B-2017-1406CITY OF. CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1406
6595 CLIFFORD DR CUPERTINO, CA 95014-4555 (369 26 006)
JEMICO LLC
HAYWARD, CA 94544
OWNER'S NAME: FRANCIS RICHARD N TRUSTEE & ET AL
DATE ISSUED: 08/23/2017
OWNER'S PHONE: 408-805-6889
PHONE NO: (966) 420-4109
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C17 Lic. #972702
Contractor JEMICO LLC Date 05/31/2018
Xi BLDG _ELECT _ PLUMB
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
license is in full force and effect.
JOB DESCRIPTION:
REPLACE(1) SLIDING GLASS DOOR IN KITCHEN - LIKE FOR LIKE;
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
erformance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
�eiq
ection 3760 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $6400.00
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
369 26 006
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 said City in consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupeerti Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Sture ����. Date 8/23/2017
Issued by: Jasmine Archbold
Date: 08/23/2017
OWNER -BUILDER DECLARATION
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 ofApplicant
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 8/23/2017
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
performance of the work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
2. I 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. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become;subj&t to the Worker's Compensation provisions of the
the Health & Safety Code, Se ' s 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed
revoked. i
n" or authorized agent:
APPLICANT CERTIFICATION
: 8 23/20
1 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
I hereby affirm that there is a construction lending agency for the performance
relating to building icohstruction, and 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 8/23/2017
Professional
UON
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT! BUILDING DIVISION
10300 TORRE AVENUE e CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(okupertino.ong
F-1 ADDiTTON
ALTERATION / TI ❑ ,REVISION /DEFERRED ORIGINAL PERMIT # > —2-C!> 11— 140 (O
PROJECT ADDRESS G, N /� I t, l' -, -Id �1
S� i
APN # (OCL . —
V
OWNERNAME
PHONE /u0 OS— Egg j
EMAII'•lp
STREETADDRESS % S 4 c� l I f o!a
V`` 'J l� T /
C TA fi`I C A 5_ b
l
FAX
CONTACT NAME
a k,n
PHONE
E- LAIL
.J til
STREET ADDRESS p!
CITY, STATE, ZIP
9
FAX
eA o,
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT �-CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER 11 TENANT
CONTRACTOR NAME
i -r we✓ Ser+
LICENSE ERLICENSE
7 2 "10 Z
TYPE
BUS. LIC #'
COMPANY NAME1
E-
FAX
vr1- rte' 'UiY ae , - C-4
STREET ADDRESS 3goo SAS t A-PJA t
CITY STATE, ZIP e A 9 q s yN
(� i
P sr �', a-63.' J/ 7 6
ARCHITECUENGINEERNAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
(Li TCL4
EXISTING USE
PROPOSED USE
CONSTR- TYPE
# STORIES
USE
TYPE
OCC. ;
� SQ.FT. '
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
.AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODELAREA
REMODELAREA
PORCH AREA
DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJDETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? ❑NO
ADDITION? ❑NO
PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
EIVED BY_[ - -` -
.TOQ�TAL VALUATION:
PLANNINGAPPL# NO PLANNING APPROVAL LETTER
❑
EICH[]NO
LER HOME? NO
-" -�'
-' w
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property o er,, s behalf. I have read this
application and the information I have rovided 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 ding construction. Lauthorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: b J Z 3 1 7
SUPPLEMENTAt INFORMATION REQUIRED
rJ w cHEcx
❑ OVER-TH11rCOUN1ER
ElBUILDING'ELAN 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. I
❑ EXBRESS:.
❑ PLANNING'PLAN-REVIEW--'
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
0 STANDARD'
❑. PUBUC WORK .,
form if any Hazardous Materials are being used as part of this project.El
LnRCE`
❑ F>iE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to.An
D "sAinTAztY"s"EwEu'
submittal of Building Permit application.
MA70R;
DISTRICT,
�_..-_. .
❑ ,ENVIRONMENT ALHEALTHM:,
B1dgApp_2011.d6,c revised 06/21/11
. //>c-
SMOKE / CARBON MONOXIDE ALARMS
•
OWNER CERTIFICATE OF COMPLIANCE ..
�4 9Sz COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION IDS 7 i _ GsC
CUPERTINO10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•buildinq(a�cupertino.orq
Pligso,
....t ;,. ERM.-.,.'.ITCvfi..;w..BE ,NAED .�.TLTHIS CEP RTIFCATN
HASBEEN3 OI ,TG �COPLD ASIGNEDA TURNED ��E ,,IIl t
�
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 bel w have been tested and are operational;as of the
•date signed below.
Address: l // /l T �'
l Permit 1\0l l , "V
Specify Number of Alarms: #Smoke Alarms: LL1 #Carbon Monoxide Detectors: L I
I have read and agree to comply with the terms and conditions of this statement
•
Owner(or Owner Agent's)Name: r
Signature /....�:........1 Dater/" '/—`4.4 Itr`-
Contractor Name:
Signature Lic.# Date:
i
Smoke and CO fonn.doc revised 12/15/16