B-2017-1375CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1375
21155 OROGRANDE PL CUPERTINO, CA 950144151 (362 17 008)
KITCHENS BY MEYER
INC
MOUNTAIN VIEW, CA
94040
OWNER'S NAME: KUMAGAI SHOJI AND CAROL M TRUSTEE
DATE ISSUED: 08/17/2017
OWNER'S PHONE: 650-796-2106
PHONE NO: (650) 968-7866
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class 5 Lic. #323091
Contractor KITCHENS BY MEYER INC Date 03/31/2018
7X BLDG —ELECT _ PLUMB
MECH X RESIDENTIAL COMMERCIAL
Thereby 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: � pp
KITCHEN REMODEL (10 S.F.) -' 9-e0au � v�
reby'affirm under penalty of perjury one of the following two declarations:
11. 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
erformance of the work,for which thi's 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: $3000.00
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
362 17 008
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 in co equence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the licant u e ds and will comply with all non-point
source r ula . ns per th p i ipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
gnat a Date 8/17/2017
Issued by: Abby Ayende
9
Date: 08/17/2017
OWNER-BUILDER.DECLARATION
Ii 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
4.` I, asowner 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, Busines's & Professions Code)
z. I; as owner of the propeity, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct ,the project (Sec.7044, Business & Professions Code).
Date: 8/17/2017
I hereby, affirm und'r penalty of perjury one of the fallowing three declarations:
e
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I. 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
I
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. L certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(x) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
shall,not employ any Berson in any manner so as to become subject to the
air contaminants as defined by the Bay Ar Air Quality Management District I
Worker's Compensation, laws of California. If,!after making this certificate of
will maintain complia a with the C rtino nicipal Code, Chapter 9.12 and
exemption', I become subject to the Worker's Compensation provisions of the
the Health & Sa Co , Sectio 505 25533, and 25534.
Labor Code, I mustfoithwith comply with such provisions or this permit shall
be deemed revoked.
ner or authorized age
APPLICANT CERTIFICATION
Date: B 017
I certify that I have read this;application and'state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply With!all city and county ordinances and state laws
I hereby affirm that there is a construction lending agency for the performance
relating to building construction, sand 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 8/17/2017
Professional
?9101-4- Vl�
CONSTRUCTION PERMIT APPLICATION 2' :
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING. DIVISION ~a g
10300 TORRE AVENUE a CUPERTINO, CA 95014-3255
(408) 777-3228 o FAX (408) 777-3333 • building(cDcupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTF.RATTON/TI I I RRVTRVITT/TIRRRDDRTI nDTlSTKTAT DL`DLATTA
BldgApp 2011.doc revised 06/21/11
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CONTRACTOR N ` �
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ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
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CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
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EXISTING USE-
PROPOSED USE CONSTR_
TYPE
# STORIES
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USE
TYPE
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VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
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AREA
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AREA
NET AREA
KITCHEN
DELAREA REMODELAREA
OTHER
REMODELAREA
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DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
ATTACH
LLING UNITS:
LSA SECOND UNIT ❑ YES
BEING ADDED? ONO
SECOND STORY YES
ADDITION? ❑NO
PRP APPLICATION ❑YES IF YES, PROVIDE COPY OF
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑ YES`RECEIVED.BY.
EICHLER HOME? 13 NO
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T VALUATION:
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By my signature below, I certify to each of the following: I am the property; owner or authorized agent to act on the roperty wner's befialf. I have read this
application and,the information I have prov' Orrec ha d e Descriprion of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and, state laws, re ing to '
n of re resentatives of Cupertino to enter the a-ide fled7pro rty for inspection puiposes.
Signature of Applicant/Age Date: /
SUPPI MENTAL INFO TION REQUIRED
PLAN TYPE
ROUTING §LIP'.
_ New SFD or Multifamily dwellings: Apply for demolition permit for
ovElt-iTiE
existing building(s). Demolition permit is required prior to issuance of building
cour^rER
0 BUH !NG PL. N ItEVIEw
permit for new building.
❑ EXPRESS
❑ PLANNINGPLAN REVIEW =
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
D STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
0 LARGE°
D FIRE DEPT..
_ Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
0 I�IAIox
SANITARY sEwER bISTRICT
dro
ENVIRONMENTAL:REALTH
BldgApp 2011.doc revised 06/21/11
M
Abby Ayende
08/17/17
08/17/17
B-2017-1375
Abby Ayende
t SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
+# COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTJNO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinq a(�,cuoertino.orq
•
PERMIT CATLIT:BE 'INALED_DNTIL THIS UhR1I I°CATE HAS BEEN,
rATra SID, PN7, �+ �7��
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 f 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)maybe 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 alarms)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: /2 11J`'j OI4 "k?1 6.( 2f/ Permit No.$2J -k
Specify Number of Alarms: #Smoke Alarms:I 1 #Carbon Monoxide Detectors:► 2- t
J have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name: /
Ruey—V z uJema Signature .. r71.-1 �' Date: �g22�
ntractor Name:
e. Signature t
Lic.# .. 1 Date:
Smoke and COform.doe revised I2/I5/16