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B-2016-2527 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PEkN.Tr NO:B-2016-2527 873 FERNGROVE DR CUPERTINO,CA 950144636(375 39 049) BETSY R SMITH CUPERTINO,CA 95014 OWNER'S NAME: SMITH DAVID G AND BETSY R TRUSTEE DATE ISSUED:08/16/2016 OWNER'S PHONE:.408-205-6329 PHON NO: LICENSED CONTRACTOR'S DECLARATION N BUILDING PERMIT INFO License Class Lic.# Contractor BETSY R SMITH Date X_BLDG X ELECT X PL I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby.affirm under penalty of perjury one of the following two declarations:. RE-PIPE INTERIOR;REPLE:(2)OUTLETS IN BEDROOM 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. 2. 1 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: Valua on:$7500.00 APPLICANT CERTMCATION 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: Occup Incy Type: and state laws relating to building construction,and hereby authorize 375 39 049 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 DAY 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 Issued by:PHUONG DE S Date:08/16/2016 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 o any roofing material being installed.If a roof is 1. 1,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) 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: I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVE GS TO BE CLASS"A"'OR BETTER 1. 1 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 C Dde,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the C pertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Sectio 25532(x)should I store or handle hazardous shall not employ any person any manner so as to n ibecome subject to the material. Additionally,should I ase equipment or devices which emit hazardous air contaminants as defined by t ic Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with t1 e Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety C idtions 25505 255 ,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner roor euthrized age APPLICANT CERTIFICATION Date //,6 certify that I have read this application and state that the above information is Ul/�! CONSTDCtTION 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 ARCHITFCT'S DECLARATION Code,Section I understand my plans shall be ysed as public records. 6 Licensed Signature ate Professional ._._....._.......__.____.._- GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333 building(aCUPERTINO .cupertino.orgMISC LUMBING ❑MECHANICAL ❑ELECTRICAL Elm S LLANEOUS PROJECT ADDRESS APN r SLC OWNER NAMEc ,?,J� s„� PHONE E-MAIL s l� t STREETADDRESS 0- / v !/ CITY, G `f .� ! FAX 1-U119 CONTACT NAME PHONE E-MAIL/ / v l'-9m (."/4 4zf STREET ADDRESS //(�I i CI STATE,ZIP FAX ORR.'ER ❑ owNER-BUIIAER ❑ OWNER AGENT L❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑l uDEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER Q1gt(��(� LICENSE TYPE BUS.LIC# N COMPAY NAME , E-MAIL (� �7 J FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME 7 LICENTSE NTMBER COMPANY NAME EMAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF XSFD Or Duplex Q Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ] No FLOOD ZONE ❑ Yes No DESCRIPTION OF WORK ' ' ( TOTAL VALUATION By my signature below,I certify to each of the following: I am the property owner or authorized agent to acttaccurate. ner's behalf., I have read this application and the information I have p vided is correct, I have read the Description of Work and verify it ito coinply with all applicable local ordinances and state law relay to it �construction. a re resentatives of Cupertino to enter throperty for inspection proposes. Signature ofApplicant/Agen. Date: SUPPLEMENTAL INFORMATION REQUIRED 'OFFICE' oiY _ w OVER THE-COULTER U SI ". w ❑ STANDARD U z c J•LAJOR,�,`� � h... ME iscApp_2011.doc revised 03116111 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10,300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CtJPERTIN 3 (408)777-3228•FAX(408)777-3333•building(cDcupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS APN BP# _,7 ( 2*71 OWNMA E OWNER ADDRESS�'n'n n rnLG / j qOff DESCRIPTION OF WORK: 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 erify this information.) 61.1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder"building permit that erroneously implies that the property owner is providing hi or her own labor and material personally. I, 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 ho eowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. �P 2. 1 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. 66;?S3. I understand as an "Owner-Builder"I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead instead of my own. I 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 Californie 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. ff6. 1 understand if I am considered an "employer'under state and federal law, 1 ML st register with the state and federal government,withhold payroll taxes, provide workers'compensation disability insurance, and contribute to unemployment compensation for each"employee." I also understand my failure to abic a by these laws may subject me to serious financial risk. 7. 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, un ess all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general bdilding Contractor. 8. 1 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 owner(s)that result from any latent construction defects in the workmanship or materials. OwnerB ilderFonn 2010.doc revised 04114/10 4 9. 1 understand I may obtain more information regarding my obligations as an"err ployer"from the Internal Revenue Service, the United States Small Business Administration, the California Dep rtment 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 www.cslb.ca.gov for more information about licensed �coonttractors. t 10. I am aware of and consent to an Owner-Builder building permit applied for in My name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. W-1 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. ,A-12. I agree to notify the issuer of this form immediately of any additions,deletions or changes to any of the information I 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 Boardmay be unable to assist you with any financial loss you may sustain as a result of a complaint: Your only remedy against unlicensed Contractors may be in civil count. It is also important for you to understand that if an un icensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers'compensation nsurance 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: A 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-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 si tur Property Owner's Signature: Date: i2k1 ------- -------------- -------------------------------- ------------------------------------------------------------------------------------ (NOTE: The following Authorization Form is required to be completed by the property own gr 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 I 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. (��a Scope of Construction Project(or Description of Work): 7 Project Location or Address: l (�•L�f'7/`t� 7 / Name of Authorized Agent: Tel No Address of Authorized Agent: F60 r I declare under penalty of perjury that I am the property owner for the address listed above and 1 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. 6 / I Property Owner's Signature: Date: ` L OwnerB ilderFonn 2010.doc revised 04/14/10 MONOMBALARMSFILE 11 C- NMMU.NITYlDE4VELa(?MENT;DEEPARTMENT®BUILDING DIVIS{ON T ` PuRT'n,H.0 10 00lORRE:AVEN,UE DUPERTGNO�,:GA95014-8255 i (4 8)777-3228 o FAIX 1C49,8)777-8338 buil�u�i..a}cir_ rtlno. - tat ` ,. MUD This a€fidaVit i,s a self certifica tion for the installation of all required Smoke and Carbon Monoxide Alarms for corriplia`nce W11,11 201-3 CIBC Section R814,2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for inspecti©Ms ark required. ist e,&-hmgtefafflily and f nt lei farrtily dweIlings shall be provided with Smoalke Aiarrns and Catrbm M-10—Mxicle al`laMns deft the Najua€lo�of additions, all er-ai olis,or. re: airs t&ex-JA i �g a,. ts,e�,ceeds 1 p Sing d�wellrzl izni $10,01A CRC Section R-3,14 ai id CBC Sectioiis 507.2.115,aizc 420.6 regigt e that Smoke Alarrms andf o�Carba o o ide Alawimbe inslalie in- the folloowingAMA UA iacatio is; Ad t - - S' C'Oi D, C0 f i Outside of, each,separate sl=epirr area in theiri� iediate victnity o the x ' I bed��ao�m( )f_ ®ns e er fe el(A a dwellit _ rini;l!ftl,(Oudism basement } �$ °I�orto�de ala�rrt�sacre naf re tiprcd iii dime`G, _ `' ' q, -Ilimg�w'litcli cl©I�ti©�canto:_�f etel-buzn�g a�;i�'Sta a��lk 'n lla�ti dog � �t hat re- a aMEbched gaga R e Caro i2oilaxi cle ala i�ri�s co f Yne�1 with sinal`e Alarm s--mill co�zi;is w7i�tl a �,p P`O>wet Sq c© :, 1_ s 1 a a c j a b a iiniercial p c ery sii aplY,alar a l iW innay, D e solely, b-atkT-y ogrer e'cl., a e- it sti dw'elllk mmfts, al:�rrma are e-rr iiRed to,b sol'ry � g p � LeI�balktery operatte'di w.here repamra,Qlr a�llteirao7lDs,a�� not,reswid m,tie remomaal 04 1A,all mqd ceil,1 fj&hes oY�th6er,e is mc,access,bymes,4 al i?c,blaseme-at om.crawl space Refer tuCSC S'eetzo i',''314 a"Zd CDC Sections 907.2..11.4 and 42©:.61,An electri icallper:,=gistrs,xeq. e$;fog Ata mts,W-Mcl-u musf,bee coir y=1e�to�;to the bail `i ng;tWrii1%. As ov�ner o bite a�bo e-refer:nce `pz�ap rflr�I�1`exe y certify tL�at th ala�rin(s)r referenced above Inas cze b erg installledl mh accordance wifthc ;,e.i+1an,ufactnzrer's:im- 10 ctim-,s almtd lR co;rnpl aR.,ce with,the Cal arma VmldhI,I am,d Ca=1Hom-nia,Resbdenihal C -des.The altairmss lraue•km,tested a=i1d aire operant oiall,.as:of the date sig��ed= � (t`aueread;and,a:<te taco With7fhe:termssandcomy j,ons,of,`flitssst��amen:[� r[Pr te:. .b Lica, } byre j i WATER-CONSERVING PLUMBING FIXTURES mo OWNER CERTIFICATE OF COMPLIANCE q- 3 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228.,FAX(408)777-3333+building(cDcupertino.org Owner Name Permit No ) f Address 3 71 1. Is your real property a reg stered historical site? C)�❑ Yes Civil Code Sec ions 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 ofater-conserving plumbing fixtures is not technically feasible? El Yes Civil Code Sec ions 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.. No Go to Question 3. 3. Is water service permanen ly disconnected for your building? � ❑ Yes Civil Code Sec ions 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. �' N 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 prope 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. 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 al te ations 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 tures throughout the building(regardless of whether properly 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). 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, nd that the water-co serving plumbing fixtures comply with the requirements as indicated in the table on the following a Owner or Owner Agent's S gnaturej ~ Date:~' Upon completing and si ning this de7316-aTe,please retur it to the Building Division in order to final your building permit. SB4072015.doe revised 08126115 i WTO ~� , 4 .tel i Non-Co pliant Water-Conserving Plumbing Fixture Plumbin Fixturel (Fixture Complying with Current Code Applicable to New Construction) Maximum Water Usa a/Flow Rate Fixture Type 2013 CPC Ch.4 2013 CPC Ch.4 2013 CPC Ch.4 Water sage 2013 CALGreen Div.4.3 2013 CALGreen Div.4.3 2013 CALGreen Div. 5.3 /Flow Rate Single-Family Multi-Family Commercial Residential Residential Water Closets Exceed 1.6— Single flush toilets: 1.28 gallons/flush (Toilets) Gallons/flu h Dual flush toilets: 1.28 gallons/flush effective flush volume(the composite, average flush volume of two reduced flushes and one full flush) Urinals Exceed 1. Gallons/flush 0.5 gallons/flush Showerheads Exceed 2. 2.0 gallons per minute @ 80 psi. Also certified to the performance criteria of gallons per minute U.S. EPA WaterSense Specification for Showerheads (A hand-held shower is considered a showerhead.) For multiple showerheads serving one shower,the combined flow rate of all showerheads and/or other shower outlets controlled by a single valve shall not exceed 2.0 gallons per minute @ 80 psi,or the shower shall be designed to allow only one shower outlet to be in operation at a time. Faucets– Exceed 2. gallons Maximum 1.5 gallons per Within units: 0.5 gallons per minute @ 60 Lavatory per minute minute @ 60 psi; minimum Maximum 1.5 gallons psi Faucets 0,8 gallons per minute @ per minute @ 60 psi; 20 psi minimum 0.8 gallons per minute @ 20 psi In common and public use areas: 0.5 gallons per minute @ 60 psi 1.8 gallons per minute 60 psi Faucets– Exceed 2.2 gallons 1.8 gallons per minute @ 1.8 gallons per minute 1.8 gallons per minute @ 60 Kitchen per minute 60 psi @ 60 psi psi Faucets May temporarily increase May temporarily up to 2.2 gallons per increase up to 2.2 minute @ 60 psi,and must gallons per minute @ default to maximum 60 psi,and must 1.8 gallons per minute @ default to maximum 60 psi 1.8 gallons per minute Where faucets meeting @ 60 psi the above are unavailable, Where faucets meeting aerators or other means the above are may be used to achieve unavailable, aerators or reduction. other means may be used to achieve reduction. 1. If the existing plumbing fixe are water usage/flow rate is equal to or lower than the figure shown,it is not required to be upgraded. SB407 2015.doc revised 08126/15 1