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B-2016-3091 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3091 18817 PENDERGAST AVE CUPERTINO,CA 95014-3620(375 33 021) THE PLUMBING GUYS SAN JOSE,CA 95127 OWNER'S NAME: DE BLEECKER REGIEN D AND GIELENS MARIE C DATE ISSUED:11/10/2016 OWNER'S PHONE:408-398-0154 PHONE NO:(408)637-1682 ► r Ilk, :. S .' D .. ._. S k BUILDING PERMIT INFO: , License Class C-36 Lic.#982128 Contractor THE PLUMBING GUYS Date 03/31/2017 X BLDG _ELECT X PLUMB 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: GAS LINE INSTALLATION FOR BBQ I hereby affirm under penalty of perjury one of the following two declarations: REV#1-NEW 1 1/2"GALVANIZED GAS LINE-WATER HEATER, 1. I have and will maintain a certificate of consent to self-insure for Worker's PATIO HEATER AND FIRE PIT(7200 BTU)-ISSUED 11/17/2016 Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Piave and will maintain Worker's Compensation Insurance,as provided for by 'on 3700 of the Labor Code,for the performance of the work for which this ` L permit'' slued. Sq.Ft Floor Area: Valuation:$7400.00 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 33 021 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,the applicant understan.. . i co ply with all non-point source regulation the Cu. mo Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. !Signa e / ._ Date 11/17/2016 Issued by:AbbyAyende Date: 11/10/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the ontractor'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 i. 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:11/17/2016 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 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. 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 1 ,1 anage. ent District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cuperti,, 1 unicipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safe 'ie,Sectio; 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall ,.----,:2 { ---=. be deemed revoked. Owner or author ix APPLICANT CERTIFICATION L Date:11/17/2016 ! I I certify that I have read this application and state that the above information is CONSTRUCTION LENDINGAGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a constructiop lending agency for e 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 ARCHITECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records. Code,Section 9.18. Licensed Signature Date 11/17/2016 Professional I . ' Y.-e.t.) ... -:\ , _ - . GENERAL PERMIT APPLICATION` j i COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION --,ess ', ' 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•buildinq(&cupertino.orq, .. C . i t > PLUM$ G ElMIECHANICAL .. []ELECTRICAL .f MIS.CELLAIVEOUS PROJECT ADD _'.... `riAPN# o e AME _ P ,, • 7.'596:n -e.."4,42,---e Qat,__d - , -- . '„-- 1 i' f�JV ! G -E v- Ar4 ..1/ G / 'Ll ge - 1'�. i STREET �d CIT SS) fr—.7 _ /_ ,__,. _ ,S CONTACT V , �+HONE. � ��6! �� - - c 4_, b.. i7'ltd?.2 E- STREBT D ` I i 7 c{ �ZL� C TA . ZIP FAX L r� I1 / S/1 / { ; ❑OWNER D.OWNER-BUILDER 0 OWNER AGENT TRACTOR D CONTRACTOR AGENT 0 ARCHITECT D ENGINEER 0 DEVELOPER 0 TENANT 69171 ORN i3 B s, LICENSENUME gZ/Z 0 LICENSE TY E. BUS.LIC# - COMP V!. r Lf�.''- 919 . �Yf t STREET D CITATE; J P NE ARCHITECT/ENGINEERNAME . LICENSE NUMBER BUS.LIC# I - - COMPANY NAME E-MAIL FAX i STREET ADDRESS CITY,STATE,ZIP PHONE , •� •USE OF 0 SPD.orDUPLEX O TI-FAMII Y PROJECT IN WILDLAND .❑�,.�}ES PROJECT IN I]YES. IS THE BLDG AN 0 YES BUILDING: ❑COMMERCIAL: - URBAN INTERFACE AREA NO FLOOD ZONE 0 NO EICHLERHOME? 0 NO DESCRIPTION OF WORK T Lef,c, c,,,_ ,-G, .fir ' #.. " ' 2.A-(L. C-- l h f V . / n - . a � i � TOTAL VALUATION: lZ� C/�.! l�L?J IUEDSY i y „,,,,::;v,:;,,,,,,,,,,,,,,,,,,„ By my signature below,I certify to each of the follovAg: I am the property owner or authorized agent to act on the property own'er's behalf. I have read this application and the information I have provided is correct. I hav -the-Description of Work and verify itis accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin nuc•on> I a e represen tive��s of Cupertino to enter the above:idden/tified ro lefty forAinspection puiposes. Signature of Applicant/Agent:, .. Date: / ”/ -?; "y PLEMENTAL INFORMATIONQUIRED Ft ] £)'i' 01Wlei W.tER e4. i fi 7 fgg b t),g mss} S DARD 4:040!'.**igiiiilltirdSIST,I. •`° = �N1AT0 ' �z� �: ..,. ,..%fie :L_.,,,. " �,x..,;...,< MEPMiscApp_201 L doc revised 06/21/11 1 i j CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3091 18817 PENDERGAST AVE CUPERTINO,CA 95014-3620(375 33 021) THE PLUMBING GUYS SAN JOSE,CA 95127 OWNER'S NAME: DE BLEECKER REGIEN D AND GIELENS MARIE C DATE ISSUED:11/10/2016 OWNER'S PHONE:408-398-0154 PRONE NO:(408)637-1682 T ICEN D ONT ACTOR'S D T ARATIQ BUILDING PERMIT INFO: License Class C Lic.#982128 Contractor THE PLUMBING GUYS Date 03/31/2017 X BLDG _ELECT X PLUMB 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: GAS LINE INSTALLATION FOR BBQ 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. c have and will maintain Worker's Compensation Insurance,as provided for by - w o 700 of the Labor Code,for the performance of the work for which this permit' issued. Sq.Ft Floor Area: Valuation:$7400.00 APPLICANT CERTIFICATION I certify that 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 33 021 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. Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations p theupa mo Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. k Sig r Issued by:Abby Ayende Date 11!10/2016. Date: 11/10/2016 4 OWNER-BUILDER DECLARATIO 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:11/10/2016 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 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 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 hazardous 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 Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal C.'• a e 12 and exemption,I become subject to the Worker's Compensation provisions of the2 ' 1� ?'9. the Health&Safety Code, . ctior� 25505,2. 33,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall 1 be deemed revoked: Owor authorized age _mow APPLICANT CERTIFICATION Date:11/10/2016 I certify that I have read this application and state that the above information is s M: M U t k a. ._- 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 perfo once 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. Signature Date 11/10/2016 Licensed Professional 1, i � M E P . GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 44"P- .t, 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•buildinq(a�cupertino.orq IS C LI IM= IG ❑MECHANICAL ELECTRICAL �"' ,.jl_ AA � ❑ ❑MISCEL/L}ANEOUS PROJECT ADD S' �-7 r �. `�-'�1 ` - '� - -3 - �J 1 ..._(.4r �f / ! 7� ��Glf��� APN# STRE 'AmE - ,Da Sta ,c,i,_,ev"-- Pi', ) -c---3i9 0 1,- .gdel-e- ehi ®ET �•d ei -eec G tO" €J4 / j!.1 17 c e i.Az 4p;�IT , S IP 4�4_ .G�y./ j 4, f� CONTAC E tt a / STRE` 7572R37,_57'. CIT TAT ,ZIP FAX 6,4_ ❑OWNER 0 OWNER-BUffDER 0 OWNER AGENT \\ TRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT ` � ia n ,/n_ / LICENSE NUMB/ LICENSE TY BUS.LIC# -,e COMPAJ 9- 12,0/1‘).. ..1-• v }/i��/{/��_�t�J PLUM ] \ �j/yam/p f// Q',//�f�(\/'���� —l.�L�U� til l L./G./ [. �6/✓� �'' STREET /D' CIT ATE,ZIP ! 0 G 412-•1 �^�'t'V i .'-". / 7 / 2 P NE ��]r [- L ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX ' STREET ADDRESS CITY,STATE,ZIP PHONE USE OF 0 SFD or DUPLEX A LTI-FAMJLY PROJECT INWILDLAND ❑�`/yES PROJECT IN 0 YES. IS THE BLDG AN 0 YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA. /tXNO FLOOD ZONE 1:1 NO EICHLER HOME? 0 NO DESCRIPTION OF WORK `� ' 1Q.e u-3 li)._,,,S (...v&.)--e__ -- - TOTAL VALUATION; 1�� �/ / ' !N 0I-L.P'�, C.� RECEIVET BY Q' a By mysignature below,I certify to each of the follov� g: I am the property owner or authorized agent to act on the property owner's behalf. I have read thus application and the information I have provided is correct. I hav thy- cription of Work and verify itis accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin• en con. I a e represen tivee�s of Cupertino to enter the above-identtified rro ertyfor inspection purposes. Signature of Applicant/Agent: Date: // / "SUPPLEMENTAL INFORMATIONQUIRED Y oETYCk6SE ON,IX '' eE OVE1t-TIIE COUNTER " D-EXP sS f ©'"STANDARD 0 LARGE MAJOR, 1 MEPMiscApp_2011.doc revised 06/21/11 SMOKE I CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE s.ryr' COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•buildinq(a�cupertino.orq PERMIT CANNOT BE EINALED UNTIL TI3IS CERTIFICATE IIAS BEEN COMPLETED,.SIGNEDAND:RETURNED TO DIE BUILDING DIVISION 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,R315,2016 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,R315, 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 the X X bedroom(s)-(Smoke alarms shall not be located within 3 feet of bathroom door) On every level of a dwelling unit including basements and habitable attics 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 alaims 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 b- 2-0I/ Address: (8s I E A a' '' MD CA Permit Na2Q((�. SOT Specify Number of Alarms #Smoke Al. a S #Carbon Monoxide Detectors 1 L 1 i have read and agree to corn.1 ith the terms and conditions of this statement Owner(or Owner Agent's)Name: ( t Signature !.)1{!�. . Date:?./4"/RIC/. Contractor Name: ` Signature Lic.# Date: Smoke and CO form.doc revised 01/10/2017 WATER-CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE �.pCOMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION U , 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 Q y n,�l4 ® 3 ,p (408)77 -3228•FAX(408)777-3333•buildinq(a.cupertino.orq t7 �ncth/ Owner Name `F P/vl. r "2016 5lQ ,� � ��,..�C Permit No. � Address ,U 6 / J1vemdtirt#, q / Ck 1. 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. 61 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? DI Yes Civil Code Sections 1101.1 through 1101.8 do not apply. CI 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? El 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 4. 4. Is your real property built and available for use or occupancy on or before January 1, 1994? 0 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. Ad 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: it 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). El 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, 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,certii nder penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water-con.e i g plumbing fixtures in accordance with Civil Code Sections 1101.1 through 1101.8,the current California Plumbing Coda an. California Green Building Standards Code,and manufacturer's installation requirements,and that the water-conserv' g .lumbing fixtures comply with the requirements as indicated in the table on the following page. Owner or Owner Agent's Signa ure: r) Date: 'D Upon completing and signing this`Oertif ca , ease to the Building Division in order to final your building permit. SB407 2015.doc revised 01/05/17