B-2017-1358CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1358
10961 LUCKY OAK ST CUPERTINO, CA 95014 (326 51068)
A & H HEATING & AIR
CONDITIONING
SERVICE INC
SAN JOSE, CA 95110
OWNER'S NAME: BOUJA SANDRA L TRUSTEE
DATE ISSUED: 08/16/2017
OWNER'S PHONE: 408-455-7254
PHONENO: (408) 279-0722
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-20 Lic. #304472
Contractor A& H HEATING &AIR CONDITIONING SERVICE INC Date
7{ BLDG _ELECT _PLUMB
05/3112019
X 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
JOB DESCRIPTION:
license is in full force and effect.
INSTALL (N) AC UNIT
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
ompensation, as provided for by Section 3700 of the Labor Code, for the
erformance of the work for which this permit is issued.
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: $4980.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have readthis application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
326 51 068
and state laws relating to building construction,, and hereby authorize
representatives of this city to ente(upon the above mentioned property for
inspection purposes: (We) agree to save indemnify and keep harmless the
PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities;.judgments, costs, and expenses which
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in'' consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non point
180 DAYS FROM LAST CALLED INSPECTION.
source regulations per the Cupertino Municipal Code, Section 9.18.
^ A
Issued by: Jasmine Archbold
Signa / w Date 8/16/2017
Date: 08/16/2017
OWNER -BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material.being installed. If a roof is
following two reasons:
installedwithout fust obtaining an inspection, I agree to remove all new materials for
1. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
Signature of Applicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date: 8/16/2017
contractors to construct the project (Sec.7044, Business & Professions Code).
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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
Section 3700 of the Labor Code; for the performance of the work for which this
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
s: I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants defined the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
h
Worker's Compensation laws of California: If, after making this certificate of
the Health & Safety Code, Sections 25505, 25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
I
Labor Code, I must forthwith comply with such provisions or this permit shall
O authorized agent:
be _deemed revoked,
p : 8 6
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
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.)
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
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
j
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Licensed
Professional
Signature Date 8/16/2017
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333• building0cunertino.ora
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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 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.
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Signature of Applicant/Agent: nDate: l9 l
SUPPLEMENTAL INFORMATIONUDIRE
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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• buildinq(a�cuoertino.orq
,I s CQ n z� x
m APERMANNOT EF.IINAIIED TITS THIS CERTIFICATE HAS BEEN ,
OMPLETEI3�I NED RETUR VED TO BU TNSD I N nt
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. f I
Address: 10 9 // I L C /l,Y OR/( a Permit No. t (7 '
Specify Number of Alarms: #Smoke Alarms: J $ I 2#Carbon Monoxide Detectors: I
I have read and agree to comply with the term and conditions,of this statement
Owner(or Owner Agent's)Name:
Signatur .. r .. Datey-/hr
Contractor Name: _ n /
Signature Li .# Date/14/
Smoke and CO fonn.doc revised 12/15/16