B-2017-1434 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1434
22741 MEDINA LN APT A CUPERTINO,CA(342 30 005) PALO ALTO
PLUMBING HEATING
AND AIR INC
PALO ALTO,CA 94303
OWNER'S NAME: EVANS VIRGINIA L TRUSTEE&ET AL DATE ISSUED:08/28/2017
OWNER'S PHONE:408-398-1124 PHONE NO:(650)856-3400
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 Lic.#797913 •
X BLDG _ELECT _PLUMB
Contractor PALO ALTO PLUMBING HEATING AND AIR INC Date 07/31/2019
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
license is in full force and effect. JOB DESCRIPTION:
ADD(N)AC
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
performance of the work for which this permit is issued.
rya I have and will maintain Worker's Compensation Insurance,as provided for by
/0Section 3700 of the Labor Code,for the performance•of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$7420.00
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 342 30 005
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 HERMIT ISSUANCE OR
Additionally,the applicant understands an.will comply w'th all non-point
source regu : ioo: per theo unici..I Code Sec ion 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signa /L//i,%/�'�Al �' nate 08/28/2017 Issued b :Abby A ende
9 , Y Y Y
, Date:08/28/2017
0 ER-BUI i ER DECLARATION ,
I hereby affi .• 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 roofmg material being installed.If a roof is
1. 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 of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:08/28/2017
I hereby affirm under penalty of perjury one of the following three declarations: 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
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 dei es which e,.1' hazardous
air contaminants as defined by the Bay Area Air Qua.ty Management a istrict I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino nicipa .ode,Chapter 9. 2 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safei C' •, etio l. ! ,25- : .425534.E
Labor Code,I must forthwith comply with such provisions or this permit shall r V
be deemed revoked. „, '+ ” �� /-e_���i►
Owner or authorized a.;a, i
—
APPLICANT CERTIFICATION Date:08/28/2017
I certify that I have read this application and state that the above information is CO • T 0 LENDING•GENCY
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 •
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. I understand my plans shall be used as public records.
Signature Date 08/28/2017 Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
- COMMUNITY DEVELOPMENT DEPARTMENT •• BUILDING DIVISION
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10300 TORRE AVENUE •• CUPERTINO,CA 95014-3255
�t:rrs
4 (408) 777-3228 • building@cupertino.org PEMIT#B- �� 1�
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. p ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS APN# !) 42,--'00-00 227 Ail Bear,4ai L�► `^/[- 5
OWNER NAME ,`_ PHONE E-MAIL
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STREET ADDRESS CITY, STATE,ZIP .
CONTRACTOR NAME 0 OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
? , Pcdfo1?-C7-C D141"..‘«f
/Ad - 7975/'3 c, 36 - C. 2 O.
ISTREET ADDRESSQ�t C �� CITY,STATE,ZIP I
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E-MAIL
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fPHONE BUS.LIC#
i/ti4X Yr?erlc.42,72`?C`"t'w :4•1 * Ater 6 ?G c 5'6 ` 7YG0
0 ARCHITECT -0 OWNER 0 OWNER AGENT(ZriCONTRACTteR AGENT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTACT E-MAIL �/�
(i1,C'' .e<S 4— dye' Ql K Aare. 2,2 A.1",C,•y f .. A(r- r
STREET ADDRESS CITY,STATE,ZIP PHONE '
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DECRII'TON d1 / G 7"--C77"--C7Gr Ci is L-e 15 !j��.^l--C 4 G n
piiNGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISING DYES EICHLER 0 YES SECOND STORY ADDITION ❑ ES
FIRE SPRINKLERS 0 NO 0 NO 0
DWELLING SECOND DWELLING 0 YES 0 ATTACHED❑DETACHED OTHER
uNns# UNIT ADDITON: 0 NO S F
POOLS! ❑FIBERGLASS 0 VINYL-LINED 0 GUNITE 0 PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED ❑YES 0 NO I TOTAL-SF '
REC ED BY: ��II TOTAL VALUATION:
• 1 Commercial or Multi-Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval l,, 0.. I . '--Z )1 z. et
RE-ROOFI EXISTING ROOF TYPE: ['BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES I=1 WOOD SHINGLE ❑W ITILI`EV��O/THHER(SPECIFY) 7
REMOVE/REPLACE❑NOI IF NO PLYWOOD ❑ie ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
YEs #OF LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER •12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER• ,
*Provide a signed copy of the Cupertino's Tear-Off Policy SF lot
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 ord.•ances and state laws relating to b ' : g construction. I authorize representatives of Cupertino to
enter the above-identified property .V".r.•.,:on p .os . I ' o ._•• authorize all information contained on this application form
to be made available for public r-✓•
. Signature of Applicant/Agent. - Date: de',Z r
SUPPLEMENTAL INFORM• 0 N REQUI, D
*New SFD/Second Dwelling Units/Multif. 'ly Dwellings:A Demolition permit is required priofto issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project. •
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08/01/17
AT,
SMOKE / CARBON MONOXIDE ALARMS •
t OWNER CERTIFICATE OF COMPLIANCE iki" AI��In
1
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPER1- o 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
' (408)777-3228•FAX(408)777-3333 buildinc cupertino.orq
g ` ; ERMtT flT4tE f �> ED 7,IL THIS CERTIPICA.TE� S..BEEl igtr;
x Is :PIPM"z 3r A A�. M 'FM',���i..�?:e`.`�x " �'-xx ORIU, s ar k. ' "�,;� ~tri ''
42 CnoV ET I3AISI f�I� �
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 appliandes 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,ias of the
date signed below.
Address: r
�a� I(� ) I � 1�-�1�X., CSL � f�-� Permit No.
Specify Number of Alarms: #Smoke Alarms: L.Lgi #Carbon Monoxide,Detectdrs: Li
I have read and agree to comely with the terms and conditions of this statement '
}� � Signat . ... {. Date! /
Owner(or Owner Agent's)Name:
\ 11\aa/215
ure ....... . V0 I r�
7
Contractor Name:
Signature •Lic.# ' Date:
I1
Smoke and CO fonn.doc revised 12/15/16