B-2017-0976CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0976
10138 IMPERIAL AVE CUPERTINO, CA 95014-5955 (357 22 045)
K S ELECTRIC
SAN JOSE, CA 95129
OWNER'S NAME: CHI CHIEH AND TAN QIAOLIN
DATE ISSUED: 06/21/2017
OWNER'S PHONE: 408-666-5327
PHONE NO: (408) 568-0928
LICENSED D ONT A TOR' DECLARATIQNL
BUILDING PERMIT INFO:
License Class C_-10 Lic. #768223
Contractor K S ELECTRIC Date 09/30/2017
X BLDG X ELECT —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:
INSTALL 3 LED LIGHTS - BEDROOMS
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
l Compensation, as provided for by Section 3700 of the Labor Code, for the
formance of the work for which this permit is issued.
2. 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 this
permit is issued.
Sq. Ft Floor Area:
Valuation: $200.00
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
357 22 045
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 per the Cupertino Municipal) Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
�►
Signature s �—� v Date 6121/2017
Issued by: Abby Avende
Date: 06/21/2017
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 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)
z. 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: 6/21/2017
1 hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
t. 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
z. 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
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
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
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25537
553 , and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:/ i, Ot—
APPLICANT CERTIFICATION
Date: 6/21/2017
1 certify that I have read this application and state that the above information is
CONSTRUCTION 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
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Signature Date 6/21/2017
Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building(a)cuoertino.ora
❑ NEW CONSTRUCTION ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT n
PROJECT ADDRESS V j APN 35-4-
22,045 45
OWNER NAME PHONEo f.7�ja 0 / j j • E-MAIL
a y `
STREET ADDRESS CITY, STATE, ZIP FAX
CONTACT NAME r PHONE � /0 E-MAIL
STREETADDRESS CITY STAZE,ZIP FAX
en
D
❑ OWNER ❑ OWNER -BUILDER OWNERAGEN•r ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMELICENSE I lma ZZ LICENSE TYPE BUS. LIC #
COMPANY NAME T E- FAX
40
STREET ADDRESS CITY, STATE, ZIP PHONE
ARCHITECTIENGINTEER NAME LICENSE NUMBER BUS. LIC #
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
DESCRIPTION OF WORK1`%% (� ! � ( _ % /? // T cS `JI2. 7 O'� x z: 4
EXISTING USE PROPOSED USE CONSTR.
TYPE
k STORIES
I
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
ExISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECKIPORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
I
4 DWELLING UNITS:
IS A
SECOND UNTr ❑ YES
SECOND STORY ❑ YES
BEING ADDED? ONO
ADDITION? ONO
I
J_
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
- IVE BY
-:
TOTAL UA_)T�I ��rrr
PLANIN'AIG APPL # ❑ NO PLAI.'NING APPROVAL LETTER
EICHLER HOME? ❑ NO
V
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on thA property owner's 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 witb all applicable local
ordinances and sate laws relating to building construction. I authorizeZXntatives of Cupertino to enter the above-ide tifred pro rty for inspection purposes.
Signature of Applicant/Agent: az-^1 , 11
—mac
Date:
SUPPLEMENTAL INTORMATION REQL�2EDRovTrr.csl
New SFD or Multifamily dwellings: Apply for demolition permit for
❑y 6 ERTHE-COUNTER
;
❑ BIIIIDII�GPLANREVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ .rLANTtAGyL REVgW
Bldgs: Provide a completed Hazardous Materials Disclosure❑
STA.KDARD
❑LBLICwoR�s
_Commercial
form if any Hazardous Materials are being used as part of this project.
TARGE'
❑ FTREDEPT-
_ Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
❑ MAJOR
❑ S 4MTARI SE�i ER DISTRICT ."
,
B1dgApp_2011.doc revised 06/21/11
CUPERTINO
Owner Name
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building a_cupertino.org
Address TSB RYiril� Allg
ME=
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.
-1� 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.
❑ 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?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the fonn and sign bottom of form.
+F—No Go to Question 4.
4. Is ur reaI property built and available for use or occupancy on or before January 1, 1994?
No M real roe is built and available for use or occupancy after January 1 1994.
y property rh' �� p Y D' ,
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. li lease 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-conseiving 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-coinpliant 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-coinpliant 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 the following Daae.
Owner or Owner Agent's Signature: 61 Lin Lin T•poc�_ Date: 6 - 13- _ yp � J
Upon completing and signing thi\Certificate, please return it to the Building Division in order to final your building permit.
SB4072015.doc revised 01/05/17
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE FILE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION V l `
j CUPERTINO10300 TORRE AVENUE CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•buildinq(a cupertino.orq
PERMIT CANNOT BE FI NALED UNTIL TI S CERTIFICATE HAS BEEN
eitATPLE'iTE-I,,SIGNED AND I2E
TURNEb TO THE � �into �3IVISTON`
TM, ' = _:BSD
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 intenor 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
I i
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 907.2.114 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
Address lo(.3,g liftpert A\ Ave a CiAlt1' A0 Permit No g—,1017 —0176
Specify Number of Alarms _ #Smoke Alarms #Carbon Monoxide Detectors
t have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name: 6
Signature .6L, La'v
Contractor Na e: I Date:
Signature .R.4%: Lic.# Z 64'Date: / .2//2
Smoke and CO form.doc revised 01/10/2017