B-2017-1769 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1769
7505 PEACH BLOSSOM DR CUPERTINO,CA 95014-5226(366 11 130) MIKE COUNSIL ,
PLUMBING INC
SAN JOSE,CA 95131
OWNER'S NAME: HILEALVIN J JR AND LINDA S TRUSTEE DATE ISSUED: 10/13/2017 '
OWNER'S PHONE:408 252 4453 PHONE NO:(408)272-4900
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 Lic.#679261
Contractor MIKE COUNSIL PLUMBING INC Date 04/30/2019 X BLDG _ELECT X PLUMB
MECH X RESIDENTIAL_COMMERCIAL
1 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 GAS LINE FROM GAS METER TO 4 FIXTURES
I hereby affirm under penaltyof 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.
2. 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:$17872.00
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 366 11 130
representatives of this city to enterupori 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 understands and will comply with all non-point
source regulations pert e Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signaturefr
Dat /0/( 7 Issued by:Phuong Devries
Ito Date: 10/13/2017
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 roofing 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:
•
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,equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with'the Cupertino Municipal ode,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,255 ,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date/ /
I certify that I have'read this application and state that the above information is (5 7 CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm th t 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 Licensed
Professional
/ CONSTRUCTION PERMIT APPLICATION
\M/ COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • building@cupertino.org PEMIT#B- -O I- _ - 11.4-) -1
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. %MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS .•) 5� n / j ��� �APN a p._ ` \ O
ili
OWNER NAME /� ( �i I a.1 c.,k. �1 ��� 2- +� -� E-MAIL
STREET ADDRESS 5 S�t q 3l c 5o� ^ r
CITY, _ nz�ZIP f ' Col 4
91 CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME `'V) \ JLJ LICENSE NUMBER ( �(LICENSE TYPE
I� �y M��L� �5� I ,1 � Co"'M Z6 s C 3k
STREET.10 PRESS CITY,STATE, ZIP
/s I o01Q Wer,) Z!)CAA-, e. a* 15131
E-MAIL
t (fPHON
/%l (4&irCnWv !L lVcloIn � uQ0 Z12 - ygao
❑ARCHITECT 0 OWNER 0 O ER AGENT jC NTRACTOR AGENT ENGINEER 0 DEVELOPER 0 TENANT BUS.LIC k
903 (-13a
CONTACT NAME E-MAIL
5c mve cel yZ ''o.e..-cfa
STREET ADDRESS CITY,STATE,ZIP PHONE
DECRIPTON J .a(�, RC1 `� IGO v , I Q. O/l� 1 ' C..G"- c'tte iL
v
INGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL I
EXISTING USE EXISTING SF NEIN FLOOR,SF PORCH SF DECK SF DEMO SF STORIES if TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE o ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISING I:1 YES
SPRINKLERS 0 NO EICHLER ❑❑ ES SECOND STORY ADDITION El YES
FIRE
0 NO •
DWELLING SECOND DWELLING ❑YES ❑ATTACHED DETACHED OTHER
UNITS# UNIT ADDITON: - ❑NO S F
POOLS, ❑FIBERGLASS 0 VINYL-LINED 0 GUNITE 0 PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED❑YES ❑ NO I TOTAL-SF
RECEI
�•.' TOTAL VALUATION:
Commercial or Multi-Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval �,0� l 1 1 i CZ -1 Z'
RE-ROOFI EXISTING, ROOF TYPE: El BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES 1:1 WOOD ".INGLES a TILE OTHER(SPECIFY) t l � l C�
REMOVE/REPLACE Q NO IF NO PLYWOOD ❑1"" ❑3/8" PLYWOOD TYPE: PITCH: .., ROOF CLASS
❑YES II OF LAYERS THICKNESS❑5/8" OTHER I=1 OSB ❑CDX OTHER
• 2 A
PROPOSED ROOF TYPE:OBUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER
*Provide a signed copy of the,Cupertino's Tear-Off Policy SF #of SQUARES
. By my sign ature'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 ordinances and st to laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection poses. I acknowledge and authorize all information contained on this application form
to be made available for public re.,.y'; ` (��
Signature of Applicant/Agent: .-4/64411111,/----•• Date: 3/17
SUPPLEMENTAL INFORMATI• REQU ED
*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 approval from the Home Owner's Association
BldgApp_2017.doc revised 08/01/17
SMOKE / CARBON MONOXIDE ALARMS
• OWNER CERTIFICATE OF COMPLIANCE F1H7
c.F COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION40.
CUPERTINO10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 *IAL
(408)777-3228•FAX(408)777-3333•buildinq c(Dcupertino.orq
PERMIT CANNOT BE FINALE))l NTIL TI IS CERTIFICATE HAS-BEEN.
COMPLETED,SIGNET),AID ETT RNF,D 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,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 Alarms 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 attics 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 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: .75-05- 5105001 c C- Permit No. -ZP n- i i6 !
Specify Number Of Alarms #Smoke Alarms I ! #Carbon Monoxide Detectors .
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
Signature . Date:
Contracto(Name:M t n
CUOV\(�( JV� ¶ ) Signature `� Licit 'f` + .I Date:
Smoke and COfonn.doc revised 01/10/2017