B-2017-1878 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1878 •
21612 COLUMBUS AVE CUPERTINO,CA 95014-4711(356 18 052) PLUMBING WERX
CAMPBELL,CA 95008
OWNER'S NAME: SOROOSHIAN FEREIDOON AND MOJDEH DATE ISSUED: 11/01/2017
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OWNER'S PHONE:408-910-6558 PHONE NO:(408)646-3808
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#1010949
Contractor PLUMBING WERX Date 02/28/2018 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)GARAGE
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.
t I have and will maintain Worker's Compensation Insurance,as provided for by
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Section 3700 of the Labor Code,for the performance of the work for which this
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permit is issued. Sq.Ft Floor Area: • Valuation:$925.00
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 356 18 052
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 understands and will comply with all non-point
source regulations p- the,C pertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
SignaturM Date 11-1-2017 Issued by:Kim Dunbar
`r Date: 11/01/2017 •
OWNER-BUILDER DE LARATION •
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: 11-1-2017
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
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permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. 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 Cuperti : Mun'"pal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety C de,Sect'. 2551,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked.` Owner or authorized agent 7 -4
APPLICANT CERTIFICATION Date:11-1-2017 •
I certify that I have read this application and state that the above information is CONSTRUCTION LEND G 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. • "
Licensed •
Signature • Date 11-1-2017 Professional
CONSTRUCTION PERMIT APPLICATION
Via` .`_;
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
ti=w:Fo wa01 - lK��
.,,,,t (408) 777-3228 • building@cupertino.org _
PEMIT�B-
CUPERTINO REVS DEF;
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❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS 2 i 6 )2 co (l.'n'1 /✓s Ave APN; 35-6g ,....__05--;.z_.a
OWNER NAME J (J PHONE E-MAIL
/ 'e rei'%on 5oroosAipc) 40S - 9/0- 6558 p
STREET ADDRESS CITY, STATE,ZIP G O�5 O/
29(, 1Z Go lu+✓I vs ,4Ue Gorer -1-in c. ` 4 -
®CONTRACTOR NAME 0 OWNER-BUILDER COMPANY NAME • LICENSE NUMBER LICENSE TYPE
05C-AV --zAjuirre Plurn my ( J c,ic JO.Io94q c 3‘,,,
ISTREET ADDRESS CITY,STATE, ZIP , A O I
35 3 S� 6Asc- Ave 9 C .lphe (/l v
E-MAILPHONE BUS.LIC;
ry,e/Au , --/e r21 y,�A,ia 4,r, 4os - , .5t6.-.380 8
0 ARCHITECT 0 OWNER.0 OWNER AGENT 0 CONTRACTOR AGENT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY,STATE,ZIP PHONE
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DECRIPTON / '
exi#1- /eK � e-ATec r��/ACPinen 71 40 9 A 1(6 n ' 7 .tl e—A9 e.a
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❑SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL I
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EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES; TOTAL NET SF USE TYPE OCC SQ.FT. ,VALUATION(5)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE 0 ATTACHED ,
BATHROOM SF SF SF SF 0 DETACHED
EXISING ❑YES EICHLER 0 YES SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS❑ NO 0 NO 0 NO
DWELLING SECOND DWELLING ❑YES 0 ATTACHED DETACHED OTHER
UNITS; UNITADDITON: El NO SF
POOLS 0 FIBERGLASS 0 VINYL-LINED 0 GUNITE ❑PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED ❑YES 0 NO I TOTAL-SF ff
RECEI D 4 . ! atioil ,CATION:
I Commercial or Multi-Family Buildings with Publir 5wimmine Pools reavires Department of Enviro nnental Heath approval i •
��///
44,C...,
RE-ROOF EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES ll 4'OOD SHINGLES 0 TILE OTHER(SPECIFY) '
REMOVE/REPLACE❑NO IF NO PLYWOOD 01" ❑3/8" ' PLYW•OD TYPE: PITCH: ROOF CLASS
N 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 ;of SQUARES
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 ordinances and stat- laws relating to building construction. I authorize representatives,of Cupertino to
enter the above-identified property for inspe . pur9oses. I acknowledge and authorize all information contained,on this application form
to be made available foripublic record., ','/ / Zp
Signature of Applicant/Agent: Date: ' .
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-Proyide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08/01/17
If reil
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE It'? t�
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
��� � � 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
C (408)777-3228•FAX(408)777-3333•buildino a(�cuoertino.orq
PERMIT CANNOT BE FINALED TT;I THIS:CERTIFICATE HAS:`BEEN
CO LETED,SIGNED AN RETi3RN'EI)TO THE BOOING 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, alauu(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 If Ati � ���3 /a t Aie, sl/frySilio) 6,Q 4-156/4 Permit No. -4=20/7,,475
475
Specify Number of Alarms #Smoke Alarms 4 1 #Carbon Monoxide Detectors I ( 1
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name: // / ` 7
F' 1e 1106fr1 Cllrodchifl/r7 Signature. - .____ __ Date:l111/I.l.>..
Contractor Name:
Signature Lic.# Date:
Smoke and COform.doc revised 01/10/2017