B-2017-1510 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1510
20272 PACIFICA DR CUPERTINO,CA 95014-3014(369 44 019) WATER HEATERS
ONLY INC
GRASS VALLEY,CA
95945
OWNER'S NAME: FRANK EDWARD M DATE ISSUED:09/08/2017
OWNER'S PHONE:626-355-4287 PHONE NO:(800)835-8345
. _ _ .._I •. Y_Z_:_ 9_t'_ i_ __._._._ •. BUILDING PERMIT INFO:
License Class C36 Lic.#374573
Contractor WATER HEATERS ONLY INC Date 05/31/2019 x BLDG _ELECT X 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 WATER HEATER(40 GAL)SAME LOCATION
I hereby affirm under pena . .f perjury one of the following two declarations:
t. I have and ..b.maintain a certificate of consent to self-insure for Worker's
Com. sation,as provided for by Section 3700 of the Labor Code,for the
,,,, J./,,, ..'ormance of the work for which this permit is issued.
i '' have and will maintain Worker's Compensation Insurance,as provided for by
g'', Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. 1 Sq.Ft Floor Area: Valuation:$1493.00
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 36944 019
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;understa •s'and will comply with all non-point
source regulations pert Cuperti•o Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur , 1 Date 09/08/2017 Issued by:Kim Dunbar
Date:09/08/2017
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 roofmg material being installed.If a roof is
i. 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:09/08/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"ORBETTER
r. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compnsation,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 Ialior Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
•' maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit;is issued., i i
Health&Safety Code,Section 25532(a)should I store or handle hazardous
3. I certify thatin die'performance of the work for which this permit is issued,I
material. Additionally,should I use,equipment or devices which emit haza dous
shalllnot employ any person in any manner so as to become subject to the
j,, , i, air contaminants as defined by the Bay Area Air Quality Manageme. I istrict I
Worker's Compensation;laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code, ..pter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Se do,•25505,25533 ,d 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall /�•la
be deemed revoked l Owner or authorized age ���
APPLICANT CERTIFICATION Date:09/08/2017
I certify that I have read this application and state that the above information is CO _Lir O L_.I i.G:_G kC
correct.I agree to comply;with all:pity 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 cornply with all non pointisource(regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section,9.18. ! I understand my plans shall be used as public records.
Signature Date 09/08/2017 Licensed
Professional
CONSTRUCTION PERMIT APPLICATION -
t' , • COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
, :
10300 TORRE AVENUE • CUPERTINO,CA 95014-3255 -
y.ina 1�/y - !tel a
�' , (408)777-3228 • building@cupertino.org PEMIT#B
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. `q MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS z 109
Wf C4 ` ` APN# cl _ L, /— Q/ ,
OWNER NAME V c I 66,-,,,,k___
� / 0PHONE.�i` �Z c Egi- -MAIL
STREET ADDRESS ( STATE,ZIP'
2'2 fa°�C . , 04. ,, 950 iy'
CONTRA OR NAME ❑O NER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
taear 064 ...0 " ,
S BET ADDRESS CI STATE,ZIP iz,,,,,,.... ex. e ,a_7.7:.,c___,
MAIL PHONE . BUS.LIC#
o ., 6-q - s
0 ARCHITECT .❑OWNER 0 OWNER AGENTONTRACTORAGENT❑ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME Aei.< 1 E-WL dit,C3fl�Z /J / �` e-J /Gi �c/Z� .,
Al" PHONE
Esq //e au& /5444427-- 3-__"� /7./e/lt c---STATE,ZIP / � S�De f/6/263-' 7.51T-
.---
�.1/ T"
DECRIPTON cu—
Re,,,-2/a-0--e ele0 17 C_[/l- ,k1-20--tie — {�' ''' `t._ (_4J L+:z'
❑SINGLE-FAMILY/DUPLEX IL LTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL I
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES S TOTAL NET SF USE TYPE OCC SQ.FT.. VALUATION($)
REMODEL REMODEL KITCHEN REMODELOTHR GARAGE ❑ATTACHED '
BATHROOM SF SF SF SF 0 DETACHED - '
EXLSING ❑YES EICHLER 0 YES '' SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS 0 NO 0 NO ' 0 NO
DWELLING SECOND DWELLING 1 0 YES 0 ATTACHED 0 DETACHED OTHER
UNITS# UNIT ADDITON: ,❑No . S F
POOLS! 0 FIBERGLASS r 0 VINYL-LINED '❑GUNITE 0 PREFABRICATED
POOL-SF _ SPA-SF I 'SPA ATTACHED ❑YES NO TOTAL-SF - Flip fremrne.0_,Dr:Commercial or Multi-Family Buildings with Puhhc Su imming Pools requires Department of Environmental Heath approval -,/. /
RE-ROOFI;EXISTING ROOF TYPE: ❑BUILT'UP ROOF❑ASPHALT SHINGLES I]WOOD SHAKES❑WOOD SHINGLES E TILE OTHER(SPECIFY)'
REMOVE/REPLACE❑NO IF NO PLYWOOD 1=1'h" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
I=1 YES I,#OiLAYERSTHICKNESS❑5/8" OTHER ❑OSB E 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 Sof SQUARES
. By my signature below I eertifyto,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 corre ,--Th-ave read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordinances and state laws re .-: g to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspectio purposes. . -.cknowledge and authorize all information contained on this application form
to be made available for public record. Ale/0
Signature of Applicant/,Agent: ;Vat Date:j_A(// 9'�
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to 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 approlval;from the Home Owner's Association
' . BldgApp_2017.doc revised 08/01/17
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SMOKE / CARBON MONOXIDE ALARMS
1 OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUP)rRTiNo 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333• buildinq(a�cuoertino.orq
-: ER1 IST CAl\ flTB iNTA .ED TTIL THIS CE4.1 �CATF l AS:. EEN?
Co h I. B;SrGN D RETLR1 :T �
r
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-fairiily dw llin`gs shallbe provided i�Tith`Smo�ce 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 907.2.114 and 420 6.2. An electrical permit is required for
alarms which must be connected to the building wiring _ � _w _
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 L)s9
a,fir �-f G�� e4_ Permit No Q' )0l7 _/5745
olY
Specify Number of Alarms' 4 Smoke AIarms ! J #Carbon Monoxide Detectors c
I have read and agree to complyth the - - -5 conditions of this statement
Owner(or Owner Agent's)Name: l
Si nature. '
011-dlC- 4 627'.5 .
/ / r Date: rte'
C tractor Name.
dpi .e.
/i/ ���✓ � Signature Lica Date:
O
/1"JSmoke and CO fonn.doc revised 12/15/16