B-2017-1428CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1428
20915 MCCLELLAN RD CUPERTINO, CA 95014-2959 (359 13 082)
MIKE COUNSIL
PLUMBING INC
SAN JOSE, CA 95131
OWNER'S NAME: HILL FENTON AAND WINIFRED F TRUSTEE
DATE ISSUED: 08/25/2017
OWNER'S PHONE: 408-252-4328
PHONE NO: (408) 2724900
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class,C36 Lic. #67=61.
Contractor MIKE COUNSIL PLUMBING INC Date 04/30/2019
X BLDG _ELECT X PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
Lhereby 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:
GAS RE -PIPE SFD (BLACK IRON) -FULL HOUSE
I hereby affirm under penalty of perjury one of the following two declarations:
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
performance of the work for which this 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: $10031.00
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
359 13 082
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.
WIT�IIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source reg lations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
S' Date 8/25/2017
Issued by: Jasmine Archbold
OWNER -BUILDER DECLARATION
Date: 08/25/2017
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
i. I,� as owner `of the property, or my employees with wages as their sole
installed without fust obtaining an inspection, I agree to remove all new materials for
'inspection.
corhpensatiori, 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
Signature of Applicant:
contractors oto construct the project (Sec.7044, Business & Professions Code).
Date: 8/25/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
r. Lhave 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
z. 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 '
a. 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 notlemploy 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
Workers 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 subject to the Worker's Compensation provisions of the
the Heal & Safety Code, Sections 25505 5533, and 25534.
Labor Gode„I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owede6 r orizagent:
APPLICANT CERTIFICATION
Datwwcaiz
I certify that I have read this application and state that the above information is
COS RUC ON 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, 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.
tosave 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 bf 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.
I understand my plans shall be used as public records.
Licensed
Signature Date 8/25/2017
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • building@cupertino.org PEMIT #B —0
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R r SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
•
i�ei 9 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
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 SectionR314 and CBC Sections 9.07.2.11.4 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.
2 e f-C F-'� 0-9--1A&,
Address: Permit No. 6-90 -171-P
Specify Number of Alarms: #Smoke Alarms: Li=1 #Carbon Monoxide Detectors: f /
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
Signature Date:
Contractor Name:
Signature Lic.# Date:
•
• Smoke and CO fonn.doc revised 12/15/16