH .49® P✓�-<V f;�J E-MAIL .� STREET ADDRESS2-1 2- Kolunj�/� � FAX CONTACT NAME Y�� tx vt-e-�747C PHONE �J x l STREET ADDRESS, +-���& �� C Y, STAT ZIP FAX J ❑ OWNER ❑ OWNER -BUILDER ❑ OWNERRAGENT 5MNTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME-- j 9 �- � LICENSE NUMBER q,71 of j �j LICENSE TIS E�� C � BUS. LIC # -;Z'UO2 j n o LJ( COMPANY NAME°^^ ,s� ((�__lh P C c4 Fred E �'�� i+L-C 1/t. '"rc.L._ ` co ¢ j% ,(.,r,�a FAX STREET ADDRESS Z w re it j �CiTY, STATE> � 7IE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIII, FAX STREET ADDRESS CITY, STATE, Z.IP PHONE USE OF 0FD or DUPLEX ❑ MULTI -FAMILY PROSECT IN WILDLAND ❑ YES PROJECT IN ❑ YES LS THE BLDG AN ❑ YES BUILDING: ❑ COMMERCIAL URBAN INTERFACE' AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? [] NO DESCRIPTION OF WORK r j ee to kc c -e TOTAL VALUATION: �� c' RECEIVEDBY: By my signature below, I 6ertify to each of the following: I am the property owner or authorized agent to act on the property own '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 truction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY W ❑ OVER-TnE-COUNTER I ❑ &PRESS U ❑ STANDARD ❑ LARGE FK ❑ MAJOR MEPMiscApp 2011.doc revised 06121111 CUPERTiNO Owner N Address WATER -CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 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. -E-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.' -[7-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. ,EI -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 1101 1 through 1101.8 do not apply Skip the rest of the form and sign bottom of form. KJ Yes __My real broperty_built and_availabke for use or ocQipancv_on_o befor_.,T___anuacy J , 199 __ Civil Code Sections 1101 1 through 1101.8 apply Check one of the three following statements and sig_ n bottom of form. Please check ONE of the following: ,,©-'Myproperty is asingle-family residential real property See Civil Code Section 11014 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, specked 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) r 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 11018, 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 Daae. I W f f Owner or Owner Agent's SignatureDate. Upon completing and signing this Certificate, pleas ff return it to tVe�Building Division in order to final your build ng pe -mit.` ,SB407 2015. doc revised 08126115