B-2017-1804 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1804
10961 NORTHSKY SQ CUPERTINO,CA 95014(316 40 047) H&S AMERICA CORP
SAN MATEO,CA 94401
OWNER'S NAME:lie Chen DATE ISSUED:10/20/2017
OWNER'S PHONE: PHONE NO:(650)619-7778
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 13 Llc.#0 86
Contractor H&S AMERICA CORP Dale 10/31/2019 X BLDG X ELECT—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:
KITCHEN REMODEL(110 SF);BATHROOM REMODEL(33 SF);
I hereby affirm tinder penalty of perjury one of the following two declarations: BEDROOM UPGRADE CREATE TWO BEDROOMS,ADD ON
u I have and will maintain a certificate of consent to self-insure for Worker's CLOSET;NEW LIGHTING(14)
Compensation,as provided forby Section 3700 ofthe Labor Code,for the REV#2-PANEL UPGRADE(I25AMP)-ISSUED 01-026-2018
performance of the work for which this permit is issued. REV 01 ADD STRUCTURAL PLANS PER INSPECTOR NOTES.ADD
I_
ave and will maintain Worker's Compensation Insuiance,as provided for by BEAM&FOOTINGS AT KITCHEN;ADD HEADER rd 2ND FLR
Section 3700 of the Labor Code,for the performance of the work for which this CLOSET-ISSUED 11/16/2017
permit is issued.
Sq.Ft Flom Arca: Vahatiom$40000,00
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 316 40 047
representatives of this city to enter upon the above mentioned properly 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.
Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 01/26-2018 Issued by:Kim Dunbar
Date:10/20/2017
O LUER DECLARATION.
1 hereby affirm that I am exempt from the Contractar's License Law far are of the RE-ROOFS•
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
r. I,as owner of the property,or my employees with wages as their sale 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)
z I,as owner of the property,am exclusively contracting with licensed Signature ofApplicanc
contractors to construct the project(S-7044,Business&Professions Code). Date:01/26-2018
1 hereby affirm under penalty of perjury one of the following three declarations:
r. I have and will maintain a Certificate of Consent to self-inswe for Worker's ALL ROOF COVERINGS.TO BE CLASS"A"OR BETTER
Compensation,as provided for by Section 3700 of the Labor Code,for the
.performance of the work for which this per is issued. HAZARDOUS MATERIALS DISCLOSURE
a 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
s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)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 lam nrdous
Worker's Compensation laws of California.If,after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I
exemption,I become subject to the Worker's Compensation provisions of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
Labor Code,I must forthwith comply with such provisions or this permit shall the Health&Safety Code,Sections 25505,25533,and 25534.
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION Date:01/26-2018
I certify that I have read this application and state that the above Information Is CONSTRU 'PION 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 thls 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 01/26-2018 Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
s
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 ((((
(408)777-3228• building@cugertino.org PEMIT Y
CUPERTIN4' REV LIDEFN_
[_1 NEW CONSTRUCTION ❑ADDITION ❑ALTERATION❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESSn m APNp
OWNERNARTE `i (� PHONE E-MAIL
STREETADDRESCm,STATE,ZIP
„n
[�I<oNTRACTORNI OWNER-BUILDER COMF 'YNAMB _ LI ENSE NURIBER LICENSE TYPE
ct C.A S OIWC, l�Y o C,F/.S-
sTR ErADDaes� _ ✓� Czm o G/a -
ONE _ ^ — V lm BUS.LICY,
❑ARCHITECT ❑OWNER❑OWNERAGENT ❑CONTRACFORAGENT❑ENGINEER❑DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
STREETADDRESS CITY,STATE,ZE' PHONE
DESCRIPTON
❑SINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY ❑INDUSTRIAL ❑COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF I PORCH SF DECK SF DEMO SF 5TORIFS TOTAL NET SF USE TYPE OCC 'SQ.PT. VALUATION(§)
REMODEL I REMODEL KITCHEN REMODEL OTFIR GARAGE E3 ATTACHED
BATHROOM SF BF SF SF ❑DETACHED
EXFSING El EICHLER ElYES SECOND STORY ADDITION OYES
FIRE SPRINKLERS El NO ❑NO ❑NO
DWELLING SECONDDWELLING EIYES❑ATTACHED❑DETACHED OTHER
UNTESr UETT.ADDITON: El NO SF
POOLS (:]FIBERGLASS ❑VINYL-LINED ❑GUNITE D PREFABRICATED
POOL-SF SPA-SF I SFAA77ACHED AYES ❑NO I TOTAL SF
Cmnmeaial or MWH-Fanrllu BuilAinvs withP.ECEIVED BY: TOTAL VALUATION:
Puhlir5u�n rs Pno(s'm<�es DennT rnfnlE ni ntnlH ntln -�I
RL-ROOFEXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD ❑rh+.. F-1 3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
❑YES C N LAYERS THICI.'NESS❑5/S" OTHER 0056 ❑CDX OTHER :12 A
PROPOSED ROOF T}TE: BUILT-UP ROOF 11 ASPHALT SHINGLES❑WOOD SHAKES C1 WOOD SHINGLES 11OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy - SF eof 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 purposes. I acknowledge nd authorize all information contained on this application form
to be made available for public record. '/
Signature of Applicant/Agent: ` Date: 2.112,
SUPPLEMENTAL INFORMATION REQUIRED
"New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building pennit 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
B1dgApp_2017.doc revised 08/01/17
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1804
10961 NORTHSKY SQ CUPERTINO,CA 95014(316 40 047) H&S AMERICA CORP
SAN MATEO,CA 94401 ,
OWNER'S NAME: DATE ISSUED: 10/20/2017
OWNER'S PHONE: • PHONE NO:(650)619-7778
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#1008156
Contractor H&S AMERICA CORP Date 10/31/2019 X BLDG X ELECT _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:
. KITCHEN REMODEL(110 SF);BATHROOM REMODEL(33 SF);
I hereby affirm under penalty of perjury one of the following two declarations: BEDROOM UPGRADE CREATE TWO BEDROOMS,ADD ON
1. I have and will maintain a certificate of consent to self-insure for Worker's CLOSET;NEW LIGHTING(14)
Compensation,as provided for by Section 3700 of the Labor Code,for the REV#1 ADD STRUCTURAL PLANS PER INSPECTOR NOTES. ADD
. 4, .erformance of the work for which this permit is issued. BEAM&FOOTINGS AT KITCHEN;ADD HEADER @ 2ND FLR
I have and will maintain Worker's Compensation Insurance,as provided for by CLOSET-ISSUED 11/16/2017 _
i. Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$40000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above •
information is correct.I agree to comply with all cityand county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 40 047
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 Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
`/
- ' nature /� Date 11/16/2017 Issued by:I{t -Btber �'^
Date: 10/20/2017 •
OWNE'-BUILD:v' '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 toremove 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)
z. 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:11/16/2017
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
z. 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 Califomia. 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 the Health&Safety Code,Sections 25505,25533,a �.-
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. e 0 r authorized agent:
• APPLICANT CERTIFICATION Im a e:11/16/2017
I certify that I have read this application and state that the above information is .` t_ l I` "" '
correct.I agree to comply withall 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 11/16/2017 Professional •
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1804
10961 NORTHSKY SQ CUPERTINO,CA 95014(316 40 047) H&S AMERICA CORP
SAN MATEO,CA 94401
OWNER'S NAME: JIE CHEN DATE ISSUED: 10/20/2017
OWNER'S PHONE: PHONE NO:(650)619-7778
_.'S I- --._-t-.--IP-I. BUILDING PERMIT INFO:
License Class B Lic.#1008156
Contractor H&S AMERICA CORP Date 10/31/2019 X BLDG X ELECT _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:
KITCHEN REMODEL(110 SF);BATHROOM REMODEL(33 SF);
I hereby affirm under penalty of perjury one of the following two declarations: BEDROOM UPGRADE CREATE TWO BEDROOMS,ADD ON
1. I have and will maintain a certificate of consent to self-insure for Worker's CLOSET;NEW LIGHTING(14)
Compensation,as provided for by Section 3700 of the Labor Code,for the
is erformance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
- ction 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$40000.00
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 316 40.047
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 Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
/) Date 11/7/2017 Issued by:ABBY AYENDE
Date: 10/20/2017
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 exclusivelycontracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:11/7/2017
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 the Health&Safety Code,Sections 25505,25533,and 2553
Labor Code,I must forthwith comply with such provisions or thispermitshall �
be deemed revoked. 0 er or authorized agent:
APPLICANT CERTIFICATION t ate:11/7/2017
I certify that I have read this application and state that the above information is CONST CTION 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 . 1///V / Dale—11/7/2017 Licensed• 1/7/2017 Professional
i i
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1804
10961 NORTHSKY SQ CUPERTINO,CA 95014(316 40 047) OWNER/BUILDER
OWNER'S NAME: JIE CHEN DATE ISSUED: 10/20/2017
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
•
License Class Lic.#
Contractor OWNER/BUILDER Date • X BLDG X ELECT _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:
KITCHEN REMODEL(110 SF);BATHROOM REMODEL(33 SF);
I hereby affirm under penalty of perjury one of the following two declarations: BEDROOM UPGRADE CREATE TWO BEDROOMS,ADD ON
1. I have andwill maintain a certificate of consent to self-insure for Worker's CLOSET;NEW LIGHTING(14)
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
2. 1 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:$40000.00
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 316 40 047
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 Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
• Signature Date 10-20-2017 Issued by:Kim Dunbar
Date: 10/20/2017
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.
/I `� sale(Sec.7044,Business&Professions Code)
. q I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
ontractors to construct the project(Sec.7044,Business&Professions Code). Date: 10-20-2017
I ereby 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
z. 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
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 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 the Health&Safety Code,Sections
25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall• C} /
be deemed revoked. Owner or authorized agen
APPLICANT CERTIFICATION Date: 10-20-2017
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 10-20-2017 Licensed
Professional
�C 9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service, the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors'State
License Board (CSLB)at 1-800-321-CSLB(2752)or www.cslb.ca.gov for more information about licensed
contractors.
C 10.I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
C 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
JC 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
• information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors'State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property,you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: Date:
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declareunder penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above'information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification;!acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property,Owner's Signature: Date: /0/;0/1,01/
OwnerBuilderForm 2010.doc revised 04/14/10
Vim
SMOKE I CARBON MONOXIDE ALARMS,
OWNER CERTIFICATE OF COMPLIANCE
;00, ,p 'COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
Cu pRTt NO
(408)777-3228•FAX(408)777-3333•buildincacueertino.ora
PEnNiIT CAN OT`BE 11NALED UNT L TRIS CERTIFICATE h A: BEEN
COMPLETED,SIGNED AND RET RI ED TO THE 43. LDING DI VISION
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PURPOSE
This affidavit is a self-certification for the installation of 211 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 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the bnil ding 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. r
Address: i°9b f JO1- ;Kli . .SO , LutP?tll n , IA'S0'1J Permit No. ?2, - I/-18°4-
-
Specify
18°4-
Specify Number of Alarms: #Smoke Alarms: I - I #Carbon Monoxide Detectors: I 2
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
Signature Date:
Contractor Name:
/7/01; l rSignature ,✓ /h � Lic.# / D1/ Date: ..t.r.;:�.4 4
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Smoke and COfori3s.doc revised 01/10/2017
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