B-2017-1433 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1433
11840 UPLAND WAY CUPERTINO,CA 95014-5106(366 03 048) PETERSEN-DEAN INC
FREMONT,CA 94538
OWNER'S NAME: YOW JOSE RAND PEI-PEI L TRUSTEE DATE ISSUED:08/28/2017
OWNER'S PHONE:408-257-7501 PHONE NO:(510)371-6500
•
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-10:C-46 Lic.#468117
Contractor PETERSEN-DEAN INC Date 01/31/2019 X BLDG X ELECT _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:
(N)22-PANEL ROOF MOUNTED PV SYSTEM(6.49 KW);(N)SUB-
I hereby affirm under penalty of perjury one of the following two declarations: PANEL(225 AMP);(N)SUB-PANEL(60 AMP)
1. I have and will maintain a certificate of consent to self-insure for Worker's REV#1-MICRO INVERTER CHANGE-9/21/2017
pensation,as provided for by Section 3700 of the Labor Code,for the REV#2-(N)EV CHARGING STATION(40 AMPS)-GARAGE-
',
performance of the work for which this permit is issued. ISSUED 10/19/2017
. 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:$21613.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 366 03 048
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 Cityin 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 LAST CALLED INSPECTION.
Signature Date 10/19/2017 Issued by:Kim Dunbar
Date:08/28/2017
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 roofmg 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:10/19/2017
I 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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. 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. Additionallyi 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. ner or authorized agent: �f'2e2 l
APPLICANT CERTIFICATION Date:10/19/2017 '
• 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 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
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature _ • Date 10/19/2017 Professional
/ CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT •• BUILDING DIVISION . B
v 10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
- . 2OVR. 1(4b3
(408) 777-3228 • building@cupertino.org PEMIT#B- -
COPERTINO REV# 7 . DEF#
❑ NEW
�
CONSTRUCTION El ADDITION ALTERATION 111 T.I.T.I. MEP ❑RE-ROOF ❑SWIMMING POOL/SPA •
PROJECT ADDRESS.
f / 0 � � (om- 17_ )e '�4- 0"5- 0--(i
OWNER NAME fr PHONE E-MAIL
STREET ADDRESS CITY, STATE,ZIP
// g o c/'L4-2i2d J y.
CONTRACTOR NAME 0 OWNER-BUILDER COMPANY NAME • LICENSE NUMBER LICENSE TYPE
/1 .1-----4, i 6 (f7 LO ,:c
STREET ADDRESS CITY,STATE, ZIP ^ I
„.7—.2-7.---e€5 ,jtr, co U, -A-cAs? A-Ca_ c-Jo__„ c 9_4-e 3 }
E-MAIL PHONE 4 .7._ Iq ) BUS.LIC#
0 ARCHITECT ❑OWNER ❑OWNER AGENT 0 CONTRACTOR AGENT El ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
/*\) L� - a ✓y, Li e--K0-1-a-r2 �E.)2 Ste cA. c4 ...ca,6(j
STREET ADDRESS CITY,STATE,ZIP PHONE
01 .g4_7c5Qc .
DECRIPTON
7 -5-37.4-(k �Z kr' C---)/1_ R
,[]SINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY ❑INDUSTRIAL 0 COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR'SF1 PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL '.REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF ❑DETACHED
EXISING 0 YES EICHLER 0 YES SECOND STORY ADDITION ❑ ES
FIRE SPRINKLERS 0 NO' 0 NO 0
DWELLING SECOND DWELLING ❑YES 0 ATTACHED❑DETACHED OTHER
•
UNITS it UNIT ADDITON: 0 NO S F
POOLS" 0 FIBERGLASS ❑VINYL-LINED-❑GUNITE ❑PREFABRICATED
POOL-SF SPA-SF SPA ATTACHED❑YES 0 NO TOTAL-SF
RECVED BY: TOTAL VALUATION:
Commercial or Multi-Familu Buildings with Public Swimming Pools requires Department of Environmental Heath approval l( '
RE-ROOF'EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHING ES❑ E OTHER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD 01/2
" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
ygg I S OF LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER .12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF OASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF Sof SQUARES
By my signature below I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I
have read this 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 with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection purposes. I acknowledge and authorize all information contained on this application form
to be made available for public record. • y
Signature of Applicant/Agent: Date: .1 $'" 7
SUPPLEMENTAL INFORMATION QUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08/01/17
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1433
11840 UPLAND WAY CUPERTINO,CA 95014-5106(366 03 048) PETERSEN-DEAN INC
FREMONT,CA 94538
OWNER'S NAME: YOW JOSE R AND PEI-PEI L TRUSTEE DATE ISSUED:08/28/2017
OWNER'S PHONE:408-772-9272 PHONE NO:(510)371-6500
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class SHEET METAL Lic.#C-10
Contractor PETERSEN-DEAN INC Date 01/31/2019 X BLDG X ELECT _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:
(N)22-PANEL ROOF MOUNTED PV SYSTEM(6.49 KW);(N)SUB-
I herebyaffirm under penalty of perjury one of the following two declarations: PANEL(225 AMP);(N)SUB-PANEL(60 AMP)
1. I have and will maintain a certificate of consent to self-insure for Worker's REV#1-MICRO INVERTER CHANGE-9/21/2017
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
sf' 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:$21613.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 366 03 048
representatives of this city to enter uponythe 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 LAST CALLED INSPECTION.
Sias
ead ( j Date 9/21/2017 Issued by:Kim Dunbar
Date:08/28/2017
OWNER-BUILDER DECLARATION
I hereby affirm that 1'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:9/212017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. 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 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. 0,.;':,r `. 'forizedagent: < ..
APPLICANT CERTIFICATION a0 9/ 20 7
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 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
Code,Section 9.18I. I understand my plans shall be used as public records.
Licensed
Signature Date 9/21/2017 Professional
CONSTRUCTION PERMIT APPLICATION
\ ! COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO,CA 95014-3255 //// 2
.yc.,9s, (408) 777-3228 • building@cupertino.org PEMIT#B- 701 - /`7" ✓3
CUPERTINO REV# ;_Z DEF#
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS 1 APN#
//P'i/6 Qp/4nd 1.1_3-A17
OWNER N PHO E-MAIL
NAME PHONE
)/ tv 4400 :7-7 Z• 47,27.
STREET ADDRESS CITY, STATE,ZIP
/ 1 s ti-0 ,ora.- 1 t, -v- �� e ine i e, i 4 .
p CONTRACTOR NAME 0 OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
/124 ..5.-44n1m 1G �"Z' 5' nc�eA� r' SCS SI I.7G1a- `��' I
ISTREET ADDRESS CITY,STATE,ZIP
02.2.28 .....(t4, -.',74.c:. 1 X 31? 1��2`- c,4 ��l�`
E-MAIL PHONE kg BUS.LIC#
Asl. tJcls11? � � -d4 n •as,-.7 S...6--- -fy / I
0 ARCHITECT ❑OWNER OWNER AGENT WCONTRACTORAGENT❑ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL
N6Cf c fc-n-viirlQe. ..),_,4_5, ..0 deAn •c....., r-,,-)
STREET ADDRESS CITY,STATE,ZIP PHONE
L-S .1�./t�Tt o>� +i P 4n 4.kms 92- 1 3 I F S -Z' r
DECRIPTON
r�-� eIvJ�r T z � n9� ',gee'ten ..9 .-rip -AS ' rn -7Q,7.I3=S X10
•
4 FYI le,lima viz 4, - Go�z - u S C i .c,1 a) v'
❑SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY ❑INDUSTRIAL 0 COMMERCIAL I
' EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE 0 ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISING 0 YES EICHLER 0 YES SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS 0 NO 0 NO 0 NO
•
DWELLING SECOND DWELLING ❑YES 0 ATTACHED 0 DETACHED OTHER
•UNns# UNIT ADDITON: 0 NO S F
1 •
POOLS" ❑FIBERGLASS 0 VINYL-LINED ❑GUNITE 0 PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED OYES 0 NO I TOTAL-SF
- RECEI Y: / TOTAL VALUATION:
Commercial or Multi-Family Buildings:with Public Swimming Pools requires Department of Environmental Heath approval
RE-ROOF'EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NOI IF NO PLYWOOD ❑'" El3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
D YES #OF LAYERS THICKNESS❑ El OTHER OSB CDX OTHER •12 A
PROPOSED ROOF TYPE:DBUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER _
*Provide a signed copy of the Cupertino's Tear-Off Policy SF #of SQUARES
By my signature below I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I'
have read this 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 with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection p oses. I acknowledge and authorize all information contained on this application form
to be made available for public record./ ,t
Signature of Applicant/Agent: r,. I V z_______C '______C ' Date:�^ 2-1---') ' .
SUPPLEMENTAL INFORMATION REQUIRED (J
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08/01/17
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1433
11840 UPLAND WAY CUPERTINO,CA 95014-5106(366 03 048) PETERSEN-DEAN INC
FREMONT,CA 94538
OWNER'S NAME: YOW JOSE RAND PEI-PEI L TRUSTEE • DATE ISSUED:08/28/2017
OWNER'S PHONE:408-772-9272 PHONE NO:(510)371-6500
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C10 C46 Lic.#468117
Contractor PETERSEN-DEAN INC Date 01/31/2019 X BLDG X ELECT _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:
(N)22-PANEL ROOF MOUNTED PV SYSTEM(6.49 KW);(N)SUB-
I hereby affirm under penalty of perjury one of the following two declarations: PANEL(225 AMP);(N)SUB-PANEL(60 AMP)
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.
or 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:$21613.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 366 03 048
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,theapplicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur Date 08/28/2017 Issued by:Kim Dunbar
Date:08/28/2017
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:08/28/2017
I 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 Ldbor 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
s. 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 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 as
APPLICANT CERTIFICATION Date:08/28/2017
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 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
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 08/28/2017 Professional
•
} f ALTERNATIVE ENERGY PERMIT APPLICATION
x COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION Ai
gni
trs'' 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•• buildino(a cupertino.orq
CUPERTINO
6--2D1 . -) X33
PROJECT ADDRESS 1 18 VAI , A ct \.3 )r APN n 3& (0 .. 3 ._6 e
OWNER NAME /�!/�} P ONE E-I IL
J 5c -r" -�0. 1 c �� �� J®S'.e.f®iU' rn4 L cc -
STREET ADDRESS CITY, STATE,ZIP FAX
'i - ,a. ^V Cbz;
CONTACT NAME PHO t(c pG&N't!)-- 0-57-7(( E-MAILnEi n te,24->/)
STREET ADDRESS CITL STATE,ZIP FAX
❑ OWNER 0 OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT '
CONTRACTOR NAME' • LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMP MAIL dL / FAX '
� � ),\a r rsc,Pr.,ic,(,�l-44 Q-�c� 5eAd • co Ell
STREET ADDRESS '' CITY,ST TE,ZIP P 0
,,)c.116371t' zoc) . Y ri �o G- -9�1g) a ,56-vf--74cj !.
ARCHITECT/ENGINEER NAME LICENSENUMB4 } BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
' USE OF 0 SFD or Duplex 0 Multi-Family .PROJECT IN WJLDLAND PROJECT IN
STRUCTURE: ❑ Commercial URBAN LNTERFACE AREA 0 Yes 0 No .FLOOD ZONE 0' Yes ❑ No
0 SOLAR PANELS 0 ELECTRIC VEHICLE CHARGING STATION 0 SOLAR WATER HEATING ❑ OTHER:
FOR SOLAR PANELS: NUMBER OF PANELS/UNITS: • KILOWATTS(COMMERCIAL ONLY): TOTAL VAL ATION:
DESCRIPTION OF WORK . .,
' 1 it--LP a) 3 5, 'tel c Z_ - ti ,
t22` 'V k2 I n.Vei t �_-.,2., . - -a_ - (l: I
L -44
6o A- tkc G'Q, ,e,,..)p n ..q,‹.
Yom: �,s f.�� ��'+Y.r:.5.... ,.
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's beha f. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I armee to comply with all applicable local
ordinances and state laws,relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for,inspection purposes.
Signature of Applicant/Agent: Date:1 _2, t
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PVApp_2011.doc revised 03/16/11
,f SMOKE / CARBON MONOXIDE ALARMS
. t OWNER CERTIFICATE OF COMPLIANCE
4 ` _• COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
uQER No 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•building(o cuoertino.orq
, .> 0 1 C N1 JO,V.ONiA 1ED:UN L*T-.$
. MPEETE1 S-OWNAND RETU TEI 'O 8 G DIVISIO
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms
for compliance with 2016 CRC Section R314,2016 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
S1000 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 X X
the bedroom(s)
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 1
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 907.2.114 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 specified below have been tested and are operational, as of the
date signed below
Address l i 9'1/ ' Li lCnz, vl.„. 11T
c 0Permit 0. Q 2p1 "7-
'
Specify Number of Alarms: #Smoke Alanns NMI #Carbon Monoxide Detectors.
I have read and agree to comp1i the a :conditions of this statement
Owner(or Owner Agent's),Name: c�
�0 Signature Date: t/
r7Contractor Name:
Signature Lic.# Date:
Smoke and CO fonfa.doc revised 12/15/16