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B-2017-0793CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0793 22731 MEDINA LN CUPERTINO, CA 95014-2617 (342 30 004) ELDRIDGE & SONS PLUMBING CAMPBELL, CA 95008 OWNER'S NAME: JTV INC DATE ISSUED: 05/18/2017 OWNER'S PHONE: 650-948-2831 PHONE NO: (408) 371-8221 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class t-¢ Lic. #Z69568 Contractor ELDRIDGE & SONS PLUMBING Date 10/31/2017 X BLDG —ELECT X PLUMB — MECH X RESIDENTIAL _ COMMERCIAL 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. JOB DESCRIPTION: REPLACE PROPERTY LINE CLEAN-OUT/INSTALL (N) BACK-FLOW I hereby affirm under penalty of perjury one of the following two declarations: VALVE 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. .) 2. 1 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 Sq. Ft Floor Area: Valuation: $4500.00 permit is issued. 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 30 004 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. Signature Date 05-18-2017 Issued by: Kim Dunbar OWNER DECLARATION Date: 05/18/2017 -BUILDER I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: t. 1, 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. 1, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 05-18-2017 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 s. 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 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: W APPLICANT CERTIFICATION Date: 05-18-2017 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 Signature Date 05-18-2017 Professional CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinaZcupertino.or L A-UMBING ❑ MECHANICAL ❑ELECTRICAL AM I S (00;46 %3_ 14 -6?-93 ❑MISCELLANEOUS PROJECT ADDRESS APN, Ll OWNER NAME 1 P � � 3 STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME, - y F476A—To�1-16-5� E-MAILSTREET ADDRESS CITY, STATE, ZIP FFIX ❑ OWNER ❑ OWNER-BUID-DER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CON'TRACTORAGENT ❑ ARCHITECT ❑ E*:GLNEER ❑ DE\,ELOPER ❑ TENA--,\r CONTRACTORNAME' , `C 'S AL E LI .'SE PE BUS. LICii')0 /�� COMPA E-MAIL FAX D69l�u ST A. DC CI ,STATE; ZI TA ARCHITECT/E-NGINEER NAME LICENSE NUMBER BUS.. LIC' COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE; 'LIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY I PROJECT LN WILDLlAND ❑ -I-ES BUILDING: ❑ COMWER.CLAL URBAN INTERFACE AREA ❑ NO PROJECT IN FLOOD ZONE ❑ YES ❑ NO IS THE BLDG AN ❑ YE -S EICHLER HOME? ❑ NO DESCRIPTION OF R'ORK L TOTAL VALU.ATI Q B ' LC By my signature below, # 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 building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE bNLY ONLY,.,, ❑, OVER -THE COUICTER' ❑ EXPRESS ❑ .STANDARD, < ❑. L:4RGE ❑ MAJOR A4'EPA11isc,4pp_2011.doc revised 05/21,11 CUPERTINO SANITARY DISTRICT 20863 Stevens Creek Blvd #100, Cupertino, CA 95014 Tel (408) 253-7071 - Fax (408) 253-5173 `AQ 5Aw1lggj,4 f'P4ettsw€ot9�� CUPERTINO SANITARY DISTRICT PERMIT LETTER Cupertino Sanitary District has adopted Resolution No. 1263. Building Permit Request (Over -the -Counter) XS'ingle Family Project ❑ Multi -Family Project ❑ Commercial Project Project Address: 22 -73 1 M-e_t k NA, Permit Number: l � 0 Scope of Work: GUQi (-A- Owner/Applicant Name: Address: Date: Prepared By: City Authorized Representative 1, as property owner or authorized agent, acknowledge that all Cupertino Sanitary District requirements will be met and all required fees will be paid prior to the approval of final inspection for proposed project. Date: Date: Signature: Owner / Authorized Agent CUPERTINO SANITARY DISTRICT OFFICE USE ONLY F-] Required Date Scheduled: Conditional Approval By: Final Inspection Required Authorized Representative Cupertino Sanitary District District will notify owner of the required fee within 5 days after Pre -Inspection has been completed and cc City of Cupe ino. Inspection Fee Paid Date Paid: Inspe tiOFees: $250/unit - Single Family Residential already connected, but new cleanout is required D $150/unit - Single Family Residential already connected with existing cleanout in working order (� $350 Minimum — Commercial and Retail Actual Amount: $200/each — Disconnect and/or abandon lateral service Connection Permit Fees: $350/unit - Single Family Residential connecting to existing lateral D $650/unit — Single Family Residential connecting with new lateral D $100/unit — Multi, Hotel, Living Units, etc. Actual Amount: D $500/connection - Commercial and Retail Actual Amount: Connection Use Fees (See Attached Calculation Sheet): Area and Frontage Fees Amount: Residential Excess Fees over 3.5 unit/acre Amount: D Commercial and Retail Connection Fees Amount: Commercial and Retail Chane in Use Fees Amount: 9 Date: lFinal Approval By: /h —�a— Authorized R Pres ntative Cupertino Sanitary District SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE PURPOSE This affidavi-t is-a-sel-f-certification#or the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2016 CRC Section 8314, R315, 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 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: 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 Slee -.in room Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and 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. 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 permit is required for alarms which 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 bean --tested= and are operational as=of-the date signed below. Address: Z? i p�-,�4i. p Permit No.2 o�� Specify Number of Alarms: # Smoke Alarms: # Carbon Monoxide Detectors: I have read and agree to comply with the terms and conditions of this statement Smoke and COform.doc revised 01/10/2017 Owper (or Owner Agent's) Name: 1 Signature......... ..............�................. ............................................ Date r�... V1 Contractor Name, 1. �^ ✓ � Signature...................................................................... Lie.# ........................................ Date:................... Smoke and COform.doc revised 01/10/2017 WATER -CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION CUPERTIN 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777- 228 • FAX (4,OD.77-3333%buildinci a�cupertino.org Owner Name v ) G{ /y,e Permit No. 2-0 Address O Is your real prop rtrty as registered historical site? ❑ ''es Civil Code Sections 1101.1 through 1.101.8 do not apply. Skip the rest of the form and sign bottom of form. a No Go to Question.2. -- _ --- - - ----- - �---------f ��---_ 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. NTo Go to Question 3. 3. Is water service permanently disconnected for your building? '- i11 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 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 ` - "ivIy real property is buil ani avarTable fC ruee 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:. ❑ My properly is a single-family residential real property. See Civil Code Section 1101.4. On and after January l; 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-coinpliant plumbing fixtures shall be replaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or unprovements). ❑ My property is a commercial real. property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements-shal�equi e 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 peijury 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 110 1.8, 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 page. Owner or Owner Agent's Signature: I( fj� f cz-'(- Date: 51-9, 11.7 upon compieung ana signing tors uernincate, please return it to the Building Division in order to final your building permit. SB4072015.doe revised 01105117