B-2017-0704CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0704
10660 JOHNSON AVE CUPERTINO, CA 95014-3817 (375 28 022) A & W PLUMBING INC
LOS GATOS, CA 95032
OWNER'S NAME: HANSEN CHRISTINE I TRUSTEE DATE ISSUED: 05/03/2017
OWNER'S PHONE: 408-887-0716 PHONE NO: (408) 887-0716
License Class C-36 Lic. #967664
ContractorA & W PLUMBING INCDate 11/30/2017
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:
m. 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.
e d will maintain Worker's Compensation Insurance, is provided for by
ction 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 nori-point
source regulations per the Cupertino Municipal Code, Section 9.18.
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law, for one of the
following two reasons:
m. 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)
z. 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.
a. 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 j G
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 5/3/2017
BUILDING PERMIT INFO:
BLDG —ELECT X PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
REPLACE WATER MAIN SERVICE
Sq. Ft Floor Area: I Valuation: $1000.00
APN Number: Occupancy Type:
375 28 022
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
by: Abby A ewe
RE -ROOFS:
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: 5/3/2017
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, Sections 25505, 25533, and 25534.
G
Owner or authorized agent.
Date: 5/3/2017
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
CUP`4RTINO
GENERAL PERM[ T APPLICATION mm" E F3
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • C1UPERTINO, CA 95014-3255 MR m I S
(408) 777-3228 • FAX (408) 777-3333 • building(a-kupertino.ora
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A,fEPA47sc.4pp_M1.doc revised 05/21/II
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LJ MISCELLANEOUS
PROJECT ADDRESS
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OWNIER NAME /per p
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CONTACT NAME
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E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ ORINERAGENT ❑ CO
CTOR ElCON'TRACTORAGEN'r ❑ ARCHITECT ❑ ENGA`EER El DEVELOPER ❑ TENAIQ'T
CONTRACTOR NAME L CEN jJ� E�
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PHONE
ARCHITECT/ENGINEER NAME
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L10E1dSE NUMBER
BUS. LIC Y
COMPANY NAME i
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZI?
PHONE
USE OF SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ CON414ERCLAL
PROJECT IN RInALAND ❑ 'YES
URBANINTERFACE AREA NO
PROJECT IN ❑ YES
FLOOD ❑
IS THE BLDG AN ❑ YES
❑
ZONE NO
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
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TOTAL VALUATION': /O / �� RECEINTI) BY
By my signature belo%w, I certtiifyy to each of the following: 1 am the properTy owner or authorized agent to act on the property ow er's bel al£ I have read this
application and the information I have provided is correct. I have read the Description of Rork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil ' onstruction. I authorize representatives of Cupertino to enter the above -i entified property for inspection proposes.
Signature of Applicant/Agent:7-r''+ Date:
SUPPLEMENTAL INIFORA REQUIRED
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Pica usE:oNr i
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❑ OBER-THE-COi7NTER -.
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❑ EXPRESS
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.STANDARD
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G� LARGE
MAJOR
A,fEPA47sc.4pp_M1.doc revised 05/21/II
I
SMOKE I c4RBbN MONOXIDE ALARMS
CERTIFICATE OMCO LIOWNER CERT ENT . BUILDING DIVISION
COMMUNITY DEVELOPMENT DEPART
10300 TORRE AVENUE CUPERTINO, CA 95014-3255
'I in cut)er-Iino.or
(4008) 777-3228 •* FAX (408 777-3333 - bull
.... .. .. ...
arms for
Carbon Monoxide Al
PURPOSE required Sinoke and access
This affidavit is a self -certification for the " Lstallat'on Of all tions 420.6 and 907.2-11.2.whe-re no interior
016 CRC Section R314/- R315,12016 CBC Sec
compliance with 2
for inspections are'required.
GENERAL INFORMATION Smoke Alarms and Carbon
GEN 0
Existing single-family and multi -f
inti -family dwellings shall be provided With exceeds
b s, or rep airs to existing dwelling units
valuation of additions, alteration
When the 20.6 require that Smoke Alarms and/or
Monoxide alarms. fections 907.2.11.5 and 42
$1000.00, CRC Section R314, R315, and CBC S;
e installed in the following0
locations:
ALARM Alarms b CO ALAR
Carbon Monoxid SMOKE ALA
AREA
A
frdtY of �e
diate vicinity of the
nme
sleeping area in the inunediate vicird 5:
OutsideF-777ofeach separate A vithin 3 feet of bathroom Y X
-(Smoke alarms shaurJOL X
b urd including basents . ard habitable attics
- every level of a dwelling
Within each sle :,ira room -dmc)Y alian and d that
ontain fuel -bun pp
dwellings which doned
comply with
e not require 1,11 0 with smoke alarms shallarbon Monoxide alarms ar rms con-lb
C Carbon monoxide ala
in
do not have an 0.6
ached gaagethe StateFire Marshal.
and shallbe approved bv� the office ofCBC Section 42may be solely battery operated.
supply,
alarm(s) In
In dwelling U-rdts with no commercial power SuLPI perated where repairs Or alterations do
Power supply, alarms are permitted to be solely battery 0 of attic, basement Or claw'
In existing dwelling units, or there is no access by means cal p eryrdt is -required for
' Val of wall and ceiling finishes
the remove 10 Ons 907.2.11.4 and 420.6-2. An electri
not -result in and CBC- Secti
Space. Refer to CRC Section R314:
must be connected to the building "rmc" 'beer,
above has/have alarms which referenced
'by certify that the alaln-'(S) CaliforniaBuilding)
f the above -referenced Property, I here ctions and in compliance with the as of the
As ONNT ler 0 th the n-jan-af a�tu-rer's instr"' been tested and are operational,
installed in accordance ,,,,Tl alarms specified belo1v have
a Residential Codes. The ala
and California permit N 0.h -?O
below.
i 1
date signed A -, � =::;- 0 '� 71)- 6iaot—� 1:5y L� r ------1
Address'
Specify Number of Alarms:
37aTor OwnerAgent's Name:
Smoke
I have read and agree to
nature........
#Caiboa-1\1o110-xid Detectors:
with the tarrn3 and conditions of this statement
W Date
Lic, # ...... -.1 ..............................
Yh_v_�� At
Cont�radtor Name: sig:nature .................... I .................................................
Smoke and Coform.doc revised 01/10,r-' '01:
CUPERTINO
Owner Name
I
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 47��
10300 TORRE AVENUE!- CUPERTINO, CA 95014-3255
(408) 777-f3228 • FAX (408) 777-3333 • buildingcupertino.ora
Permit N of c�_f� rl C� 7`
Address 10to(0Q ��hN5btir auC C u4t5:r-�-i'Qp G4 150.1 �z
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1.101.8 do not apply. Skip the rest of the form and sign bottom of fon..
M- No Go to Question 2.
�I
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.
X 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 fonu.
[ No Go to Question 4.
4. Is your real property built and available for use or, occupancy on or before January 1, 19949
❑ No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 11:01.8 do not apply. Skip the rest of the fonu and sign bottom of fonu.
N� 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:
f9 My property is a single fmnily 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 proper ry is a nzultifanuly 7 esidential 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 cornpliant 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 uaae.
Owner or Owner Agent's Signature: ,a , ..,y Date: �5 /� 1 `J
Upon completing and signing this Certificate, please return it to the Building Division in order to final your building permit.
SB4072015.doc revised 01/05/17