B-2017-1334CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1334
20217 NORTHBROOK SQ CUPERTINO, CA 95014-0501 (316 39 033) JEFFREY L FORCIER
CONSTRUCTION CO
HALF MOON BAY, CA
94019
OWNER'S NAME: BENHAM MARY II TRUSTEE I I DATE ISSUED: 08/11/2017 1
OWNER'S PHONE: 310-545-6549 I I PHONE NO: (650) 726-1129 I
License Class 5 Lic. #510906
Contractor JEFFREY L FORCIER CONSTRUCTION CO Date 05/31/2019
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:
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.
V 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.
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 Cup rt'
o Municipal Code, Section 9.18.
/ )/7 / / n T /(,..
Date 08/11/207
BUILDING PERMIT INFO•
X_ BLDG —ELECT _PLUMB
_ MECH X RESIDENTIAL, COMMERCIAL
JOB DESCRIPTION
REPLACE DAMAGED BEAM IN GARAGE
Sq. Ft Floor Area: I Valuation: $500.00
"N Number- Occupancy Type:
316 39 033
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by' Kim Dunbar
Date: Q8/11/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -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)
2. 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: 08/11/207
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.
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.
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 ode, Sections 2 50 255 , and 25534.
Owner or authorized agerit
Date: 08/11/207
STRU MING AGENCY
hereby affirm that there is a constr clLaw(ending 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
Signature Date 08/11/207 professional
CONSTRUCTION PERMIT APPLICATION
its COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950147-3255
CUPERTINO (408) 777-3228 FAX (408) 777-3333 • buildingCa7cupertino.org m 13 3
❑ NEW CdNSTpR�UC�TION ❑ ADDQmoN ❑ ALTEIRATION 1 Ti ElREVISION/ DEFERRED d'±RIGINAL PERMIT #
PROTECT ADDRESS ! i / "' ,� 1, 4" c APN #31(
-21
OWNER NU ( N
CIS.
STpvET j� �/
7-15 P
AWIv
i its 1 � f / 1 a �
2-4 '6
FCONTACI��PHONE
E-MAIL
3S
0 OWNER ❑ OWNER BUILDER ❑: OWNERAGENT ❑ CONTRACTOR CI CONTRACTOR AGENT ❑ ARCHPrECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
.�Y �...
g
/. � :.
BUS. LIC#
00
eS t � JVr
C J4`AiZ ? /
95 ✓ 3 fRSR
ARCHIT`ECTT/ENGINEERNAME
LICENSENUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE; ZIP
PHONE
DESCRIPTION OF WORK R f— F -cc P.0- kLel ./ V) � r, ei r�
r:
EXISTINGUSE-
-PROPOSEDUSE 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
_
PORCHAREA
DECK AREA
TOTAL DECK/PORCH AREA
GARACEAREA: DETACH
OATTACH
#DWELLINGUNITS:
ISASECOND UNTr AYES
SECOND STORY OYES
BEINGADDED? ONO
ADDITION? ONO'
PRE -APPLICATION OYES IF YES, PROVIDE COPY OF
IS THE BLDG AN OYES
Y:
T ATiON:
PLANNINGAPPL# ONO PLANNINGAPPROVALIEITER
EICHLERHOME? ONO
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 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 Iocal
ordinances and state laws relating t onstru ti I orize representatives ofCupertino to enter the above -identified roperty for inspection purposes.
Signature of Applicant/AgerDate_ r
M_&_
i't
.. SUPPLE' y, TION REQUIRED
PLAN CHECKTYPE
ROUTING SLIP ... _
❑ OVER-THE-COUNTER
CI 9UHJ 1NGftANREVIEW
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
❑ STANDARD
PURMC W ORKS
_
Form if any Hazardous Materials are being used as part of this project.
11 LARGE
Q FIRE DEPT
_ Copy ofPlanning Approval Letter or Meeting with PIanning prior to
❑ IVIAaoIz
Q ,SANITARY SEWER DISTitlCr
submittal of Building Permit application.
D ENVHtONMENTALHEALTH
BIdgA4pp 2011.doc revised 06121111
SMOKE / CARBON MONOXIDE ALARMS PILE
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
CUPERTINO
10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333• buildinq(a�cupertino.orq
MOM..CANNOTBE FIN/WED UNTIL'THIS CERTIFICATE HAS.BEEl ;
CQM I.,ETEI3 SIGNED t AM)RETIURNED Tt 1HE BITiI I G DI i$Ifll
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 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
Address. 4l 0i � \ Permit No. 6-9-6(7- /
3
Specify Number of Alarms: #Smoke Alarms. #Carbon Monoxide Detectors:
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
Signature Date:
tract
V � 1 Signature ... Ao.' /.._ ... Lic.# Date: �� r//
Smoke and CO fo»us.doc revised 12/15/16
1