B-2017-1972 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1972
21102 WHITE FIR CT CUPERTINO,CA 95014-4235(359 05 087) AFFORDABLE WATER
HEATERS AND '
PLUMBING INC -
28358
CONSTELLATION RD
• VALENCIA,CA 91355
OWNER'S NAME: PETOVSKY JIRI AND MICHIKO TRUSTEE DATE ISSUED: 11/15/2017
OWNER'S PHONE:408-253-4037 PHONE NO:(855)345-9087
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 Lic.#627368
Contractor AFFORDABLE WATER HEATERS AND PLUMBING INC Date X BLDG _ELECT X PLUMB
09/30/2018 _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 JOB DESCRIPTION:
license is in full force,and effect. (N)40 GALLON WATER HEATER-INSIDE CLOSET
I hereby affirm under penalty of perjury one of the following two declarations:
i. I have and will maintain a certificate of consent to self-insure for Worker's .
C,mpensation,as provided for by Section 3700 of the Labor Code,for the
1 � •
s''=rformance of the work for which this permit is issued.
.0 '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
$11Sq.Ft Floor Area: Valuation:$3253.00
permit is issued,
APPLICANT CERTIFICATION
I certify that I have read this applicatioh and state that the above APN Number: Occupancy Type:
information incorrect.I agree to comply with all city and county ordinances 359 05 087
and state laws relating to building construction,and hereby authorize
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgments,costs,and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of this permit.
Additionally," e applicant understands arid will comply with all non-point 180 DAYS S FROM LAST CALLED INSPECTION.
•
sour rregul.,ion•, e Cupertino•Municipal Code,Section 9.18.
m Issued by:Jasmine Archbold
;gnature Ai Date 11/15/2017 Date: 11/15/2017
li
OWNER-B DECLARATION
RE-ROOFS: •
I hereby affit I amexempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: • installed without first obtaining an inspection,I agree to remove all new materials for
1. I,asowner of the property,or my employees with wages as their sole inspection.
compensation,will do the work,and the structure isnot intended or offered for
sale.(Sec.704.4,Business&Professions Code) Signature of Applicant:
• 2. I,as owner of the property,am exclusively contracting with licensed Date:11/15/2017
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one,of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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 HAZARDOUS MATERIALS DISCLOSURE
performance df the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance,as provided for by 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
s. I certify that in the performance of the work for which this permit is issued,I 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 .� it Quality Management District I
will maintain compliance with the II its .1 k unicipal Code,Chapter 9.12 and
' Worker's Compensation laws of California. If,after making this certificate of the.Health&Safety Code f:ectiiiiI\ '505,25533,and 25534.
exemption,I become subject to the Worker's Compensation provisions of the ,
• Labor Code,I,�must forthwith comply with such provisions or this permit shall �/•'Y
O .r authorized agent:
be deemed revoked.
an.' . 11/15/2017
APPLICANT.CERTIFICATION , . C•NSTRUCLYR ENDING AGENCY
I certify that I have read this application and state that the above information is • I hereby affirm that there is a co structiln lending agency for the performance
correct.I agree to comply with all city-and county ordinances and state laws pf work's for which.this permit is sued Sec.3097,Civ C.)
relating to building construction,and Thereby authorize representatives of this city Lender's Name
to enter upon the above mentioned(property for inspection purposes. (We)agree
to save indemnify and keep Harmless the City of Cupertino against liabilities, Lender's Address .
judgments,costs,and expenses;w110 may accrue against said City in• •
consequence of the granting Of this;permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18. '
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION .
. ,0
. :. _
,....,,,A‘: 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
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(408) 777-3228 • buildh gcupe.rtino.org PEMIT#B- . - (°l 2- ,
CUPERTINO REVt •DEFF
❑ NEW CONSTRUCTION ❑ADDITION•❑ALTERATION E T,1. MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS z i (02 - �p •p,\� n� A N 5-CV O C)B
OWNER
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4 a E-MAIL I
STREET ADDRESS �� ,SVT`~',z n f Ai
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IjONTRACTOR NAME 0 OWNER-BUILDER C AP'ANYNAME LICEN9ENUMBER LICENSE TYPE
. I__, I,Z.A.:7D. ,c [ c - MLA �Jq � iL4jr (,2 7-SkC- ;'r(
E-MAB PHO £ BUS
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0 ACHITECI OWNER.0 OWNER AGEN ❑CONTRACTOR.AGENT❑ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL'
•
STREET ADDRESS CITY,STATE,ZIP PHONE
DECRIPTON
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tGLE-FAMILY/DUPLEX (]MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL
EXISTING USE EXISTING SF NE11'FLOOR SF PORCH SF DECK SF DEMO SF STORIES t TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5)
REMODEL REMODEL KITCHEN REMODELOTHR GARAGE 0 ATTACHED •
BATHROOM SF SF : 'SF SF , 0 DETACHED 1
EXISING ❑YES. EICHLER ❑'YES SECOND STORY ADDITION D ES
FIRE SPRINKLERS 0 NO ❑ NO
DWELLING SECOND DWELLING ❑YES 0 ATTACHED DETACHED OTHER
UNITS; UNIT ADDITON: ,;,,, ONO 5 F .
POOLS 0 FIBERGLASS ❑,VINYL-LINED 0 GUNITE 0 PREFABRICATED C
POOL-SF SPA-SF " ;'l SPA ATTACH ED❑vas. ❑ NO l TOTAL-SF I -
t /RE " D BY:
1 ,, / T AL VALUATION:
Commercial orMulti-family Buildh;gs with,Public Swiimoiue Pools remtires Department of Environmental Heath amwroal .f
_
RE-ROOF EXISTING ROOF TYPE. '❑BUILT-UP ROOF❑ASPHALT SHINGLES D WOOD SHAKES❑1A OD SHINGLES 0 TILE OT:-IER(SPECIFY)
REMOVE;REPLACE E NO' IF NOPLYWOOD ❑1" ❑S/B" ' PLYWOOD TYPE: PITCH:
-1 ROOF CLASS
El YES.I €'OFLAYERS (THICKNESS O SIB" OTHER ❑OSB 1=1CDX OTHER :12 A
•
PROPOSED ROOF TYPE:❑BUILT-UP ROOF DASPHALT SHINGLES D WOOD SHAKES DWOOD SHINGLES ❑OTHER
`Provide a signed copy of the Cup'ertino'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 applicobl'e local ordi an d state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified!property for i s tiurposes. I acknowledge and authorize all information c ntaine on this application form
to be made available for public record.
Signature of Applicant/Agent: Date: I1/ )IS /° -
SUPPLEMENTAL INFORMATION REP . ED
"New SFD/Second Dwelling.Urlits/Multi y Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
, "Commerdial Buildings: Provide la 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
•
Bldg.4pp_2017.doc revised 08;`01/17
SMOKE / CARBON MONOXIDE ALARMS
• OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ati-►� -17
CUPERTINO 10300 TORRE AVENUE• CUPERTINO,CA95014-3255
(408)777-3228•FAX(408)777-3333•buildinq(c cupertino.orq
ERTCANOT,BE`FADINTITIIS CRICATEHAS-
CONiP-LETED,SIGNED ])RETURlhJED,TO 1IIE BU LDING 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 mustbe--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 belowWIZ.- G q5D jam.
Address 2119(2. FF4:4., t p rz.✓L�i ei-41) J1ePermit No.n—2 0 ) 7 -1 ` 7 2
Specify Number of Alarms #Smoke Alarms 3 J #Carbon Monoxide Detectors f
I have read and agreeto comply the to-ms and conditions of this statement
Owner(or Owner Agent's)
4
"Date:f f71/.r�R` / � D Signature. ..... .
Contractor Name:
r-r) b I e /t/�ll/,J f�' r - Signature " . . Lic.# Z 3 �.V Date: /././2(, '•7
ft ec -1-c /
Smoke and COform.doc revised 01/10/2017