B-2017-1206CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1206
22607 ROYAL OAK WAY CUPERTINO, CA 95014-5617 (342 32 010)
BELLOWS PLUMBING
HEATING & AIR INC
SOQUEL, CA 95073
OWNER'S NAME: POLSON THATTIL J AND JOSE MERCY C
DATE ISSUED: 07/24/2017
OWNER'S PHONE: 650-430-2953
PHONE NO: (831) 477-7150
LICENSED CONTRACTOR'S DECtIARATION
BUILDING PERMIT INFO,
License Class C-20: C-36 Lic. #483881
Contractor BELLOWS PLUMBING HEATING & AIR INC Date 12/31/2017
X BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
X 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.
REPLACE FURNACE, INSTALL (1) A/C
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
' performance of the work for which this permit is issued.
I � "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: $11800.00
permit is issued.
APPLICANT CERTIFICATION
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
342 32 010
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.
,Signa'ture c _ Date 7/Z4/2017
Issued by AbbyAyende
/
OWNER -BUILDER DECff%T50N
Date: 07/24/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
RE -ROOFS:
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)
2. I, as owner of the property, am exclusively contracting with licensed
Signature ofApplicant:
contractors to construct the project (Sce.7044, Business & Professions Code).
Date: 7/24/2017
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. 1 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.
O' -'wrier or authorized agent:
Date: 7/24/2017
APPLICANT CERTIFICATION
I certify that I have read this application. and state that the above information is
CONSTRUCTION L t5nGENCY
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
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
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
DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 7/2412017
Professional
UPE T€ O
COMMUNITY DEVELOPMENT DEPARTMENT , BUILDING DIVISION
10300 T ORRE AVENUE . CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 . buiidina Dcupet Eino.org
❑PLUMBING I1/1MECHANICAL MFT.F('TRT(-AT 71 ASK( -PTT A'.r>~nTTC
PROJECT ADDRESS �/� �i a63 fi �lJ 1 r� •
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OWNER NAMEt
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EMAIL
STREET ADDRESS 30 6 0 L(
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OWNER ❑OWNER-BUII.DER ❑ OWNER AGENT ❑ CONTRACTOR ONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑. TENANT
CONTRACTOR N AMEP
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LICENSE NUMBE
LICENSE TYPE
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Cy�OivIP,A(NY NAME ��/J�J �j�
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ARCHITECT/ENGINEER
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COMPANY NAME
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FAX
STREET ADDRESS
CITY, STATE,
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMTLY PROJECT TN WiLDLAND ❑ YES PROJECT IN ❑ YES
BUILDING: E]COMMERCIAL URBAN INTERFACE AREA O FLOOD ZONE ❑ NO
i5 THE BLDG AN :❑ YES
EICHLER HOME? ❑ NO
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TOTAL VALUATION: 4
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RECEIVED BY:
By my signature below, I c rtify to each of the following: F am the proper= owner or authorized agent to act on the property ow er's beh lf. 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 bui g constr do re es of Cupertino to enter the above-idp perty fo> ns o
ectin purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFO
N REQUIRED
"_
OFFICE USE oni Y
ca ;
❑ " OVER-THE-COUNTER '
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❑ EXPRESS .
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❑ STANDARD.
❑ LARGE -
❑ ..MAJOR
MEPMiscApp_2011.doc revised 06121111
M
Abby Ayende
07/25/17
07/25/17
B-2017-1206
Abby Ayende
F h:
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333• buildingna cupertino.orq
PERMIT CANNOT BE FINALED UNTIL THIS'CERTIFICATE HASBEEN
COMPLETED,SIGNED AND,RETURNED TOS THE=BUILDING DIVISION
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms
for compliance with 2016 CRC Section R314,2016 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
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA SMOKE ALARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of X X
the bedroom(s)
On every level of a dwelling unit including basements X X
Within each sleeping room X
Carbon Monoxide alarms are;not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shal comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply:In dwelling units with no commercial power supply, alarm(s)may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of:wall and ceiling finishes or there is no access by means of attic,basement or crawl
space.Refer to CRC Section 8314 and CBC Sections 907.2.11.4 and 420.6.2.An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above-referenced property,I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes.The alarms specified below have been tested and are operational, as of the
date signed below. /� r pp
Address: 7_,Z6O ' ' pt,` I d 4 uo, ) C\f4,40 Permit No. 8261 tt®..
7
Specify Number of Alarms: #Smoke Alarms: I 5 I #Carbon Monoxide Detectors: I '� I
I have read and agree to compl with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
SignatureDate:$/0..4 la cri -
Contractor Name:
Signature Lic.# Date:
Smoke and CO fonm.doc revised 12/15/16