14060162CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6149 SHADYGROVE DR
CONTRACTOR: BAYSHORE PLUMBERS
PERMIT NO: 14060162
OWNER'S NAME: O LEARY FREDERICK A JR AND BAR
PO BOX 2579
DATE ISSUED: 06/25/2014
OWNER'S PHONE: 4089963101
MENLO PARK, CA 94025
PHONE NO: (650) 323 -6464
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
LICENSED CONTRACTOR'S DECLARATION
REPLACE 20' OF MAIN WATER LINE FROM FOUNDATION
License Class Lic. 0 qu a e g o
WALL TO METER IN V COPPER
Contractor
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:
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
I rformance of the work for which this permit is issued.
Sq. Ft Floor Area:
Valuation: $1300
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 37540013 00
Occupancy Type:
ection 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
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 D IT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
DA O ALLED INSPECTION.
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
City in consequence of the
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costs, and expenses which may accrue against said
Issu Da e:
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. t� e�{�
�vl Pill % 26 ) `f
- ROOFS:
is
Signature Date
All roofs shall be inspected prior to any roofing material being installed. If a roof
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER- BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self - insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Cod $, for the
air contaminants as defined by the Bay Area Air Quality Management District I
of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
performance
I have Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
and will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
r
Owner or authorized agent: Date
permit is issued.
2-0
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
CONSTRUCTION LENDING AGENCY
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
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9 18.
Signature Date
GENERAL PERT APPLICATION Q\ MEP
.' "aFu COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 90014 -3255 O
(408) 777 -3228 • FAX (408) 777 -3333 buildino(a cuDerino.ora M I
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PPOIF=DIVILDLAND ❑ YES I PROTECTA ❑ YES
JJRBAN IN =1 ACE AREA ❑ 1"0 FLOOD ZONE ❑ NO
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By my signature below, I certify to each of the follo',ving: I am the property ovmer or authorized a-aent to act on tl;e property ovmer's behalf. I have read thds
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 vrith all applicable local
ordinances and state la-,vs relating to b am onsuuc ' . I authorize representatives ofCuptrtino to enter the above identifieedd property �� T for inspection purposes.
S i--nature of: _pplican /Aeent: Date: (� Ke, l/�r
S7UPPFh�NITAI LNTFORMATION RE Q TJ=D
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2viEP)jisa,ipp_2011.doc revised 06 121111
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CITY OF CUPERTINO
FW- A-W 1PIP.V 1RqT1MATnR — RITILDING DIVISION
10 ADDRESS: 6149 SHADYGROVE DR
Plumb. Plan Check 0.0 1 hrs $0.00
TDATE: 0612512014
REVIEWED BY: MELISSA
APN: 375 40 013
1 BP#:
0,h A
*VALUATION: 1$1,300
'A PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
I
$0.00
PENTAMATION 1 RPWS
I PERMIT TYPE: 19
WORK
REPLACE 20' OF MAIN WATER LINE FROM FOUNDATION WALL TO METER IN 1" COPPER
SCOPE
F
AT"T17• Thh actimato dnp.v not im-lude f.-..--,v due to other Denartments (i.e. Planninz, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept-for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711113)
Plumb. Plan Check 0.0 1 hrs $0.00
J� lec, Plan C! e(A,
We,;,h PefwO Fee:
Plumb. Permit Fee: IPPERMIT
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Other Plumb Insp. � �hrs �$47.0�O
ED
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11"Undl, Fee:
PME Plan Check:
AT"T17• Thh actimato dnp.v not im-lude f.-..--,v due to other Denartments (i.e. Planninz, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept-for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fl, e:
1"ce
PME Plan Check:
$0.00
Permit
F
PME Unit Fee:
$24.00
PME Permit Fee:
$47.00
Administrative Fee: ]ADMIN
$44.00
Work Without Permit? 0 Yes (E) No
$0.00
Travel Documentation Fee: ITR,4VDOC
$47.00
Stroh Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
TOTAL FIE -t $163.50
$163.501 $0.00 E]
Revised: 04/01/2014
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SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
CU'PERiiNO 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • building aOcuoertino.org
Address
Permit No. 1V 0(P 0/?—
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 907.2.11.2 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 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:
,rwn S
AREA
SMOKE ALARM
CO ALARM,
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On every level of a dwelling unit including basements
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 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 have been tested and are operational, as of the date signed
below.
I have read and agree to com °/v with the terms and conditions of this statement
Owner (or Owner Agent's) Name:
F
Signature ............. ..... .. ...... ..... .....:............ ............. ............................... Date:...................
Contractor Name:
AAcUT i kJ b-6 94
Signature ... A.�'r.hI..i.o ... ......(.15.5 ........ L(c.4 .0k.7 3 W........... Date: ... ....3.: L
Smoke and CO form.doc revised 03118114
02