B-2017-1407CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1407
10816 LINDA VISTA DR CUPERTINO, CA 95014-4749 (356 14 052) JEMICO LLC
OWNER'S NAME: MILLER PAUL V AND FUNARO GINA M
OWNER'S PHONE: 408-892-6240
LICENSED CONTRACTOR'S DECLARATION
License Class C1 7 Lic. #972702
Contractor JEMICO LLC Date 05/31/2018
I hereby affirm that I am licensedunder 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:
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
ormance of the work for which this permit is issued.
ave 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
inspectionpurposes. (Vile) 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
sour regulations per the Cupertino Municipal Code, Section 9.18.
Date 8/23/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
m. 1, 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:
m. 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.
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.
Date 8/23/2017
HAYWARD, CA 94544
DATE ISSUED: 08/23/2017
PHONE NO: (866) 420-4109
BUILDING PERMIT INFO:
X BLDG —ELECT —PLUMB
_ M ECH X RESIDENTIAL _ COMMERCIAL
DESCRIPTION:
,ACE (1) WINDOW IN DINING ROOM; LIKE FOR LIKE
Sq. Ft Floor Area: Valuation: $3500.00
"N Number: Occupancy Type:
356 14 052
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS -FROM LAST CALLED INSPECTION.
by: Jasmine Archbold
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 ofApl
Date: 8/23/2017
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 ,
Co /e�ctionss 25505, 25533, and 25534.
O authorized agent: J
8/23 201
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
70N
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TOR RE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinp(c.cuaertino.org
❑ ADDITION ' ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #-1.2 — �17
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ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
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DESCRIPTION OF WORK
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EXISTING USE
PROPOSED USE CONSTR-
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# STORIES
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VALUATION ($)
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TOTAL
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TOTAL DECK/PORCH AREA
GARAGE AREA: LJDETACH
❑ ATTACH
# DWELLING UNITS
IS A SECOND UNIT ❑ YES
SECOND STORY []YES
BEINGADDED? ❑NO
ADDITION? []NO
PRE -APPLICATION -❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
M _ EIVED BY;
- J TOTAL VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
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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 property owner's behalf. I have read this
application and the information' III rovided is correct. I have read the Description of Work and verify it is accurate. I agree to cornply, with all applicable local
ordinances and state laws relating to ding.co.truction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent:. Date: a ' Z 3 '
SUPPLEMENT . INFORMATION REQUIRED
_... ..
PLAN CHECK 1 YPD .- - -._
_ , ..._. - _ ROUTING SLIP
p ovER _z couivrEx
❑ BUH DING _PLAN REVIEW
_ 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.
0 ExPREss . `
❑- PLANNING PLANIZEVIEw
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
szANDA n
❑ rulwc'woi xs
form if any Hazardous Materials are being used as part of this project.
�_'
. L 1RGEFIRE
DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
EI
SANITARY SEWER
submittal of Building PeTnllt.appllCatlOri.
DISTRICT
_ -'
❑ ,ENYIAONNMNTAM&ALTE1.__
BldgApp_2011.doc revised 06121/11
^•• SMOKE / CARBON MONOXIDE ALARMS
t• >< OWNER CERTIFICATE OF COMPLIANCE L J " I "
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COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
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CUPERTINO 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
(408)777-3228• FAX(408)777-3333• buildinq(a cupertino.orq
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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
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA SMOKE ALARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of X X
the bedroom(s)
On every level of a dwelling unit including basements X X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply:In dwelling units with no commercial power supply, alarm(s)may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl
space.Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above-referenced property,I hereby certify that the alarm(s)referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms specified below have been tested and are operational, as of the
date signed below.
Address: IU$/(, L.J,qiDA V154 O2 areo/ O Permit No.6+ZDAA r/y
Specify Number of Alarms: #Smoke Alarms: #Carbon Monoxide Detectors: 2 I
I have read and agree to comply with,the terms and conditions of this statement
Owner(or Owner Agent's)Name: �/
Pit MUM Signature...04 Date:IrVV.
Contractor Name:
Signature Lic.# r£i Date:
Smoke and CO fonn.doc revised 12/15/16