15110071n
41
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21386 AMULET DR
CONTRACTOR: ALLSTAR PLUMBING PERMIT NO: 15110071
OWNER'S NAME:: ZIMMERMAN ALVIN K AND ARLENE S
326 PHELAN AVE DATE ISSUED: 11/12/2015
PHONE:: 4087397094
SAN JOSE, CA 95122 PHONE NO: (408) 230-5569
prOWNER'S
N❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL
REPLACE WATER HEATER, SAME LOCATION
License Class - 4 Lic. #1
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
Sq. Ft Floor Area:
Valuation: $2574
performance of the work for which this permit is issued.
ave and.will maintain Worker's Compensation Insurance, as provided for by
Section 3760 -of the Labor Code, for the performance of the work for which this
APN Number: 32643017.00
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
WITHIN 180 DAYS OF 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 D YS FROM LAST CALLED INSPECTI N.
indemnify and keep;harmless the City of Cupertino against liabilities, judgments,
costs,'and expenses which may,accrue against said City in consequence of the
�10 Q� ]A n f
OLO
granting of!this permit. Additionally, the applicant understands and will comply
Issued by: Date: VI "L a J \
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature4 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.
❑ !I',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
I, as owner 'of the,propertyof 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 &c 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. I 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: ;;.,; ! ;. c
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 Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work'for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 ,of the. Labor. Code, -for the performance of the work for which this
Owner or authorized agent: Date:
permit is issued.;
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 Califomia. 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
l ` ' . li
forthwitli';comply'witli`such provisions or this permit shall be deemed revoked.
work's for which this permit is issued Sec. 3097, Civ C.
P ( )
Lender's Name
Lender's Address
111y,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,
ARCHITECT'S DECLARATION
costs, and expensi s which' may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permii: Additionally; the applicant understands and will comply
with all,nori-po,intsou(ce•,I.regulat ons per the Cupertino Municipal Code, Section
Licensed Professional
9 18 �,
Signature!; ,P,ri���.`. ,�, `a;'., Date
CUPERTIt-40
GENERAL PERMIT APPLICATION [S)100:�-(
COMItUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • build! no POUDerilno.Orq
Rhin BnNG ❑1✓iECI?kNICAL FELECTRiCAI. nh,ISCELLANrEOT!R
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PROYECT IN WTI DLA -NTD ❑Y� PROTrCT IN ❑
IS 7 -HE BLDG AN ❑ Y! S
BULTGL�G: ❑COAR.T?CLAL
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TOTAL VALUATION: rJ
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By my signztu-e below, I certify to each of the following:
I zu the grope oN; ner or authorized agent to act on the grope. Ly owner's behalf. I have read this
application and the information I have provided is correct.
I have read the Description of Work and veriffy it is accurate. I agree to comply with all applicable local
ordinances aad state laws :elating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Si a ure of A,pplicaa /Agent:�244
Date:
SUPPLEME�AI.
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AIFPA!-scApp_ 011.doc revised 06121/11
CITY OF CUPERTINO 157i 10()?-[
9F -17M FEE ESTIMATOR —BUILDING DIVISION
imADDRESS: 21386 Amulet Dr
FEE ID
DATE: 11/12/2015
REVIEWED BY: PAUL
APN: 326 43 017
BP#:
*VALUATION: 1$2,574
*PERMIT TYPE: Minor Building Permit
PLAN CHECK TYPE: Water Heater
PRIMARY SFD or Duplex
USE:
PENTAMATION PRWHEATR
I PERMIT TYPE:
WORK
Replace Water Heater, Same Location
$29
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
MISC ITEMS
QTY
BP FEES
Water Heater/Vent Unit Fee:
1 PRWHEATR
1
permit Pee:
$29
PME Unit Fee:
$29.00
PME Permit Fee:
$48.00
- "onsh-liction
A(1rn1hfivra(;Ve Fee:
Work Without Permit? 0 Yes (E) No
$0.00
Travel Documentation Fee: I TR4 VD 0 C
$48.00
Str Mbfionf`ee:
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
TO
,SUB TAL
$126. 001
so .00 FE
TE
$126.00
-1,1ech. Plan €'�-heck Plu,,nb. P,,`a;,, ""Aie'ii
�Iech. peiwiiz f'ee: Plumb. Permit Fee: IPPERMIT
—L� 0
Lj $48-000' L ................... ; ............ I
,U,cch. Insi;, Fe'..':
lec. Fee:
VOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
,uistrict,etc.). inese-tees are toasea on the preliminary information available ana are only an estimate (,onractt1;eUept_joraaan-1 info.
FEE ITEMS (FeeResolution .1.1-053.L,ff.'-7111113J
FEE
QTY/FEE
MISC ITEMS
111-yV, N, T fiyee
permit Pee:
PME Unit Fee:
$29.00
PME Permit Fee:
$48.00
- "onsh-liction
A(1rn1hfivra(;Ve Fee:
Work Without Permit? 0 Yes (E) No
$0.00
Travel Documentation Fee: I TR4 VD 0 C
$48.00
Str Mbfionf`ee:
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
TO
,SUB TAL
$126. 001
so .00 FE
TE
$126.00
Revised: 10/01/2015
ECUPE RTINO
PURPOSE
COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION
10300 TORRE AVENUE e CUPERTINO, CA 95014-3255
(408) 777-3228 o FAX (408) 777-3333 o building(alcupertino.om
HLE
1 i iMti
PERMIT CANNOT DE FINA&QED AND COMPLETED UNTH, THIS CERTIFICATE
11ASBEEN S F' AND RE jB, Nry p( y/yp 1 p/ry Y�(TQr�iy yT:0 {e -,try
BE:E _ 4F r1L V A YAYJ :� U.1 LI) �.S T JLU,Y't/1 V
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.
GENERA, 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 includingbasements
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.
l have read and agree to comply with the terms and conditions of this statement
.arrerRgen€'teltarr�e
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Si-15af�ire. (��"
Co'Fifracto��Narne:
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Sigiaf(ire. .Lick .................................... Da'� ..
Smoke and CO forimdoc revised 03118/14
WATER-CONSERViNG PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE FILE
COMMUNITY DEVELOPMENT DEPARTMENT n BUILDING DIVISION 0 - l - 1S
� dJs
CUPIERTINO 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(40$) 77Z-!-3228 FAX (408) 777=3333 _building(o7cupertino.org
Owner Name A,, l 1 111 Permit No.
Address �� l �`�il; 1 i G1 } (, i �.� - [� r �1 .7 1, �_.
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 form and sign bottom of form.
[D`I�o Go to Question 2.
2. Does your real properly have a licensed plumber certifying that, due to the age or configuration of the property or its
plumbing, installation of water -conserving plumbing fixtures is not technically feasible?
❑ 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.
0 No Go to Question 3.
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.
jJ 5J/No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ 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.
[u` es 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
bottom of form..
5. Please check ONE of the following:
$� FV( 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 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).
❑ 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 nmproverments).
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 11.01.8, 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 indicated in the
table on the following pane. lit . __ 1 I.=
Owner or Owner Agent's Signature ),�'1,"i; �I��d ` . �ti�'12 �i1�� 0� 7 Date!_'
_J1 /
Upon completing and signing this Certificate, pled✓return it to the Building Division in order to final your building permit.
SB4071015.doe revised 08/16/15