B-2017-1277CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR:PERMIT NO: B-2017-1277
6387 ATHERWOOD AVE CUPERTINO, CA 95014-4615 (369 16 011) G M ELECTRIC
HOLLISTER. CA 95023
OWNER'S NAME: BOZEK JOHN S AND NANCY TRUSTEE I J DATE ISSUED: 08/03/2017 1
OWNER'S PHONE: 408-253-5947 1 1 PHONE NO: (408) 592-5306
P-11 IVIN C1043
License Class C-10 Lie. #756029
Contractor G M ELECTRIC Date 11/30/2018
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
Compensation, as provided for by Section 3700 of the Labor Code, for the
herformance of the work for which this permit is issued.
, ave and will maintain Worker's Compensation Insurance, as 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 non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
S' Date 8/3/2017
Wr
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
: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:
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
permit is issued.
3. 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.
Signature Date 8/3/2017
PERMIT INFO:
BLDG X ELECT _ PLUMB
MECH X RESIDENTIAL COMMERCIAL
JOB DESCRIPTION:
UPGRADE PANEL (200 AMP) -SAME LOCATION
Ft Floor Area: I Valuation: $3000.00
APN Number: Occupancy Type:
369 16 011
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Jasmine Archbold
Date: 08/03/2017
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 Al
Date: 3/201
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, 255/33,, and 25534.
Owthorized agent: i VGL�-Ci
Dat 2
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
x
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
C U P E RTI N O (408) 777-3228 • FAX (408) 777-3333 • building Cckupertino. Ong MISC
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❑ PLUMBING ❑ MECHANICAL ® ELECTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS 6397 iq4 e r W o o& iq J e
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OWNER NAME :)7C1 I %` % C, _'7-cf PH0N' I 2,3- S I
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CONTACT NAME
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❑ OWNER ❑ OWNER -BUILDER ❑ Ok7NER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME t'
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LICENSE NUMBER
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LICENSE TYPE
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USE OF ❑ SFD,or DUPLEX ❑ MULTI-FAMTLY
BUILDING: 13 COMMERCIAL
PROJECT IN WILDLAND El YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN El YES
FLOOD ZONE ❑ NO
IS THE BLDG AN El YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK i \ �� r
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TOTAL VALUATION: A 314o O
RECEIVED BY:
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I bave read this
application and the in 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 contration. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Appl.icant/Agent: Date:l
SUPPLEMENTAL INFORMATION REQUIRED
_`3 OFFICE USE ONLY
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❑ OVER THE COUNTER =.
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❑ E.lTRESS
' ❑ STAfiDARD
❑ LARGE. .
❑ MAJOR G
AIEPMiscApp_2011.doc revised 06/21/11
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
4, COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
CUPERTMO
(408)777-3228•FAX(408)777-3333•buildinq(a�cugertino.orq
PERMIT"CANNOT BE F.INNALED UNTIL.TILTS°CERTIFICATE;HAS BEEN
COMPLTETED,SI NET);AND RETURNED T{)THE BU A G 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
J'.~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 donot 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 907.2.114 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
Address. 61 V. Afar. ao D V (1/4;p6Qf11,(2) (In
/55/11 Permit No. 8" .1`t z '/2 77
Specify Number of Alarms: #Smoke Alarms. ME #Carbon Monoxide Detectors 7'
I have read and agree to omply w�th the terms and conditions of this statement �9]
Owner(or Owner Agent's)Name: Dater+` 18 f�Ot
Signature r .... l l 7
410014 S
Contractor Name: Date:
Signature Lic.#
SmokeandC f
O onn.doc revised 12/15/16
I
1
WATER-CONSERVING PLUMBING FIXTURES
0 OWNER CERTIFICATE OF COMPLIANCE
.e.494.4. COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
CUPERTINO
(408,)_7721.3248• FAX(408)777-3333• buildinc cupertino.org:
Owner Name .,.) � IA -1-9ert,
K Permit No. I r 4� 1 7- /4-i(
Address 639 A I-t CO17 1.1Eet, p t2. l 1`x(0<A `93oi
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.
1 - ,,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?
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
0_The licensed plumber,'=s=certi-fieat en has been-provided-to the BuildingDivision.
Skip the rest of the form and sign bottom of form.
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 fonn and sign bottom of form.
El 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 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:
My property is a single-family 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).
❑ Myproperty is a multifamilyresidential real property. See Civil Code Section 1101.5.
p ply
On and after January p 1 2014,specified building alterations or improvements shall require non-compliant
lumbin fip
xtures to be replaced water-conserving plumbing fixtures. = - 4 -
--g .--
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-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 1101.8,the current California Plumbing Code and California Green Building Standards Code,and manufacturer's
installation requirements, and that the re -cons -ving plumbing fixtures comply with the requirements as indicated in the
table on the following page. 7c2
Owner or Owner Agent's Signature: 4 ,�, f� J Date:
1 Upon completing and signing this Certi late,please return it to the B 'ding Division in order to final your buildi g permit.
SB4072015.doc revised 01/05/17
1