B-2017-1673 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1673
22448 SALEM AVE CUPERTINO,CA 95014-0955(326 15 101) ARROYO PLUMBING
AND DRAIN INC
DOS PALOS,CA 93620
OWNER'S NAME: CLEAVER JEAN S TRUSTEE&ET AL DATE ISSUED:09/27/2017
OWNER'S PHONE:408-354-8910 PHONE NO:(408)674-0835
,LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 Lic.#939350
Contractor • • ' . u: ►G I►D :a ► ► Date,10/31/2017 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 SERVICE
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
ormance 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:$3100.00
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 326 15 101
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 li-.ilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said r ity in consequence of the granting of Tis permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR.
Additionally,the appli - understands and will omply with all bn-point
sou - regulations-.er'he Cupertino Municip- Code,Sectio. •.18. 180 DAYS FROM LAST CALLED INSPECTION.
" ignature A� Date 9/27/2017 Issued by:Abby Ayende
•
Date:09/27/2017 •
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
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:9/27/2017
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 equipmen 'r devices which emit hazardous
air contaminants as defined by the Bay Are: it Quality Mana •ment District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupe ' •Municipal Code/ hapten .12 and
exemption,I:become subject to the Worker's Compensation provisions of the the Health&Safety Code,Seeti. s 25505,25533, , d:25534.
Labor Code,I must forthwith comply with such provisions or this permit shall / /
be deemed revoked. � Dwner or authorized agent: • v
APPLICANT CERTIFICATION Date:9/27/2017
I certify that I have read this application and state that the above information is CONSTRUCTION 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
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 9/27/2017 Licensed
Professional
(3--7.0k1-' IC143
\� i // GENERAL PERMIT APPLICATION M E P
/' COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
,St.,9ss 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 MISC
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinaecupertino.orq
-s-sib)LUMBING El MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS .
PROJECT ADDRESS -7 Z M Q'.. SA 1 i T'�' ✓V V e APN#
[�P_.. ��i`®
OWNER NAME C- 1' O PHO �(/ E-MAIL 111
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STREET ADDRESS J L 1 ,4 �+ CITY,STe�TE,S •6,4 .' c . Qty? t,v5,_y rc(— 6,6
CONTACT NAME i - I Y �•4,. .., 1._ PHONE�p,/ ��� L'I �� s ?I `T T • Al✓J 0w -H A A vvoio- ` v t l oAy v 04,
s b3"—D zi,-c o)1\ ✓V r.. s. .J CITr,ST?ZIP
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Do ❑ OWNER-BUILDER, 0 OWNER AGENT I?CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT' ❑ENGINEER 0 DEVELOPER 0 TENANT
CO�TRAC R N Y�, .LICENSE ` LICENSE TYPE BUS.LIC#
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COMPANY NAME v� . H, 4 )�J, L 1(.. r H ' ✓J Iv�9'°- )V ` C6W` AJY`n `b1 g3;
STREET ADDRESS HO
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ARCHTTECT/INOINEEtNAME IICtSENUMBER
BUS.LIC/
COMPANY NAME . i1; E-MAIL; . : FAX
STREET ADDRESS - CITY,STATE,ZIP , PHONE '
i
USE OF ❑SFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILDLAND. . ' ❑YES PROJECT IN ❑,YES, ', IS IHE BLDG AN '❑YES
BUBAING: 0 COMMERCIAL URBAN INTERFACE AREA. 0 NO FLOOD ZONE 01NO!. EICHLER HOME? 0 NO
DESCRIPTION OFWORK ) � .. . 4, •
t i.h 1 W v i" VC Ivt ciu,�,^l IA,' 'h A ex,.., . 1.C-4) CO p)2 e,t, 'l yye L-
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' TOTAL VALUATION: ? t 0I) RECEIVED DY:
( 4111 • i
By my signature below,I certify to each of the lowing: I am the property r authorized agent to act on the property owner's beI have read this'
application and the information I have pro ' is correct I have tha• esc" tion of Work and verify it is accurate. I agree to comply'with all applicable local
ordinances and state laws relating to buildin construction- I autho rep tatives of Cupertino to enter the abov dentifie i property for inspection purposes.
Signature of Applicant/Agent: Z Date: 1�Z-1 `)
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY '.'` . :. '. -
Ia. OVER THE-COUNTER`
Y
f
. x � EXPRESS,.-
0 STANDARD
U
a 0•LARGE
❑_MAJOR _
` MEPMiscApp_2011.doc revised 06/21/11
��` / SMOKE/ CARBON MONOXIDE ALARMS
` • OWNER CERTIFICATE OF COMPLIANCE
t, ;f..COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
f (408)777-3228•FAX(408)777-3333•buIIdinacuoertino.orq
E PERMIT CANNOT BE FINALED UNTIL THIS CERTIFICATE HAS BEEN
COMPLETED,SIGNED AND RETURNED Ta THE BUILDING DIVISION ,:i
;1Z.r . t,-:.. .�i Y .ii:y.o a. _ iio '-
_ a4 -�A:iY� '`utys c1:r .;4• '` ,,,.../r7;1,-.:-`;'4t
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for ..
compliance with2016 CRC Section R314,R315,2016 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 Alarm&and Carbon
Monoxide alarms: When the valuation of additions,alterations,or repairs to existing dwelling units exceeds
$1000.00,CRC Section R314,R315,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 the• X X
bedroom(s)—(Smoke alarms shall not be located within 3 feet of bathroom door): ,., .. .. .
On every level of a dwelling unit including basements and habitable atticsX X
Within each sleepingroont: ,. X
Carbon Monoxide aiarms: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. ,
I 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).refenmced 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
`t date signed below.
Address: Z.L '1 M 8'' f:l '1 C Vv., . A U" Permit No. Q'-2-d 1 t.bZ 3
(46) Uni4 Bultdin
Specify Number of Alarms: #Smoke Alarms:115 ! #Carbon Monoxide Detectors:► ...s"
-11
,,_!have read and agree to,comply,with the terms and conditions of this statement,
Owner(or owner Agent's)Name.
5HE(d S4eik �F. LP .. . Signator �a ,d' J , . _ / Dale.!6/31E7•
C tract? Name: i /
4'ly . .. 1�''. _Y..r,R. Signature '1 V •'q 7 Date:. .Z1�
Smoke and CO form.doc revised 01/10/2017