15120046-OLI CITY OF CUPERTINO BUILDING PERMIT I
IBUILDING ADDRESS: 21370 VAI AVE I CONTRACTOR: WESTSHORE ROOFING I PERMIT NO: 15120046 I
OWNER'S NAME: KADOKURA KEITH AND MOSCHEL 12245-A FORTUNE DR I DATE ISSUED: 12/07/2015 1
OWNER'S PHONE: 4084465478 1 SAN JOSE, CA 95131 1 PHONE NO: (408)694-0060 1
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lie. #
Contractor
Date
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.
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.
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.
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 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 City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply with
all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
�. I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
�. 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.
3. I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so,as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of 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 be deemed
revoked.
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 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 City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply with
all non -point source regulations per.the Cupertino Municipal Code, Section 9.18.
Signature
Date
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
HOUSE 27 QRS & DETACHED GARAGE SQRS 8 - REMOVE
EXISTING WOOD SHAKE AND INSTALL COMP OVER NEW 7/16
Sq. Ft Floor Area: 0 1 Valuation: $17457
APN Number: 36205028.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
--� t,-2
Address, D�ID-N Vag fWe -
'PURPOSE,
aC- b, -or
Th afftdayi.tj 'a -self. - cert ifica' fortho. allation.
don -q*wr Smoke. an af on MonoxicW-Alarms f
Sections 6 i .1 OZ2... interior access or
cqrnpjiaAce.Wff�, 70,1$ CRQ Section R314, 2013 CBC. Ms 9: .11.2-wjiere n0 inte.k"
i48pect ions Ateiequired..
GENERAL INFORMATION,
F $tiiig single-family and, moult i-f"y dwellings shall be provided. ,with Sze oke Maims : and Carbon
Monoxide alarms. 'When thevaluation of additions, alteraflons,, or repairs toexistingdwelling -units exceeds
$1000100, CRC Section R314. and CBC: Sections- 907.2.11.5and ,420.65'require fbaf -SmokO, Alarms and/or. Carbon
Monoxide Alarms be:installed in the. following locations:
AREA
SMOKE ALARM'
CO ALARM
TM9 areain the imaiediate vicinity oftlie
Y€
On every level ofa dwpllingujiit mdudingb*a- j2�ments
X
X
Widdh eadhsle!ti .roora
Carbon:Mon. )dde zlarms are Tioteqqiredin:dw6IIjqgsWhd-i:d0.n.ot x twin fuel urnm
:appl and that
do; not have aattached garage. C I comply with
4fbon morWxid.o alarms combined with alarms shad
CBCSectiO4 420.6 and shall b d b 'the . OfA 'Of the State Fite Marshal,
e Approve, Ce, at
Polder Supply: '1h dwehing units with no-cow.anercial,power supply, 9arm(s).nnay be soJo.Iy battery operated.,
.'In.: existing dwelling; units, ahmns are. permitted to be'solely battery operated whemT,epairs or dlteratiohs' do
not result in - the :removal of wall and :ceiling -finishes or there isno accessofa ttic, basement of crawl
�Y means
space. Refer to CRC'. Section. 93114and CBC Sections 90'7:2114 and 4.26.6.2., Aii Oleetrical permit is required for
alarm I t be connected to.
SW1,11 -Mus 01 :fhe builoing wiring;
I hereby that the alarm(s):referenced above has/have been
As:.owxip�roi.the;;6bo.ve-rc�fore.,iti�d*pr,ope'A Y, .c
led in.,accof-dahce: with the:.mahufacturer*'s instructions and.in compliance with: the California liuilding
, nd California Residential Codes. Tlfie alarms I -rage been., tested and: are opera tional,as of the date signed,
below.
[ have read and ages to. compty With the terms and.conditions ofthi$ statement
Ownbr (or Owner Agehrs) Narnl�
re .............. ................ .. D8te-
&0 1)) oQdjLl /a f1.!s:
... . ............
!9natU
............. Date:
............
E),. ............ ......... .......
sinake. qnif COPt*Aoe,-. nevhed 034.8JI. 4
COMMUNITY DEVELOPMENT'DEPARTMENT - BUILDING DIVISION
1030,0 TORRE AVENUE- CUPERTINO, CA 95014-3255'
I ( 77-S383 - buil 0.0rc
408.) 77: ;P228 • FAX (4.08) 7 dinct(aDcurIerfin -1
OWAff:Nalu'e' -e__l Permit:,No. 6P
Address.
1.'I,. your l � .. . .1.1. 1 .. . d'.histor" at site?
. s. your rea. prqp�b y a. registered IQ
F-1 Yes ovit Code Sections 1101.1 1, through _1;,101:.x. do not op IlI 'tO of form 'nd sign b6ft6jb..of.f6.rm.
_ply: $k e . st a.
N No 60 to Ouestion 2..
.2. Dbes„' bur ty'have, a licensed plumber certifying.fbat due to -tib the property. or it
y, real- proper the age or eqn.fli
�pra, of 5
plunibing, installation of water -conserving plumbing fixtures is not technically.fej�sible?
Cl Yes, Civil C*bde-gectiong9101:7 thfaugh 1101.0 do i.of apply'.
y
0 The licensed plumber's certification ,has been provided to. the Building.Divisiom
Skip the.rest of !be forn-i and sign bottom. of°Ibnn-
1No Go to QyestiOn 3:
3. Is water service permanently disconnected -•foryour building -1
El 'Yes .0 . Qbda Sections: 11thfopgb 11 GLK.do oot apply. SWO the.rest of the -form and sigi bottom of f6m, I.
J9 No: Go to:Que.fti
4. Is youf real propertybu - Ilt. a nd available for use or occupancy on or before Jar uay'y f, 1.994?
0 Nb M y realpropert built available for ti
_y, is use or mcupancy afterJanuary 1, 19 4:.
'Civ'il..Cowie .S.ecrit iis.l.tOl.,I.Oirouo.i.11.01.8.donot ,app'ly. Skip the rest :ofthe fonii-and:silrn.'bottoi-.n bfform.
Yes Ky. real property is.built and available f6r Use or occupancy oiiorbefqrelanua ly 1,199.4.
Civil Co -de SecCions 1, 10:1.1. through f apply;10i.8:.Check one 01he ihree f6lioxving statements and,sign.
bqttom of forte...
5.. Please. check QM -of thefollowing-
15a'1\4.y resideofiat fciit property, 80 Civil Gods Sepiion 11,01.4.
On. and after Janumy 1, 2014,. building41terdoons or i vements shall require MLnon-compliant plumbins
napro g fixtures
to, b'eTp-p-lapp,.d-wit*hw4ter=toii,5I Ixtures throughout the building,. On or before January 1.,. 2017, alljioii�-
ervingpum b ing,f
,coipptiantplurnbing fixtures shall be: -replaced with water-conseruing plus nbkgr fixtures ,(rcgdi'dless Of whether
ptopefty undergoes alterations or: improvements).
0 My property is a.miltifamI& reslidjnt.i4ire.al,prol)eity. See Civil Code Section -110.1.5.
0,:n and. after. January- specified building alterations or-improypipens sli
t all -require non- compliant
-plumbing. Fixtures to be top aced withwater-consprVing plumbing fixtures.
Onorbefore-laAw �1,20�*9,a'llnon-C:6ftiplioiit,plumbina:fixtures shalt be replaced, with watt
qq�nsbrvftig phin0fig fixtures flu-ou,,,ihout.theb-uiIdiiig (regardless of,%,lieffierproperty'Lifidergoeo Oterati.049, of
'.i.mprovernicotq),
El My propertyis & commercial -real proporty. S.eeG,iaril. Code Settidn.1101,.5.
`On and after fanuary 1, 2014, e . ciflied buAding after sp ations or itnprovements shall require non- compliant
plumbing .fbduresto be I ro d ' , .
paco...-,,V.ith-.water-consei4-viiij�plu-inbiingfix tures
01or bpfore: hinuary, 1, '20*19, :all non7coiliplibritp lumbing fixture'l shall, be.. replacedwith. eater. - consicning
plunfingfix res throughout the buildfiig.(TegardlcasofNvlietherprc)liettytii '.r t
dorgo6g, alle. a, ions. or improvements),
f
under penalty ofpi�rjunrthatnona_& I" "t 'b' es,vitt: be
Lft�theo*n 6t�,,�,n.er's�ageiit-of'.this,,property.,.cert�ify MR Jn a'p um in JI- fixture
replaced prior tio. date specified above with, water -conserving plumbing: fixtures;,,, d
in accordance cp With Civil Code Sections. 11M.1
through 1, IOL8,. tbe.currejit,..Califo.miA..Pliiiiibil)�g Code and Calif*omi4. Qi6ch Building Staudards Code, mid.manufacturees
zinstAltioii- requir.0ments, and that, the *ater- C-onseiving.p1dr,nbinig fimiures comply with the requiremcnts as indicated . the
O.Wrief or Owner Agents signatoee:. JJJ, (9& < 4 X pate: jaa/
Upon completing:and signing,this Ceitificate, pL6a.w rets 'rn.it to.,the.Rdildina'DIVIsIon in ord6r Wfiiiafyour building portuit.
3B407.2.015.do.c rellsed 0&2)611,5