14080237CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19721 BDMY DR CONTRACTOR: NELSON PLUMBING PERMIT NO: 14080237
OWNER'S NAME: TAMBLYN COLIN D AND VIRGINIA T 2071 MAIN ST DATE ISSUED: 08/25/2014
OWNER'S PHONE: 4082532278 SANTA CLARA, CA 95050 PHONE NO: (408)280 -5311
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
COPPER REPIPE, REMOVE AND REPLACE WATER
License Class C Lid. # (� �(l/ HEATER
Contractor Date
I hereby affirm that I am licensed under he 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 bf 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
performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $13000
1 have and will maintain Worker's Compensation Insurance, as provided for by
ection 3700 of the Labor Code, for the performance of the work for which this APN Number: 36909046.00 Occupancy Type:
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 WIT 180 DA PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save 180 DA S F LAST CALLED INSP CT N.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and exp s which may a e against said City in consequence of the
granting of is p rmit. Additi lly, the applicant understands and will comply Issued by: Date:
with all n -poin source reg ions per the Cupertino Municipal Code, Section
9 18.
�5_1c� any roofing Si ature Date 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.
❑ OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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)
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 equipme t or d ices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by t ay Are it lity Management District I
performance of the work for which this permit is issued. will maintain compliance wit a uperti M i pal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, ctio 25505 55 , nd 25534.
Section 3700 of the Labor Code, for the performance of the work for which this S —
permit is issued. Owner or authorized a nt: Date:
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 CONSTRUCTION LENDING AGENCY
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
GE NEPA- L PERMIT zPPLIGATIO N MEP
COMMUNI T" DEVELOPMEN T DEPARTMEN''T • BUILDING DIVISION'
10300 TORRE AVENUE • CUPERTINO, CA °5014 -3255
( —:08) 777 -3228 • r ?Y. ;408) 777 -3333 • buildinal�cuDe r)o,Dra �11 A
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IE4�? i�isc�ap_201_7.doc r<vised 06121111
FM--7 CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: ,19721 bixby dr
DATE: 08/25/2014
REVIEWED BY: Mendez
A
BP #:
*VALUATION:
1$13,000
rPERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 RPR
PERMIT TYPE:
WORK
co er re i 'e remove and replace water heater
SCOPE
PME Plan Check:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees! are based on the nreliminary information available and are only an estimate Contact the DeDt for addn'l info.
FEE ITEMS (Fee Resolution 11 -053 Eft. 711113)
k' i ;. Plan f: he(,-k
Plumb. Plan Check 0.0 hrs $0.00
f CC % 1' v? Check
Pe,,;rrd Fee..
Plumb. Permit Fee: IPPERMIT
Tb2'c t't«rarfr i�
cJr7re= Inv)
Other Plumb Insp. 0.0 hrs $48.00
Numb, Iusp. F(,e:
I. %CC. li 4p>, Fec_
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees! are based on the nreliminary information available and are only an estimate Contact the DeDt for addn'l info.
FEE ITEMS (Fee Resolution 11 -053 Eft. 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
0 #
$14.00
Plumbing
IPRREPIPE I Re -Pipe Interior
Suppl. PC Fee: E) Reg. C) OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
= #
$29.00
Plumbing
IPRWHEATR Water Heater
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q
OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$48.00
(",onsov,icfion T�1_11'.' 1 _T_r
Administrative Fee:
IADMIN
$45.00
Q
E)
Work Without Permit? ® Yes 0 No
$0.00
Advanced Planning Fee:
$0.00
Select a Non - Residential
Building or Structure
G
i
Travel Documentation Fee: ITRAVDOC
$48.00
Strom; Motion Fee:
IBSEISMICR
$1.69
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
t�5 "
$143.69
$43.00
TOTAL FEE:
$186.69
Revised: 07/10/2014
SMOKE / CARBON MONOXIDE ALARMS '
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEVELOPMENT DEPARTMENT • BUILDING DIVISION
1- I 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
CUPERTINO
(408) 777 -3228 •FAX (408) 777 -3333 • buildingCa.cupertino.org
hPermit No.
Address t7 7 j `� �% N # of Alarms Smoke: Carbon Monoxide:
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:
AREA
SMOKE ALARM
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On ever level of a dwelling unit including basements
X
X
Within each slee in 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.
d r e to com 1 with the terms and conditions of this statement
Iu ava tca�
an a e
Owner (or Owner Agent's) Name:
L
Signature.... Date: ..^ ..�. . .
Coontractor Name:
,w //
Y S
Date: ...:�1..:I.....
Lic.%i.
Wf.Si nat
.... 42-:;�=z
Smoke and CO form.doc revised 03118114