B-2017-1761 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1761
924 NOVEMBER DR CUPERTINO,CA 95014-4121(362 13 032) DALCON
SAN JOSE,CA 95110
OWNER'S NAME: HOSODA MORRIS AND LOUISE M TRUSTEE DATE ISSUED: 10/12/2017
OWNER'S PHONE:213-992-1140 PHONE NO:(408)278-1809
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C10 Lic.#582916
Contractor DALCON Date 12/31/2017 X BLDG X ELECT _PLUMB
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
license is in full force and effect. JOB DESCRIPTION:
REWIRE(3)BEDROOMS-(22 OUTLETS)(4 LIGHTS)(5 SWITCHES);
I hereby affirm under penalty of perjury one of the following two declarations: UPGRADE PANEL(200 AMPS)
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.
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:$10000.00
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 constructio ,and hereby authorize 362 13 032
representatives of this city to enter upon the-.ove mentioned property for
inspection purposes. (We)agree o save ind-mnify and keep harmless the
City of Cupertino against liabilitle-, udgnien,.,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue a•..inst said City in o sequen.e of the gran''. oflhis permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,t applicant un:- sta ds and ill compl ,ith all non-point
source regula •ns per the our-rti'o Muni.pal Cod=,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur-' a, Date 10-12-2007 Issued by:Kim Dunbar
Date: 10/12/2017
I hereby: t t I a exempt rom the 1 ontr•ctor's License Law for one of the RE-ROOFS:
following , e. ons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. o ner o'the property,or my: •oyees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
p'se
tt
�.n,will do the work,and the structure is not intended or offered for inspection.
e(Se 044,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: 10-12-2007
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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 Co.e,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the C .ertino Municipal Code,Chapt r 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Sectio 2.532(a)should Iore or han e hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I s:equipment.r'• ces whic •mit hazardous
air contaminants as defined by ;he It ay Area A'1 I a ty Mane 1•ment Distric
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with t,e upertino ,ici.al Code t hapter 9 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety C.d•,Se tions- 15, %5531. 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall ,L,
be deemed revoked. Owner or authorized age���t:,,;.,,
APPLICANT CERTIFICATION Date:10-12-2007
I certify that I have read this application and state that the above information is .►. rslil l _►t' t_►
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there i•, - .,.tructinn lending -gency for hep rformance
relating to building construction,and hereby authorize representatives of this city of work's for which this pe i-sued(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.
Licensed
Signature Date 10-12-2007 Professional
CONSTRUCTION PERMIT APPLICATION
/pm„ COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
=, 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 •
yc ;;:
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(408) 777-3228 • build.ing@cupertin.o.or; PEMIT#B-21)
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CUPERTINO REVS DEF S
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. VMEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS Novevv,bE� �� APN I t / — 3 3 ^®^ /7
OWNER E PHONE l/S/`fin E-MAIL ✓L• l/�
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STREET jL4w•evv.loe,r D r CITY,
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A.CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
'e Sv�'e-� -atc,ur V-e-cA-vcc S,3Dc i ko C(0
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Po Choi4l �-+- civ; Q10102... CC Sit-0
E-MAILS PHONE BUS.LIC I
tri' .,, servib clalwheleck .c. eiC2B 278 1 b6 q❑ARCHITECT ❑OWN R ❑OWNER AGENT"$CONTRACTOR AGENT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTACT AP4IE 'IL
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ZIPUS,2 CA ?SS 16 PHONES-(v0 709 O7c9(v
DECRIPTQL
G'r�l�A �-��-2_ �� IOec.\-00 vv-1 )— ou'rt-e:fs i cj 113S -3 ScAr7174C-h-eS
04rt-e) — 9D OL) €-f-S ( 1 l��GI-f I l surf/eh (jvc — 2 .-t-s
T--c vv; 1 .) q 0 v- -1-s ,A,,,,,,( (z.._,..,,.,,,r112z,.,,, - 1--/ 0 1 ft ) s�,-.-k
v e °v— � -G�n> - I CSU C�,vt.,7 _ 1- caew:t-Ft'"S* . s t,, �' -e
,_. INGLE-FAMILY/DUPLEX ❑MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES I TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISTNC ❑YES EICHLER ❑ YES' SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS 0 NO 0 NO 0 NO
DWELLING SECOND DWELLING ❑YES ❑ATTACHED❑DETACHED OTHER
UNITSA UNITADDITON: 0 N SF
POOLS' ❑FIBERGLASS 0 VINYL-LINED ❑GUNITE 0 PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED AYES 0 NO I TOTAL-SF
RECE � VtLUA O
Commercial or Multi-Famiht Buildings with Public Swimming Pools requires Department of Environmental Heath approval 4Ab
RE-ROOF EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE 0 NO IF NO PLYWOOD ❑' " ❑3/B" PLYWOOD TYPE: PITCH: , ROOF CLASS
❑y #OF LAYERS THICKNESS❑5/B" OTHER ❑OSB ❑CDX OTHER - ' 2 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF El ASPHALT SHINGLES 0 WOOD SHAKES •WOOD SHINGLES 0 OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF Pot SQUARES
• By my signature below I certify to each o he following: I- the prop•rty owner or authorized agent to act on the property owner's behalf. I
have read this application and the infor - ion I have . . •:. s corre.t. I have read th- lescription of Work and verify it is accurate. I agree
to comply with all applicable local ord., ces and s :t . elatin to building .nstruction. I authorize representatives of Cupertino to
enter the above-identified property for section .0 py .. :0 ledge .I,d • thorize all information co ltaine on this application form
to be made available for public record. /
Signature of Applicant/Agent: _Ail A A Date: I J I2 ) -
SUPPLEMENTAL INFORMATION Es I 1
*New SFD/Second Dwelling Units/Mu'tifamil, I) -lings:A Demolition permi -quired prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a co .lete. k .,dous Materials Disclosur- . • if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or 'ee. g Planning prior to submit.: .f Building Permit application. -
*HOA-Provide a letter of approval from • -Home Owner's Association
BldgApp_2017.doc revised 08/01/17
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCEmtw ,
cCOMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
CUPERTINO10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildino(a�cupertino.org
PERMIT CANNOT BE FINALED UNTIL THIS CERTIFICATE HAS BEEN '
going
7 COMPLETED SIGNED,AND RETURNET TO TH=E B t JXGIMISTOINT
OI
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 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 whererepairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement o'r crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 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 alaims specified below have been tested and are operational, as of the
date signed below.
Address: 92q p�/e P \o �( Ol -t;no C , 1c�1'i Permit No. b~-ZO« 1' (Ol
Specify Number of Alarms: #Smoke Alarms: ' 5 ( #Carbon Monoxide Detectors: ! ; c
I have read and agree to comply with the terms and cond"tions of this statement
Owner(or Owner Agent's)Name:
/11 �1 �I j/ /„mit �T
ej'r .P-1 C3017 1-- Signature ........ �� <�`�� � �'/ Date(P, /?
Contractor Name: �l J,
D1.�. 1 1C \ c_ Signature 011.0411 Lic.# '562116 6 Date:II/1S)
Smoke and COform.doc revised 01/10/2017