B-2017-2151 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR. PERMIT NO:B-2017-2151
7612 RAINBOW DR CUPERTINO,CA 95014-5247(366 11 036) MIKE COUNSIL
PLUMBING INC
SAN JOSE,CA 95131
OWNER'S NAME: LEWIS HELEN L TRUSTEE DATE ISSUED: 12/14/2017
OWNER'S PHONE:408-253-4443 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
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION
REPLACE 50 GAL WATER HEATER(SAME LOCATION)
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
NiAperformance of the work for which this permit is issued.
z! 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:$3122.00
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 11 036
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 per the uppertinooMMunicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
/ 4l/
//
/,Signature Date 12/14/2017 Issued by•Abby Ayende
Date: 12/14/2017
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:12/14/2017
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 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 Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the ,1 the Health&Safety Code,Sections 2 5 5,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. z„
Owner or authorized agent: / ---.:
APPLICANT CERTIFICATION . Date:12/14/2017
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.
Licensed
SignatureDate 12/14/2017 Professional
•
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION'
v..,
10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
1.44 $9S' (408)777-3228 • building@cupertino.org PEMIT#B- 1 - 21 5)
e CUPRTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS 76 (nTVA IO f^q 7 c APN# at�' t 1 (r
OWI Eli.NAME W_ V y/ `
-tQ4 13 P Fmk 25—`3 -t14 K 3 E-MAIL
STREET ADDRESS CITY STATE,ZIP
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cA CONTRACTOR NAME 0 OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
ISTREET ADDRESS /+� /� CITY,��STATE, ZIP /t /
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11 d 5- L/o CQi �V`'/AILPHppNE q ! ' S 1Z C//i—B IC 7r7. .)f
( / Z?2✓ 4,100 116- 11 3cp
❑ARCHITECT ❑OWNER El OWNER AGENT I/CONTRACTOR AGENT D ENGINEER❑DEVELOPER❑TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY,STATE,ZIP PHONE
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'SINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY 0 INDUSTRIAL ❑COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF •DEMO SF STORIES# TOTAL NET SF USE TYPE OCC - SQ.FT. - VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF ❑DETACHED
EXISING ❑.YES EICHLER 0 YES SECOND STORY ADDITION _171 YES
FIRE SPRINKLERS❑NO `❑ NO ❑'.NO
DWELLING SECOND DWELLING ❑YES ❑ATTACHED❑DETACHED OTHER
UNri-s# UNIT ADDITON: ❑NO S F -.
POOLS' ❑FIBERGLASS ❑VINYL-LINED ❑GUNITE ❑PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED❑YES 0 NO I TOTAL-SF .
Commercial or Multi-Famihi Buildings with Public Swimming Pools requires Department of Environmental Heath approval � �J" v+"`�1 TOTAL V)A2LU2 ON:
RECE ED BY: 4
RE-RO OFI EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD Die ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
DYES #OF LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER •12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES ❑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 state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection purpo••s. I acknowled•e •o authorize all information contained on this application form
to be made available for public reco rd. Date: I
�7��i 0t7
Signature of Applicant/Agent:
SUPPLEMENTAL INFORMATION' 'QUIRED
*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
`y �3�
\V(.141
, SMOKE / CARBON MONOXIDE ALARMS 0 -
OWNER CERTIFICATE OF COMPLIANCE
t, COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinq(a)cupertino.orq
PERMIT CANNOT BE FINALE!)UNTIL THIS CERTIFICATE HAS BEEN
COMPLETED,SIGNED,AND RETURNED 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. ( c� Ica. L,,t CJ C:..) Permit No. Don-11C)
Specify Number of Alarms #Smoke Alarms 7-1
#Carbon Monoxide Detectors. /' I
I have read and agree to comply with the terms and conditions of this statement
t �� e� "�+. .. .. . .. . . . Date
Owner(or Owner Agent's)Name:
SignaturJ � .
Contractor e:
Signature Lic.# Date:
Smoke and CO form.doc revised 01/10/2017