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B-2016-1438
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1438 1191 STAFFORD DR CUPERTINO,CA 95014-4951(362 11 026) (A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC) MEMPHIS,TN 38120 OWNER'S NAME: LOMMILLER KATHERINE A TRUSTEE DATE ISSUED:02/26/2016 OWNER'S PHONE:408-257-4232 PHONE NO:408-982-0425 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: Chi&d-c.fZ/-* License Class Lic.#2 -1(,3-1 S S- Contractor(A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA X BLDG —ELECT X PLUMB IN Date 2 � _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 JOB DESCRIPTION: license is in full force and effect. INSTALL(1)BLDG CLEANOUT. I hereby affirm under penalty of perjury one of the following two declarations: 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. Az. 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 Sq.Ft Floor Area: Valuation:$2870.00 this permit is issued. APPLICANT CERTIFICATION I certify that I 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 362 11 026 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 PERMIT EXPIRES IF WORK IS NOT.STARTED harmless the City of Cupertino against liabilities,judgments,costs,and WITHIN 180 DAYS OF PERMIT ISSUANCE OR expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will 180 DAYS FROM LAST CALLED INSPECTION. comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by:Phuong Devt7es Signature Date Z/2 Date: \ RE-ROOFS: OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of the installed without first obtaining an inspection,I agree to remove all new materials for following two reasons: inspection. 1. 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 Signature of Applicant: for sale(Sec.7044,Business&Professions Code) Date: 2. I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: 1. I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued.. California Health&Safety Code,Sections 25505,25533,and 25534. I will 2. I have and will maintain Worker's Compensation Insurance,as provided for maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the by Section 3700 of the Labor Code,for the performance of the work for which Health&Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous this permit is issued, air contaminants as defined by the Bay Area Air Quality Management District I 3. 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 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 25505,25533,and 25534. Worker's Compensation laws of California. If,after making this certificate of 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 authorized agent "( Date:2 r12� be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION 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.3097,Civ C.) correct.1 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 ARCHITE T'S DECLARATION I understand my plans shall be used as public records. consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228• FAX(408)777-3333•building(-cupertino.org CLiPERTINQ MISC 2 LUN4BING ❑MECHANICAL [:]ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS Y .� l � �� APN# ✓ u C7i� Q�1.7 OWNER NAME +� P E-MAIL STREETADDRESS CITY, STAT ZIP FA7i CONTACT NAME Q rgsc,", P 9 [/� � A E-MAIL STREET ADDRESS 2�i�S Pin CITY,STATE,ZI 0-4 'TVJ FAX El OWNER ❑ OWNER-BUILDER ❑ OVdWERAGENT ,/CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMELICENSE NUMBER LICENSE TYPE BUS.LIC� COMPANY NAME Q i9 x j__ E-MAIL ^ tea FAX STREET ADDRESS?3rj� lid 1 t 39� CITY,STATE;ZIP �f p �],, I n'1 ) PHONE �j�Z^09 ARCI-UTECTIENGINEERNAME LICENSE NUMBER �t�t c 5 BUS.LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE;ZIP PHONE USE OF ❑SPD or DUPLEX ❑ MULTI-FAMILY PROJECT IN A11LDLANID ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL _ URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: "Z RECEIVIDBY: 3 By my signature below,I certify to each of the following: I alis the property owner or authorized agent to act on the prop rty is 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 yO building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: f\ Date: SUPPLEMENTAL INFORMATION REQUIRED s QFC "USE 01�I I � � OYER TIIE COIJIST'ER STANDARD y a❑ 3,-+\RCE* � "" 0 MAJOi2! v MEPMiscApp_2011.doc revised 06/21/11 ,..---.....a--r . �s;waw.ro;�a.:�+i'm wur-owI%PI iAmr—'^L. � MIT GERT-IFICATE OF COMPLIANCE FILE COMMUNITY DEVELOPMENT DEPARTMENT.BUILDING DIVISION a�� t�� 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 (408)777-3228 n FAX(408)777-3333 p_buildin4na.cupertino.org am � - 143 rd fie:9 =W� -e. Pla;RM'T CAN-NOT BF r'1N1UX'b ANK]D'C0MPLETEID UNTIL TfUS CERTIFFCATE 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. GM,E AL IN,FORMATION Existing sh-igle-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. W,hen the valuation of additions,alterations, or repairs to existing dwelling units exceeds $1000.00; CRC Section R-314 and CBC Sections 907.2,11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: AREA S-N4101KV,AL ARM CO AtAmM Outside of,each separate sleeping area in the immediate vicinity of the X X bedroom((s) On every level of a dwelling unit including basements X X Within each sleeping room- X Carbon Monoxide alarms are not required u1 dwellings which da nat contain;fuel-burnuzg appliances and that do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420.0 and shall be approved by the Office of the State Fire Marshal. Power Supply:In dwelling;units with no commercial power supply,ala_ritii,$)'.may be solely battery operated. In existing dwelf1htig-units; alarms are permitted to be solely battery operated where repairs or alterations do not result _�fie removal of wall and ceiling,finishes or there is.no access by means,of attic,baserment or crawl space.R6er to,CR-.0 Section R3.14 and CBC Sections 997.2.11.4 and',420.6.2.An electrical pernut is required for alarms,w14ch must be eonnected to the building wir ng. As owner. 4 thie above-refereilced property,I hereby cerfrnfy than Hite alair t,(a)refeirenced above has/lnave,been msWT dt m"accordan=ce with the-man ufactuilrers instructions.anad inn eumV)li+amee wi;fh;the California=Rum ra, amid Caliiforiri a,Rees clerthal C©-des.The alarms,have been tested and are.operaHional� a6i of thle date signed] belbw.. 1,h,ave.readf arida dee to com.f i with:Ah,rawsi andl oon,d inns,0 tris..aNtament 06MA c#o nNftz'; �C �f � S;;n {ure;_.. _ Lai ...,..0 rr Qq {� .. 1Ct..V., Smoke nJ?d'CO%fa:n:doe euiseif 0311°8/l4' OWNERCERIVICATE OF COMPLIANCE 00MMUNITY DEVELMAEN `DEPARTMENT•sBU LbA�G DAUlSIG 103001 TORRE VE!'JdUE+'C<U--RTIN0,"CA'9 (J1 =3255 7179 1A8 9-32 8 fX,{4'0t�777-3333�buitdrictcuiz�r#ino.oio a �f Owner Nams G ( &X-f- Permit No Address ly 1. Is your real property. a:registered Historical site? 0 Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. VNo 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 110 1.1 through 1101.8 do not apply. D The licensed plumber's certification has been provided to the Building Division.- Skip the rest of the form and sign bottom of form. No Go to Question 3. 3. Is water service permanently disconnected for your building? ❑,ids 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 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. 0/' Civil Code Sections 1101.1 through 1101.8 do riot apply. Skip the rest of t`he forret and sign bottom of form. Yes My real property is built and available for use or occupancy on or before January 1,19914. Civil,Code Sections 1101.1:through 1101..8 apply. Check one of the three following statements and sign bottom of form.. 5. Plea<e check ONE of the following: WPM is asrrrgFe fairrFl} t&idenfal real property.. See Civil Code Section 1101.4. On amid,after Jammy 1, 20114,building alterations or improvements shall require all non-compliant plumbing:fixtures to be replaced with,water-conserving plumbing.fixtures throughout the building.0i or before January 1,2017,all non- coripliant plunnb>rig futures shall be replaced with water-conserving pfurribmg fmtures (regardless of whether property undergoes alterations or improvements}. D My property is,a.m dtifamily residential red property, See Civil Code Seetiorn 1101.5, On and after January 1,2014,specified bixrlding alterations or imp-rover encs shall req: ke,non-compliant plumbing fixtures,to be replaced with wafer conserving plumbing fixtures. On or,before 1animry 1, 2019,,alit non eomphant plumbfng,fixtures shalt be replaced,with,water- conserving plumbing fixtures throe-ghout the building(,regardless of whetl erprapetty ur d'ergoes alterations or irripravernenfs)�. ) My property I&a commercial real property. See Civil Code Section 1101.5. On and atter,January 1,2014„specified.tuildmg alterat%m or improvements shall mquiire.non-compliant Flu mbing,fixtures to be replaced with water-conserving plumbing fixtures, Go or before Jaxuary 1, 2919;, all noa^compliant plumbing fixturesshall: be replaced with water conserving plumbiing fixtures throagfroaf the buildtng(regardless of whether property undergoes akepations;or miprovements)! I,as fhe owner or,owner's>agent of this property,certify under penalty of perjury,that non-compliant plum,,bing fixtures will be I replacedtprior tot date specified'abave.w>th water-conserving plumbing fixtures irr accor=dance withiCivi41 Code Sections 1101.1 through 110%l.$,the curremt Cafi&miaPlumbing Code and California GreenzBuilding Standkids Cod'e,and manufacturer's: installation requirements,;and that the.water-conserving plumbing f res comply with the requirements as indicated isn the table on the RW1bw—ln a;e: , Owner or,OwnerAgetitis Signature rip Upon,cornpi'etfiig,and signing,this Ceitifrcat'e,please return:it to the Building Division in-,ord"er to finale y,,oue building per,mit. " SB4072D%15Agc revised018,126115,