B-2017-1449 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1449
10558 CULBERTSON DR CUPERTINO;CA 95014-3556(375 34 038) WATER HEATERS
ONLY INC
GRASS VALLEY,CA '
' 95945
OWNER'S NAME: SCHMIDT ENO A AND LILLIAN Y TRUSTEE DATE ISSUED:08/30/2017 •
OWNER'S PHONE:408-838-9133PHONE NO:(800)835-8345
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#374573 X BLDG _ELECT X PLUMB
Contractor WATER HEATERS ONLY INC'Date 05/3. 1/2019
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 50 GAL WATER HEATER(SAME LOCATION)
I hereby affirm unde penalty of perjury one of the following two declarations:
L I have.•.will maintain a certificate of consent to self-insure for Worker's
Co ,.ensation,as provided for by Section 3700 of the Labor Code,for the ,
, .., t; formance of the work for which this permit is issued.
4,(0 have and will maintain Worker's Compensation Insurance,as provided for by
'y,p Section 3700 of the Labor Code,for the performance of the work for which this
` permit is issued. Sq.Ft Floor Area: Valuation:$1900.00
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 375 34 038
representatives of this city to'enter'pon"the above mentioned property for
inspection purposes. (We)agree,to save indemnify and keep,harmless the
City of Cupertino against liabilities,judgments,costs . d expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City inconsequence o e granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands an. ,,i I comply with all non-point
source ulations.er the Cupertino t,"rnicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
/4410
Signa'ure I Date 08/30/2017 Issued by:Kim Dunbar
? I Date:08/30/2017
OWNER-BUILDER DECLARATION
I hereby affirm that ll'am exempt from the Contractor's License Law for one of the RE-ROOFS: '
following two reason's: , All roofs shall be inspected prior to any roofing material being installed.If a roof is
t. 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 constructithe project(Sec.7044,Business&Professions Code). Date:08/30/2017
I hereby affirm under penalty of!perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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 wlich this permit is issued: HAZARDOUS MATERIALS DISCLOSURE
2. I have and Twill 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 isued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. 1 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
material. Additionally,should I use equipment or devices which emit h..: dous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Manage r'_t District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Co i"', hapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Se lio 25505,2_. ,and 25534.
Labor Code;I must forthwith comply with such provisions or this permit shall
be deemedlrevoked.'
• Owner or authorized age ' /O
APPLICANT CERTIFICATION Date:08/30/2017
I certify that I have read this application and state that the above information is CONS UCTION 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 mentiohed property for inspection purposes. (We)agree Lender's Name '
to save indemnify and'keep harmless the City of Cupertino against liabilities,
judgments,costs,andexpenses which may accrue against said City in Lender's Address
consequence of the granting,of!this permit. Additionally,the applicant understands
and will comply withlall 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 08/30/2017 Professional
•
GENERAL PERMIT APPLICATION
COMMUNITY.DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
MISC
(408)777-3228• FAX(408)777-3333• buildino a(�cuoertino.orq
CUPERTINO.
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PLUMBING ❑MECHANICAL ❑ELECTRICAL �/ ❑MISCELLANEOUS
or
PROJECT ADDRESS l0 s_�s /J / o1 Ar. AP"n 3 1�-- 2 ci -03
F1 Z O
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OWNER NAME ni k s 84 `4 PHONE [ ar f r f38.173
3 E L
STREET ADDRESS /0g� % e /h -_ f ilk CITY,ST E7� y kpoe'
CONTACT NAME l `(//'J•�I7�(/�l 1�1115� f !7�
•
/ LL_/C� .L�i!/ PH•f `� r0 9' r ' 4I Ada
a ��IL C5���Gelec
STREET.4DDRE '!'(/gl AAA 1 C, ::STATE,.ZIP , Yr&o� F.
ED OWNER 0 OWNER-BUILDER ,`❑ OWNNERAGENT 0 CONTRACTOR
TRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT .
CONTRACTOR NAMLttifieettasE 6( LICENSE NUMBERS•�7/5qS J LICENSE TYPE& 6, BB1S
J r V (1f
COMPANYN,S]e4E E-MAIL � FAX
Ma_ "kf x CITY 4T ,ZI / J co
ARCHITECT/ENGLNEER NAME LICE'SE NUMBER BUS LIC
COMPANY NAME E-MAIL
FALX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF P DUPLEX ❑ MULTI-FAMILY PROJECT IIA WILDLAND 0 YES PROJECT IN 0 YES IS THE BLDG AN 0 YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE 0 NO EIdILERHOME? 0 NO
DESCRIPTION OF WORK l' —\ ?q--( )C
C14 / , •
•(TOTAL VALUATION: Ci RECEI
By my signature below;I certify'to each of the following: I am •-property owner or authorized agent to act on e property owner's behalf. I have read this
,'application and the information I have provided is correct. .•.ve read the Description of Work and verify it is accurate. I agree to comply with all applicable local
'ordinances and state laws relatins to b,.d',2c nstructi.,-.I authorize representatives of Cupertino to enter the above-iden' ed pro, rty for inspection purposes.
Signature of Applicant'Agent: yj - Date: ! Se
SUPPLEMENTAL INFORMATION REQUIRED inatinaAaVi'eatiliagin
roi.iiviiviAmniqgv.161205
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A7EPMiscApp_2011.doc revised 06/21/11
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SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinci cupertino.orq
, y
PERMIT CANNOT BE +INALEDUNTIL THIS CERTIFICATE HAS°BEEN 4
� �
tL CO.r tlikEEA,&SIGNED, D RETURNED TO'I E BUILDINGpIVISION"4 tt
IA
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
$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 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
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 specified below have been tested and are operational, as of the
date signed below.
Address: 10Fc5 eul ke.4-rot C�01'AI e �f er�'�y�e (Soli{ Permit No. re-1014ric{y lq
Specify Number of Alarms: #Smoke Alarms: #Carbon Monoxide Detectors: 7—
have
have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name:
Signature Date: Ca�3�zoctiillatc—
l�–
Contractor Name:
Signature Lic.# Date:
Smoke and CO form.doc revised 12/15/16