B-2016-2680 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2680
11228 STAUFFER IN CUPERTINO,CA 95014-5150(366 09 045) ATKINSON
CLIMATROLLERS INC
SAN JOSE,CA 95112
OWNER'S NAME: KURUMA DENNIS K AND MARGARET K TRUSTEE DATE ISSUED:09/08/2016
OWNER'S PHONE:408-252-9858 PHONE NO:(408)294-6290
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#258540
Contractor ATKINSON CLIMATROLLERS INC Date 12/31/2016 X BLDG _ELECT _PLUMB
X 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:
I hereby affirm under penalty of perjury one of the following two declarations: REPLACE 2(E)FURNACES;REPLACE 2(E)A/C UNITS(SAMELOCATIONS)
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.
f 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:$20802.00
APPLICANT CERTIFICATION
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 09 045
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 plic nt understands and will comply with all non-point
source regulati pe the Cupertino Municipal Code,section 9.18. 180 DAYS FRO CALLED INSPECTION.
e,
Signature' Date 09/08/2016 Issued Of
Date:09/08/2016
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. 1,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:09/08/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
s. 1 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
a. 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 wihich 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 Crtin Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code, ction 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent::
'44—,�/
APPLICANT CERTIFICATION Date:09/08/2016
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 agencyfor 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. 1 understand my plans shall be used as public records.
SiSignature Date 09/08/2016 Licensed
g Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•building(Wcupertino.orq
CUP RTINL misc
PLUMBING MECHANICAL ELECTRICAL MISCELLANEOUS
PROJECT ADDRESS l t�J /J �J Q i APN# r O .F -65
OWNERNAME (� (� Q i PHONE E- /
STREET ADDRESS j 1 /� ��Q �� CITY, STATE,ZIP
CONTACT NAME PHONE (1 E-MAIL
STREET ADDRESS '� ) I / 1 CITY;STATE,ZIP VVI 1 f 5
1) FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT El ARCHITECT E]ENGINEER ❑ DEVELOPER 11 TENANT
CONTRACTOR NAME Sr,— j t \ /� LICENSE NUMBER 2,5?/ Q LICENSE TYPE �7 ei BUS.LIC#
a
COMPANY NAME I V/ 1 C ' I � l�fln�C EMAIL i a j I } ('0M FAX
V
7 s �?���. c �1) voy— ,,7 ��� q
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP . PHONE
USE OF USFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑.YES IS THE BLDG AN ❑YES
BUILDING: 1-11❑COMMERCIAL URBAN INTERFACE AREA ❑.NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK Act 2, a ,:5 lotJ / 1
TOTAL VALUATION: �/ (1 V D 2' ELL:2
, E R -, I
,
By my signature below,I certify to 6chkofthe fo owing: I am the property owner or authorized agent to act on the property er's behalf. I h this
application and the information Lhave ped correct. I have read the Description of Work and verify it is accurate.;Iagr to comp y with all applicable local
ordinances and state laws relating to buc struction. I authorize representatives of Cupertino to enter the above denti d property for inspection purposes.
Signature of Applicant/Agent: Date: (J
SUPPLEMENTAL INFORMATION REQUIRED Y
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SMOKE / CARSON MONOXIDE ALARMS
LEE] OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION'
CUPERfiINO 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•'building(cDcuperfino org
CXddr-ess, 1� �1 � ermit a tN
t�#Of marms smo e. Carbon Mo�ioxide� 2
PERMIT'CANNOT BE FINALED AND COMPLETER UNTII,THIS CERTIFICATE
HAS BEEN AND RFT TRNF7i
Q THE B
DIVISION
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.112 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shallbe 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 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)
On every level of a dwelling unit including basements X X
Within each slee2i-ng 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
nof,result in the removal of wall al 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 building wiring.
As owner of the above-referenced property,I hereby certify that the alarm(s)referenced above has/have been
installed in accordance w1UL the manilfac arer's instructions and in compliance With he California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
1 have read and a ree to comply with the terms and conditions of this statement
Oyrner{o�Qw`ner A enf`s Name-
` �v►01
......... � 16
-Contractor Natale:
..... ..... �. ate
I/q)l �y G 1, � nature ° ;:,eUQ4 z5{5 y 0. 'Date.�.. . 1 14 64.14......
Smoke and CO forntdoc revised 03118114
WATER-CONSERVING PLUMBING FIXTURES.
OWNED CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-322€3.FAX(408)777w3333•building@2 pertino om
Owner Name eAIN �� �C'I t y�y+nl, Permit Nod J�iD
n
Address
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the forth and sign bottom of form.
No Go to Question 2.
2. Does your real property have a licensed plumber certifying that,due to the age or configuration of the property or its
plumbing,installation ofwater-conserving plumbing fixtures isnot technically feasible?
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
' No Go to Question 3.
. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
El No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
Yes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign
i
bottom of form..
5. Please check ONE of the following:
My property is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014,building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water-conserving plumbing fixtures throughout the building.On or before January 1,2017,all non-
compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
My property is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
- - ->----On or before January-l;201-9,all non-compliant plumbing-€xtures shall be replaced-with-water----
conservingplumbing fixtures throughout the building(regardless of whether property undergoes alterations or -
improvements).
❑ My property is a commercial real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building(regardless of whether property undergoes alterations or improvements).
I,as the owner or owner's agent of this property,certify under penalty of perjury that non-compliant plumbing fixtures will be
replaced prior to date specified above with water-conserving plumbing fixtures in accordance with Civil Code Sections 1101.1
through 1101.8,the current California Plumbing Code and California Green Building Standards Code,and manufacturer's
installation requirements,and that the water-conserving plumbing fixtures comply with the requirements as in in the
table on the fbllowinS page.
Owner or Owner Agent's Signature; Dafe: loll 906
Upon completing and signing this Certificate,please return it to the Building Division in order to final your building permit.
SB4072015.doe revised 08126/15