B-2017-0747CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0747
20121 NORTHWOOD DR CUPERTINO, CA 95014-0554 (316 36 040)
JAN EISENBACH
CONSTR
GILROY, CA 95020
OWNER'S NAME: COLON ALICE C
DATE ISSUED: 05/31/2017
OWNER'S PHONE: 408-934-0323
PHONE NO: (408) 218-3578
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class a Lie. #418075
Contractor JAN EISENBACH CONSTR Date 02/28/2018
X BLDG —ELECT —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:
TO CLEAR CODE CASE - 2ND FLOOR; DECK REPAIR - (36 SF)
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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.
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
Sq. Ft Floor Area:
Valuation: $0.00
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
316 36 040
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, c", and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence a granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understartrs and ,11 comply with all non -point
source regulatthe pertino Mur�ifipal Code, section 9.18.
r
180 DAYS FROM LAST CALLED INSPECTION.
Signatur,s� n ^'�' Date 05-31-2017
Issued by: Kim Dunbar
-�
OWNER -BUILDER DECLARATION
Date: 05/31/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RF -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
t. 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)
z. 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: 05-31-2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
r. 1 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 a azardous
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
air contaminants as defined by the Bay Area Air Quail Mana Stt District I
will maintain compliance with the Cupertino u�tfcip_ a ode apter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code�,St c' Ilio 25 r 533 p '25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
.'
be deemed revoked.
Owner or authorized agent:, %C
APPLICANT CERTIFICATION
Date: 05-31-2017
I certify that I have read this application and state that the above information is
TION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there i 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 05-31-2017
professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
1 (408) 777-3228 • FAX (408) 777-3333 • building(@,cupertino.oro
CUPERTINO 13rZQt--r-O - [` —
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDWS [ —
APN #
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OWNER N/�
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STREET ADD SS ��
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FAX
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CONTACT NAMEj-
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E-MAIL
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ADDUSs
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR „� !
S
LICENSE
BUS. LIC #
COMPANY NAME i/�1� / J� EMAIL 2 , C`
(� 4j
FAX
STREET ADDRESS CITY, ST j� Z6
/ lI
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT []YES
SECOND STORY []YES
BEING ADDED? []NO
ADDITION? [-]NO
PRE -APPLICATION El YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
TOTAL VALUATION:,;_
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
---•", i! �"
By my signature below, I certify to each of the following: I am ope owner thorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I hav esc ' n of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to build, repres fives of Cupertino to enter the above -identified proper or inspection purposes.
Signature of Applicant/Age t:
SUPPLE NTAL ORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ ovER-THE-COUNTER
❑ BUILDING PLAN REVIEW
�=
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
El STANDARD
❑ PUBLIC WORKS
1FIRE
To—nn if any Hazardous Materials are being used as part of this project.
-1LARGE
❑ DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
B1dgApp_2011.doc revised 06/21111
CUPERTINO
SMOKE / 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.orq
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, 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 sleeping room
X
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 been tested and are operational, as of the
date signed below. �/��/�,,�7
Address: Z& /2' � �f 1 7rGflre �// �/� Permit No. c?,Q//'J
07j17
Specify Number of Alarms: # Smoke Alarms: F777 # Carbon Monoxide Detectors: 1 1
1 have read and agree to comply with the terms and conditions of this statement
Owner (or Owner Agent's) Name:
Signature.......... ............................................................................................ Date:......jr—.
Contractor Name:
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Si nat e......,,:::.. �. ... ................... Lic.# ..../.CXi/...J.................. Date:Y/.
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Smoke and CO form.doc revised 01/1012017