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11120107 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10561 CYPRESS CT CON'T'RACTOR:SERVICE PERMIT NO: 1 1120107 CHAMPIONS OWNER'S NAME: CUMINE HEATHER M 7020 COMMERCE DR DATE ISSUED: 12/20/2011 OWNER'S PHONE: 4082553296 PLEASANTON, CA 94588 PHONE NO:(925)44417444 'vi LICENSED CONTRACTOR'S DECLARATION r r r BUILDING PERMIT INFO: �BLDG ELECT PLUMB License Class CZp Lic.N '31 7 0 Liv r r r MECH RESIDENTIAL COMMERCIAL Contractor GL..�-1��,Fj Date to�'z0-JJ I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE FURNACE IN SAME LOCA'T'ION (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is In full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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. Sq.Ft Floor Area: Valuation:$5414 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 ApN Number:31630057.00 Occupancy'1'ype: permit is issued. APPLICANTCERTIFICATION I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against l iabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signaturc�^AA.Q — d _Date 12�wv�/ Rroofin FS: - All roofs shall be inspected prior to any roofing material being installed.If u root'is installed without first obtaining an inspection,I agree to remove all new materials for inspection. Fl OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Low for one of Signature ofApplicant: Data the following two reasons; ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUSMATERIALS DISCLOSURE construct the project(Sce.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(x)should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Arca Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: 7i� Za-I I permit is issued. 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 m to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCI'ION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked, work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 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 harmless the City ol'Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records, granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Data CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION 19 ADDRESS: 10561 cypress ct. DATE: 12/20/2011 REVIEWED BY: bobs. APN: BP#: *VALUATION: $5,414 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: A. WORK replace furnace only. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: $130.00 Mech.Plan Check 0.0 hrs $0.00 1'lunrb. Plan Check Elea. Plan Chccb' Mech.Permit Fee: IMPERMIT I Plund"Ile)n.er fee: Flet /lemur Fee: Other Mech.Insp. 0.0 hrs 1 $44.00 Chher PLuph I""P. 07- (biter 67ee.l;lrp. Hoch.In,n. Fire: Plumb. Insp,I-'ee: Ele.0 Inc). Pee, NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District etc. . These fees are based on the preffindina in orna tion available and are only an estimate. Contact the Dept for addn'l in a FEE ITEMS (Fee Resohdion II-053 EfI 7/UI!) FEE QTY/FEE MISC ITEMS Plan Check Fee: Satppl. I,C F I:e PME Plan Check: $0.00 Pfll7ilil Ff'ee: Sup/,?L Imsp Vee PME Unit Fee: $130.00 PME Permit Fee: $44.00 C oustrilc7ion 1 ac: Administrative Fee: (ADMIN $41.00 Work Without Permit? 0 Yes 0 No $0.00 /afiancarlF'/<7nninr fees: Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: IBSEISMICR $0,54 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $260.54 $0.00 TOTAL FEE: 1 $260.54 Revised: 12/04/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOBADDRESS: OS(ol re5S Cf I PERMIT# OWNER'SNAME: Rieo-tkoCU irk IPHONE# #0d ISS - 3�9Co GENERAL CONTRACTOR: V1c e., �o tM COTnS BUSINESS LICENSE# ADDRESS: �DZO epytuyyl2/GQ, 1-2 CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 1 am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum / Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date ShnpflfiedPresc tiveCerdlicateofCo fiance:2008ReridendalRVACAIreradolcr CF-IR-ALT-HVAC Clhwate Zoon 10 to 15 e SbeAddmsa r EOrmrentA�tv.• Date Permit ik . Conditioned Floor ([ l List M>mmem Effiacocyx Doti hamladm requirement Area 7'hmmostet PBeitoed unit Over 40 A of ducts added or .M sal-Art,�Fmnaa in Mal ✓� O COP_ replated in unconditioned spice saved by system (Umt an'aedi. ` -0%,daorCoff OSffit OHSPF_ Oam gtldt OMM_- ORads�ee ORB ( I ORB (CL1413) of pomc=who tZhIJ) awralfed 1.Bgalparmt7�pe:Chante rhe agrtrymanr bmrghaaaRa�tfwrwe thaw oaagatw,are awatho CF-IR-ALy'-fIVACforeach.rystear. .7.1Mho ms Bg4avot8. olanc i:138EEt78%AFUB,7.7WFfor Oydca/mldmdidrlw m 'HERS VERMCA77ON SUAlbURY listed bdm=Som HVAC altastlm Optlaas The installer derides wiatwark is being dam and :&Jtvono ofthe appropriate Options. Fadi Optlm Este the HBR4 incomes ebatwnat lccoaductod.A copy of the fame shall bo leftori site for final :inspection and a copy given to theiomewraw. At tonal,the mspeamverifies Poet the wade Noted m this faun was in bathe work completed by Poe � Cr.The inspecti r alsovedfles tort dash apptoprfste CM and iegishwd CF4R$eine(no hand find C3F4Rs allowed)am filled int and ed. Oembor 1 2010.•reahatired coy of the CF-1R and CF431 siafi also be to We for final hapectlon, $11AMACClistagetiot Required Foran: <^..=. CF-6R fates MECH-KMECH-2I-HERS and(forep0t systems)MCH-25-HM -rt— NVACAuipmcstreptead CF4R6mrsr MECH-21 and 1br spht MUM-2S �. a Condenser Call and/or . CF-6R furmc MlCfl-21.HBRS and(for split syame)MRCH-25-HERS • lactam Cal sod/err CF4R lhtmr. MBCH-21 and(fm split systema) MECH-25 a Face For.SpBt Systems:Dud leakage<15 perccat; RG CCA>_300 CM/tm(Minimntn Air Plow Reilairerueag,TMAH For-Packaged UnRL- Dad leakage<15 percent O 1.Duet-system war documented tohave beeapeviemly sold and mrdnmed if BI HBR4 verific dick tr .. O2.Dad o ianswlteitsdim40llocar29Inuncondmmedspace,or 03. ' dud ateconstructed.insulated mauled with whom o I New HVAC SYSUM Regalred Formr. Cm in arChan1Foust widi non . CF4R f cnic MECH 06.MECH-204MRS,md(fmsAit p nems)MBCA-22-EMS,and MMH-25-HERS Acute(a0 new ductmg�all CF41R fame: MBCH 20•,and(S)rsptit sync=)MECH-22.=d MECH 25 new For Split Systmst Dud leakage<6 percent;RC,CCA>_350 CFM/toa,FWD,TMAH,9rMS,and either HSPP orPSPP. For Pu Unks:Duct leakage<6 t ' ❑3.NewDadb mM Peplacemigst Raquked Foran: • ir]ada rty6emg m hon Mag aH xwdacting CF-6R>0aw: MECH-04,M=4-20-HERS,and(for split systema)MEIN-25-HERS M&OromdoacoodemmgunitmNmiodoor CF4R>ntm4MEM20and(Air split ayrteme)MBCH•25 call Muftfamce. Nd all mdtAranged For Split Systems:Duct leakage<6 percent,RC,CCA>_300 CFMkon,TMAH . For Packaged Udls:Duct l <6 etcem O 4.New Da over 40 rat Resivilred Forum: a hv]tdm sddmg mreplcmgmtae Poo 40 CF-6R f tome MEM-04,MECH.21-HERS CF4R forms: MM-21 Haearf dofductin meadidoned Spam For split systemorpackapil tmlts: Duct leakage<15 pemeut O BXCEMCN-Existing doctor saledwith asbesms. Cmh'seto!(Dornmentet(oa Author's/Rapendble Destgoer9 Declaration Statement) .a lvv*dw&tftizCkrdflcwcfCcmpHw dowwwwadmisacturmadcacq4to . ,. .tam egp`hbooder•DjaldmJ.ofPoe Califeraialtashwas adPmtmdam Code ton $rnpoeatdgry tlrWadcdgn Idmtltidmthistkrtifma of IUdivaea •, Imdty dat'Ihe esetgffisoucs and_pratmgwd8utimafLrecddgsidm fdmths CaOcftcfCaa em5ammlhe mgtdtaaeaa al7mo24, Pater 1 sed 6 of do Pdd0 ia.CM4.olRRvlXbxn . . • The daiptA 31dodgd as mo CadBcam efCmopliaocewmw*iatmevdtb dm kdbFmetim dxommmd®oWerappl?—�'bcmg0mm tmma,wr�hma, int edspedficidaus`oohmimdmtheft tion vdm dw RuGan. •. Noise BROOKS F�OO°er IONS Dam 'g•�"ZoCOrhm" r✓iZe Pr B,�oao leascL+1 Y15n Gc� c 2008 RaMlleadd Compliance Form �r�vIFI*arch 2010 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN 31630057 . 00 DATE ISSUED. . . . . . . : 12/20/2011 RECEIPT # . . . . . . . . . : BS000015597 REFERENCE ID # . . . : 11120107 SITE ADDRESS . . . . . : 10561 CYPRESS CT SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . OWNER CUMINE HEATHER M ADDRESS . . . . . . . . . . : 10561 CYPRESS CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2423 RECEIVED FROM . . . . : !E INC CONTRACTOR . . . . . . . : KEVIN COMERFORD LIC # 31833 COMPANY . . . . . . . . . . : SERVICE CHAMPIONS ADDRESS 7020 COMMERCE DR CITY/STATE/ZIP . . . : PLEASANTON, CA 94588 TELEPHONE . . . . . . . . : (925) 444-4444 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---- -ADMIN HOURS 1 . 00 41 . 00 0 . 00 41 . 00 0 . 00 1BCBSC VALUATION 5, 414 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 5, 414 . 00 0 . 54 0 . 00 0 .54 0 . 00 1MFR=<100 UNITS 1 . 00 130 . 00 0 . 00 130 . 00 0 . 00 1MPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 260 . 54 0 . 00 260 .54 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 260 . 54 12169 --------------- TOTAL RECEIPT 260 . 54 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DMSION 10300 TORRE AVENUE•CUPERTINO,CA 9501432552 �1 CUPERTINO (408)7T7-3228• FAX(408)777-3333•building(cDcuperdno.0m M ' c l l l 2 a r o�-- ❑PLUMBINO MECHANICAL ELECTRICAL CIMISCEU.ANEOUS PROJECT ADDRESS lAFNf1()S(01()S(01. C cess et w'I(-o 3 1!) CSS OWNER NAME �eaclla..f C(-L i17-e/ k aSS- ,3a9 Co "AILSIREETADDRES$ 7 SSS C l QTY�STATE4 ' ✓LQ L/ FAX CONTACT NAME STREETADIJAES9 CITY,STATE Z@ FAX ❑owNFR ❑ OWNER-00EDER ❑ OWNFAAGFM 8n CONTRACTOR ❑OONTMCIVRADENT ❑ AJL=n= ❑FNOD+EER ❑ OEVEI.DPFA ❑M N'R CONTRACTOR N BUS LIC a W ILJ2 G a�,�S °$M oyv ` �" zc COMPANYNAGie &MAD. FAX STATES4S r6 T� ✓vv-yyyy �jp D ✓vl�vurc D r 1 r BUSIJCi ARCIRSFITJFNODJEFB NAME u�sE NIRdHflt I COMPANY NAME. E-MAIL FAX STREET ADDRESS CTIY,STATE,ZIP PRONE U58 OF ®sm.uu IFX ❑ WuLTT.FAMJLY PRtNECr'N n L ND ❑ YTS FRaEcrw ❑t'tg L9THE BLDOAN ❑YES m111DwCs �COMMFRCLU. iRBAIt JNrERPACE AREA pNO Prl]OD zoes ❑NO IIQQFA HOA/ET C3 DESCRIFRONOF WORK. . lc.�� . VIac2 D+ti TOTAL VALUATION: 54jj / r OV RECEIYED BY: By my signature below,I catify to each of dw feilowing I am the property owner ar authorized agent to Ret on the propWmaces behalf I have Rad this application and the infmmatioo I have provided is coc ect j have read the Description ofWo*and verify it is accurate. I erg=m coatply with all applicable local mdmances and scam laws relating to building coasoom*u I emhmies regresmtatives of Cupertino to entur the above-idenaed property for inspection pot¢o 3 Signature ofAppli®VAgent✓Lk" t�L � Date' /`P ,16+r/ SUppLEmENTAL INFORMATION REQUIRED OFFICE USE ONLY N Tffr COUNTRR 6 ❑ zx"FSS Y Y er ❑ STANDARD u S ❑ tARCE E ❑ M OR MEPffwcApp 1011.doc revised 06/11111