B-2017-1489 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1489
6387 ATHERWOOD AVE CUPERTINO,CA 95014-4615(369 16 011) SANDIUM INC
SAN JOSE,CA 95134
OWNER'S NAME: BOZEK JOHN S AND NANCY L TRUSTEE DATE ISSUED:09/06/2017
OWNER'S PHONE:408-253-5947 PHONE NO:(408)894-9072
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: ,
License Class j3 Lic.#888119
Contractor SANDIUM INC Date 12/31/2018 X BLDG _ELECT _PLUMB
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:
REPLACE FURNACE(SAME LOCATION);INSTALL(N)AC UNIT
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.
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. Sq.Ft Floor Area: Valuation:$15000.00
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 369 16 011
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 inconsequence 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 Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature j� Date 09-6-2017 Issued by:Kim Dunbar;
' Date:09/06/2017
�i
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
r. I;as owner'of,he property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
compensation,will do the work,and the structure is not intended or offered for
sale,(Sec 7044;Business&.Professions Code)
2. I,ai owner of the property„am exclusively contracting with licensed Signature of Applicant:
contractors'toiconstructathe project(Sec.7044,Business&Professions Code). Date:09-6-2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. !lave andwili maintain a Certificate of Consent to self-insure for Worker's
Compensation as pr ivided`for by Section 3700 of the Labor Code,for the
performanciel of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I�habe;and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
§" ct i California Health&Safety Code,Sections 25505,25533,and 25534. I will
Section 3700 of the Labor Code,for the performance of the work for which this
.i I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Ipeimit,is issued. Health&SafetyCode,Section 25532 a should I store or handle hazardous
3. l certifythatkin the performance of the work for which this permit is issued,I ( )
t material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
'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 subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,!I must forthwith comply with such provisions or this permit shall
be deemed'revoked. Owner or authorized age
APPLICANT CERTIFICATION Date:09-6-2017
I certify that I have(read this application and state that the above information is CONSTRUCTION LENDING AGENCY
' correct.I agree to coria ly,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,icosts arid 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 09-6-2017 Licensed
Si
9 Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
s (408)777-3228 • building@cupertino.org PEMIT#B-20 1 * ` 0
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION ,ALTERATION ❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS 6.-s737 ( APN# /_pj ! / _ _ 11
OWNER NAME -- ,;\()Vl1/1. ID L PHONE 40
253
C? git jq E-MAIL
J, �0ek 1„,e41. Cil
STREET ADDRESS � a„,,le a, at, CITY, STATE,ZIP`7
CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
s 88g\VI C20
IsTA j0„�G ,J �`�. CITY,STATE,�7jP�� ��� // Q j:+ I
E-MAIL , !/x' VW `� PHONE S BUS..'LIC Ir ( ;/
Cs c 4gg�4ga7z .
❑ARCHITECT, 0 OWNER ❑OWNER AGENT' 0 CONTRACTOR AGENT ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL .
STREET ADDRESS CITY,STATE,ZIP PHONE
DECRIPTON , •
MINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL ❑COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SFS PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODELOTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF ❑DETACHED
EXISING ' ❑YES EICHLER •❑,YES SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS❑ NO ' ❑ NO 0 NO
DWELLING SECOND DWELLING' ❑YES'0 ATTACHED DETACHED OTHER
UNITS# UNIT ADDITON ; '❑NO S F ,
POOLS' I❑,FIBERGLASS',❑j/INY1',,- ❑GUNITE ❑PREFABRICATED ,
POOL-SF I SPA-SF I SPA ATTACHED❑YES ❑ NO I TOTAL-SF '
I I, RECEI r o ti a T Aqt VSA- UA ON:
Commercial or Mull:Familq Btulchn s with Public Swiuunin3 Pools requires Department of Environmental Heath approval ) `/( ''Y '. — ` �O�
RE-ROOF'liEXISTING ROOF TYPE: ❑'BUILT-UP ROOF E ASPHALT SHINGLES❑WOOD SHAKES❑ OOD SHINGLES El TILE OTHER(SPECIFY) '
i
REMOVE/REPLACE El'NO IF,NO '; PLYWOOD El v2- ❑3/8" PLYWOOD TYPE: • PITCH: ROOF CLASS'
Q YES' #19F LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER :12 A
PROPOSED ROOF TYPE:((]BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES❑WOOD SHINGLES 0 OTHER
*Provide assigned copy of'the Cupertino's Tear-Off Policy SF #of SQUARES I
By my signature below1I ceirtify�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'applicablelocal ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified,prolpertyfor inspecti purposes. I acknowledge and authorize all information contained on this application form
to be made available for public record. ,, '
Signature ofApplicant/Agent. :il . � k-/✓Iv Date: ��/l��
SUPPLEMENTAL INFORMATIOr REQUIRED ,
*New SFD/Second Dwelilmg Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings i Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are beingused as part of this project. i '
*Copy of Planning Approval'Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval Froin the Home Owner's Association ,
i' BldgApp_2017.doc revised 08/01/17
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
4y ap COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333• buildinci(a�cugertino.orq
PERMITC.ANNOT BE:YINAI ED°UNTIL:THIS:CERTIFICATE,HAS-BEEN
,, COMPLETED,SIGNED) AN RETURAD TO THE BUILDING DIVISION.
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 mspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shall be provided with S_moke Alarms and Carbon __
�y
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 907.2.114 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 herebycern that the alarm s referenced-abov been --
p p ty, certify ( ) e has/have
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. 63 q 7 Z''ac Fd 11 06 V Permit l\To. l Th' ?
l
Specify Number of Alarms: 11 #Smoke Alarms 1 3 ! #Carbon Monoxide Detectors 1 /
I have read and agree to •mply with the terms and conditions of this statement
O� Name: 411 /'
O Signature . . . :. - .IS do, . . 1. V12/21:68/1
Owner(or Owner Agent's)
N S L<
Contractor Name:
Signature Lic.# Date.
Smoke and CO form.doc revised 12/15/16
1
/ SMOKE / CARBON MONOXIDE ALARMS ,,k., 1 t E
OWNER CERTIFICATE OF COMPLY CE "
F .s1.Y;9,;; COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinq a(..cuoertino.orq
b. : PERMITS CAM OT BETE+ALN LEI?UI TIL THIS(.,FRTIFICATE HAS BE le
1 i -r'. X 'c'"�t ;. 'A V �. -i t-W4 a gay.•�'c' F tt5
�„A COI 14—cED,'Sl(l\TED; PETUI TEI3 r.0 # ,; I D1NG,DI SI01i -.i A
'`"x ,�;„ 9 ,, 7 —,r.i '>' ,J,_..` sb_ra. e` sfi s_ . '--"� ,4x.e. .,'ma„- "w '
`�..m,;.x•-..,n:..,v.::,ar<_oe�:,.,-.;xzc..a:e,,:.,.w.....<:,».._cie..�s.. ,.,mow:... _ -,. ;; �F v..<..?;,.b_Y.Kinnu�.,..rt...-r+_..<w-:�.,.�.s...:,a.,..w..w.•r.:s..�r_-:,.a
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:
ARES 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 arc 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 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. I •..
Address: , 63 g 7rac 81406 b / VI Permit 1\To. 2°l 7 1 4g7
Specify Number of Alarms: 4/ #Smoke Alarms: 13 I #Carbon Monoxide Detectors:Li ` I
t have read and agree to amply with the terms and conditions of this statement
Owner(or Owner Agent's)Name: � / ,Q ��l
Signature d 1/.1 2�
Join _ Bo..z. I(
adgeli
Contractor Name:
i
Signature Lic.# Da
Smoke and CO form.doc revised 12/15/16