B-2016-1385 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1385
1469 POPPY WAY CUPERTINO,CA 95014-5316(366 15 024) OWNER/BUILDER
OWNER'S NAME: MALESKI GREGORY J AND JOAN M TRUSTEE DATE ISSUED:02/17/2016
OWNER'S PHONE:408-255-0597 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.# X BLDG _ELECT X PLUMB
Contractor OWNER/BUILDER Date —
I hereby affirm that I am licensedMECH X RESIDENTIAL—COMMERCIAL
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(E)SEWER LINE&INSTALL BOTH FOUNDATION&
I hereby affirm under penalty of perjury one of the following two declarations: PROPERTY LINE CLEANOUT VA € �
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. F° $ !
z. I have and will maintain Worker's Compensation Insurance,as provided for r ��`,.
of the work for which '
by Section 3700 of the Labor Code,for the performance
this permit is issued. Sq.Ft Floor Area: Valuation:$5000.00
APPLICANT CERTIFICATION
1 certify that 1 have read this application and state that the above APN Number: Occupancy Type:
information is correct.I agree to comply with all city and county 366 15 024
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,costs,and PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will
comply with all non-point source regulations per the Cupertino Municipal 180 DAYS FROM LAS PECTION.
Code,Section 9.18.
Issued by: ELIS AN
Signature Date Date: 7- 117
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the 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
t following.,,two reasons: inspection,
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
r sale(Sec.7044,Business&Professions Code) Signature of Applicant:
z.t I,as owner of the property,am exclusively contracting with licensed Date:
contractors to construct the project(See.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1, /,,1 have and will maintain a Certificate of Consent to self-insure for Worker's
mpensation,as provided forby Section 3700 ofthe Labor Code forthe HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued I have read the hazardous materials requirements under Chapter 6.95 of the
z. I have and will maintain Worker's Compensation Insurance,as provided for California Health&Safety Code,Sections 25505,25533,and 25534. I will
q by Section 3700 of the Labor Code,for the performance of the work for which maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safety Code,Section 25532(x)should I store or handle hazardous
this permit is issued. material. Additionally,should I use equipment or devices which emit hazardous
a.C%I certify that in the performance of the work for which this permit is issued,I air contaminants as defined by the Bay Area Air Quality Management District I
all not employ any person in any manner so as to become subject to the will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
�orker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 25505,25533,and 25534.
exemption,I become subject to the Worker's Compensation provisions of the ~
Labor Code,I must forthwith comply with such provisions or this permit shall Owner or aut orized agent:% n
be deemedrevolted. Date
APPLICANT CERTIFICATION /ONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
I'certify that I have read this application and state that the above information is of work's for which this permit is issued{Sec.lending
Civ C.)
correct.i agree to comply with all city and county ordinances and state laws Lender's Name
relating to building construction,and hereby authorize representatives of this city
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Address
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally,the applicant I understand my plans shall be used as public records.
understands and will comply with all non-point source regulations per the
Cupertino Municipal Code,Section 9.18.
Licensed
f2 Professional
Signature ��` Ana—&—Dates'
i
GENERAL PERMIT APPLICATION MEP
'
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228 FAX(408)777-3333•buildinaCaoupertino.ora misc
CUPERTINO _ Zo �6
MLUMBING ❑MECHANICAL ❑ELECTRICAL, �7 ❑/MISCELLANEOUS
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STREET ADDR // CI Y,STATE,ZI �� FAX /
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❑OwNER OWNER BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑2 TENANT
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CONTRACTOR NAME CENSE NUMBER LICENSE TYPE BUS.LIC#
G�.1!?Prr �(�r
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCFIITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMILYPROJECT IN,)ILDIA ND ❑ YES TPROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA El NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DIJSCRIPTIONcOF WO /
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TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the property o e uthorized agent to act s behalf. I have read this
application and the infonnation I have Prov d is correct. I have read the De cription of Work and verify it is accurate. e to c ITI all applicable local
ordinances and state laws relating to build* a c tion: orize re enta'res of Cupertino to enter thea e pr perry for inspection purposes.
Signature of Applicant/Agent: Date:
S PPLEME AL INFORMATION REQUIRED
'`:.,-, -,,., OP�CE:USE
flVERT3ECOLISTEB
AIEPMiscApp_2011.doc revised 06/21/11
i
1 „ OWNER-BUILDER DISCLOSURE FORM
t' COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•building ftupertino.orq —'
CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
j
improvements specified at:
sl DRESS .. ... ... - �.. .� 0 1 g -..1'3Y
O
ER NAME
oW ADDRES . -
DESCRIPTION OF WORK: Pie'
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision,signed,and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you,the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify,you understand or verify this information.)
4Bfflder"
understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. 1, as an Owner-Builder, may be held liable and subject;to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries.l am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
. 2-I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
3.1 understand as an"Owner-Builder" t am the responsible party of record on the permit. I understand that t may
protect myself from potential financial risk by hiring a licensed Con
p tractor and having the permit filed in his or her
name instead of my own.
. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. i understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
Total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an"employer" under state and federal law.
5. 1 understand if I am considered an"employer" under state and federal law, I must register with the state and
sfederal government, withhold payroll taxes, provide workers'compensation disability insurance,and contribute to
unemployment compensation for each"employee." 1 also understand my failure to abide by these laws may subject
me to serious financial risk.
I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless
o aral(of thdby
z vork
licensed subcontractors and the number of structures does not exceed four within any calendaryer o
is performed under contract with a Incensed general building Contractor.
i understand as an Owner-Builder if i sell the property for which this permit is issued, i may be held liable for
any financial or personal injuries sustained by any subsequent owners) that result from any latent construction
defects in the workmanship or materials.
Du,nerBuilderForm 2010.doc revised 0"/1 /10
understand I may obtain more information regarding my obligations as an employer from the Internal
Revenue Service,the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of industrial Accidents. I also understand I may contact the California Contractors' State
License Board(CSLB)at 1-800-321-CSLB (2752) or wvrw.csib.ca.gov for more information about licensed
contractors.
I am_ aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party iegally and financially responsible for proposed construction activity at she site address listed above,
11. 1 agree that, as the party legally and financially responsiblefor this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders,as well as employers.
k2. l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information-1 have-provided on this form. Licensed contractors are regulated by-laws designed to protect.the.public. If
you contract with someone who does not have a license,the Contractors'State License Board may be unable to
assist you with any financialloss you may sustain as a.result of a complaint..-Your only remedy against unlicensed
Contractors maybe in-civil court. If is also important for,you-to understand that if an unlicensed Contractor or
employee of that individual or firm is injured.while working on your property,you may be held liable for damages. If
you will be responsible for veri in whether or note
you obtain a permit as Owner-Builder and wish to hire Contractors,y - p fy' g
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY _
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ..)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owners driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the eroperty owner's si na '
Property Owner's Signature: c Date:
-- - - ---- ------- - - --- ------- ---- ----_- --------------------------------------------------------------------
-- -
s(NOTE: The iollov✓Ing Authorization Form is required to be completed by the properly owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which l understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
(dame of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OwnerBuilderForm 2010.doc revised 04,114110
Building Department
City Of Cupertino
- 10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U P E RT1 N 0 Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
70B ADDRESS: LO
PERMIT# L3 - Z® 1 ,6 - 1 .3
OWNER'S NAME`. PHONE# 0S
GENERAL CONTRACTBUSINESS LICENSE
ADDRESS: C �eka CITY/ZIPCODE: vr'b d
*Our municipal code req u r all businesses worki g in the city to have a City of Cuper"no business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
~ignature D alto
Please check applicable subcontractors and complete the following information:
✓ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork j
Cement Finishing
Electrical
a
Excavation
- Fencing
Flooring/;Carpeting
Linoleum/Wood
Glas /Glazing
I
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
- Date
Owner/Contractor Signature
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C O P E RT 1 N 0 Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: q (,� PERMIT# 5�j
OWNER'S NAME: - PHONE# -
GENERAL CONTRACTOR./ R-kx
BUSINESS LICENSE#
ADDRESS: §4CITY/ZIPCODE:
*Our municipal code requi 11 hus6esses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
`/ SUBCONTRACTOR. BUSINESS NAME BUSINESS LICENSE#
Cabinets&Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing s2
W
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
f
O er/Contractor Signature Date
-N MONOXIDE ALARMS
OWN RCERTIFICATEOF COMPLIANCE
Ei
COMMUNITY DEVELOPMENT DEPARTMENT®BUILDING DIVISION
CUPERTIR0 10300 TORRE AVENUE®CUPERTI'NO,CA 95014-3255
(408)777-3228 o FAX(408)777-3333•buildingOcupertino.org
PFR'-kZIT CXN1NOTBF F,!Ni .l3FD ANTS COMPFFTED UITII yTMS C7-IGR'1tFICAT
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.
GPNEIIAL 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 CQ A,LAR,M
Outside of each separate:sleeping area in the immediate vicinity of the X X
bedroom(s)
On every level of a dwelling unit including basements X ?(
Within each,sleeping in room X
Carbon Monoxide alarms are not required un 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 cl welling units with no commercial power supply, alarm(s)may be solely battery operated.
Tn existing dwelling,units, alarms are permitted to be solely battery operated where repairs or alterations,do
not res alt inthe 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
a fain,•which must:be connected to the building wiring.
As owner of the above-refer.enced property,I hereby certify that the alarm(s)referenced above IZas/have been
'installed llnti a�co>rdancez with the innar►.izf acturer's imstructPon�s anclE fn coi�ipxli�ance wiith.the California B'�ilding;
and CaINIon{ua Resiidlenizal.Codes.The alarmns havebeen tested amd,are operaf onal,as of the datesignedi
bellow..
G have)read andwea to comA_U,wrtli�r tJia t'erwmsi and�.ondltiw s,of this statam,enr t
i
.m.. ..<��'� � � � � 6
.. _
r �
S:" afore ae
Smoke a,idfC'O)fbrna:do-e isei,isedIO3/1811;4
i
CATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTl O 10300 TO:RRE AVENUE•OtJPERTINO,CA.950'14-3255
� (408 777-3228•F' . 1408)777-3333®building0a WDertino.orm
Owner Name l.,'-"" 6� Permit No,
Address1
I. 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.
' ;(No 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.
El The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
At No Go to Question 3
3. Is water service permanently disconnected for your building?
13 Yes Civil Code Sections 1101.1 through.1101.8 do not apply. Skip the rest of the form and sign bottom of form.
ED-
f 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.
Yes 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, 20.19, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures,throughout the building(regardless of whether property undergoes alterations or.improvements),,.
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 tht following,page.
Owner or Owner Agent's Signature-L, #
Upon completing and signing this Certificate,p]' e return it to the Building Division in order to final your building permit.
SP407 201 S.doc revised'08/26/1 S