B-2016-2028 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2028
18870 PENDERGAST AVE CUPERTINO,CA 95014-3621(375 33 045) DEMPSTER
PLUMBING
SAN JOSE,CA 95110
OWNER'S NAME: CARROLL BARBARA C DATE ISSUED:05/25/2016
OWNER'S PHONE:408-591-1084 PHONE NO:(408)597-5877
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC=36 Lic.#881509
Contractor DEMPSTER PLUMBING Date 07/31/2016 X BLDG —ELECT X PLUMB
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:
REPLACE GAS LINE
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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.
bF z. 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:$2500.00
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 PN Number: Occupancy Type:
375
and state laws relating to building construction,and hereby authorize 375 33 045
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 applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAS CA LE SPECTION.
Date 5/25/2016 Issued b Alex Vallelunea /
Signature- Y�
Date:05/25/2016
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. I,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:5/25/2016
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
Health&Safety Code,Section 25532(a)should I store or handle hazardous
a. 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 material. Additionally,should I use equipment or devices which 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 Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall �,
be deemed revoked. Owner or authorized agent." \ \
APPLICANT CERTIFICATION Date:5/25/2016
1 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 agency for 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
I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 5/2512016 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(o�cuDertino.org t
CUP�RTINO S - 2,UI
PLUMBING ❑MECH.ANIC.AL ❑ELECTRICAL ❑huscFLLAINTOUS
PROJECT ADDRESS PN A # "15 3
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OWNS NAME
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STREET ADDRESS CITY,STATE,ZIP/ FAX
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STREET ADDRESS CITY,STATE, ZIP FAX
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El OwNiR ❑ OwNER•BUIIDER ❑ OR?SERAGENr_� CON7KkCTOR ❑CONTRACTORAGEI.T E) ARCHITECT 11 ENGA'EER 11DEVELOPER ElTENA'<T
CONTRgCTONAME LICENSE NL AIDER LICENSE TYPE BUS.LIC
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STREET ADDRESS CITY,STATE,ZIP _ PHONE
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ARCHITECTENGNEER NAME LICENSE NUMBER BUS.LIC r
COMPANY NAME E-114a11. Fax
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMULY PROJECT IN WI DLAND ❑ 1's PROJECT IN ❑YES IS THE BLDG AN ❑ YES
B1JIlDA'G: ❑CO1,=c1.aL URBAN INTERFACF AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF NVORK
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TOTAL VALUATION:� Z SOS ItECEI\EDB }
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prop. y own'eils behalf. read 's
application and the information 1 have provided is collect.I have read the Description of'Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatinn�e�to building construc' n. I zuthorize representatives of Cupertino to enter thea ve-identified property for inspection purposes.
SignatureofApplicanUAgent:� —\�C�ea i Date:
SUPPLEMENTAL INFORA4ATION REQUIRED
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COMMUNITY DEVELOPMENT DEPARTMENT►BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO,CA 95014-3255
(408)777-3228* FAX•(408)777-3333►building(o)cupertino.or4
76 � 4e, -
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.
GE ERA-L I POI MATION
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
$10001.001 CRC Section 8314 and CIBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AIUA SMOKE AAIi,AItM Ca ALAl�1V,l
Outside of each separate sleeping area in the immediate vicinity of the X X
bedroom:s
�s)
On every level of a dwelling unit including basements X X
Within each sleeping in; room
Carbon Mionoxide alarms-are not required m dwellings which do itot contain fuel-burning appliances and that
do nat leave an attached garage. Carbon monoxide alarms-combined with smoke alarms shall coinply with
CDC Secttoaa 420.6 and shall be approved by the Office of the State Fire Marshal.
I''ovaer Supply:Tn dwelluzg,units with zo cornmercral power supply, alarms)inay be solely battery oerated.
In existing:dwelling units; alarms are permitted to b-e- solely battery operated where repairs or alteratio;ls do
not result iii the removalof walk and ceiliitig finishes or there is no:access by means of attic; asernent ox crawl
space,.Refer to,CRC Sections 83,14 and CBC Sections 901.2.11.4 and 420.6.2.Ail.electrical permit is required for
alarms w1aicht must be connected to the building wiring..
As owner of the above-referenced property,l hereby certify that the alarin(s)referenced alcove has/have Been,.
installed in accordance with the ir=on} facturer s instructions and iii compliance with the California Bu l'duzg
and Cahfonlifa.Residential Codes.The alarms have been tested and are operational, as of the date sig ed
below.
I?have read and agree:ree to com .1,;,with the terms and conditions of this statament
Sitnattire > ......... ...............
......... Date
WATER-CONSERVING PLUMBING FIXTURES FJ ' IE,
OWNER CERTIFICATE OF COMPLIANCEP0551'513161 ,
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTI 4 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777- 228•FAX(4 8)777-3333•building(c_cupertino.org„
"Oiv�er N�►zne� I Yerril7t No. �_
CA:dc`iess
1. Is your real property a registered historical site?
0El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
1 XNo 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 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.
id No Go to Question 3.
3. Is water service permanently disconnected for your building?
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
0 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.
ElYes 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:
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 improvements).
n
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 indicated in the
table on the following page.
Owner or Owner Agent'sSignatu're: c9 ,
Upon completing and signing this Certificate,please return it to the Building Division in order to final your building permit.
SB40 7 2015.doe revised 08126/15