11120063 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19811 PRICE AVE CONTRACTOR:SERVICE CHAMPIONS PERMIT NO: 11120063
OWNER'S NAME: ADAM JOEL F AND SHARON M TRUSTEE 7020 COMMERCE DR DATE ISSUED: 12/08/2011
O ER'S PHONE: 4084720451 PLEASANTON,CA 94588 PHONE NO:(925)444-4444
LICENSED CONTRACTOR'S DECLARATION r r
BUILDING PERMIT INFO: BLDG ELECT '" PLUMB "
License Class C?C Lic.N $176C(O
//// MECH r RESIDENTIAL r COMMERCIAL r
Contmctor�A4.,t,L/ ,dT� Date U-q-lf
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE EXISTING DUCT WORK
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is In full force and effect.
1 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:$5099
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. APN Number:36905017.00 Occupancy Type:
APPLICANT CERTIFICATION
1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accme against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: te:,-'2 (�
9.18.
Signature Date ug—l 1
roofing
ROOFS
my
•
9WNER-BUILDER DECLARATION All roofs shall be inspected prior to material berg installed.If a roof is
hereb affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
Y P inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044, .
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(x)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall health&Safety Code,Sections 25505,255339 and 25534.
not employ any person in any manner so as to become subject to the Worker's 0w4teh or utl r' e e t
Compensation laws of California. If,after making this certificate of exemption,1 Date:
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.1 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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
fINL and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
ng of this permit.Additionally,the applicant understands and will comply 1 understand my plans shall be used as public records.
all non-point source regulations per the Cupertino Municipal Code,Section
9.18, Licensed Professional
Signature Date
• CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36905017.00
DATE ISSUED. . . . . . . : 12/08/2011
RECEIPT 4. . . . . . . . . : BS000015527
REFERENCE ID # . . . : 11120063
SITE ADDRESS . . . . . : 19811 PRICE AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ADAM JOEL F AND SHARON M TRUST
ADDRESS . . . . . . . . . . : 19811 PRICE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : IE 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, 099.00 1.00 0. 00 1.00 0. 00
1BSEISMICR VALUATION 5, 099 .00 0.51 0. 00 0.51 0. 00
1MPERMITFE FLAT RATE 1.00 44 .00 0. 00 44 . 00 0 . 00
1MRRAA UNITS 1 .00 65. 00 0. 00 65 .00 0. 00
1TRAVDOC FLAT RATE 1 .00 44 . 00 0. 00 44 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 195 .51 0.00 195.51 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 195.51 #12131
---------------
TOTAL RECEIPT 195. 51
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
•
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 950143255
&UPERTINO M ' /1
(408)777-3228•FAX(408)777-3333•buiidino(alcupertino.om ■V_
[-]PLUMBING JA M.LECUANICAL ELECTRICALMvIIISS�CMANEOUS
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OWNER NAAffi'TOe l -Aao-mPHONE 40$ N7 aZ-U�I S/7�.-yE MAIL
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CONTACT NAME IRIOtg E-MAII.
SIREETADORM CmISTAM ffi FAX
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COMPANY NAME• E-IAIL FAX
STREET ADORESS CRY.STAT$ffi PHONE
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OERC LIMON OF WORK. .
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TOTAL VALUATION. 50 ( . 0o RECEWED BY:
By my sipatme below,I eetify to each of the follcwing: I am tha Propertyowaa m cat m imd MMM m act GR thepwpmtf manes behalf. I have read thio
application and the mt'ormadan I have provided is cor ecL`�have read the
Description of Work and verify i[is attardi< t ag[a m oomph/with an applicable tool
otdinmca and state laws relating m - g construction. andsmiae represent of Cupertino m enter the aborvrle1-idepatiied property farinspection po4$¢sea
Sigoatma of Applicmr/AgentrOuuDan: t p4
SUPPLEMENTAL INFORMATION REQUIRED mmice6sr om.Y
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MEPMIscApp Z011.doc revised 06121111
CITY OF CUPERTINO
WWI FEE ESTIMATOR-BUILDING DIVISION
• ADDRESS: 19811 price ave. DATE: 12/08/2011 REVIEWED BY: bobs.ull
APN: BP#: *VALUATION: $5,099
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK re lace existin duct work.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Heating System 1MRRAA 1 # $65
TOTALS: $65.00
Meeh.Plan Cheek 0.0 hrs $0.00 Plumb, Flan Check Eh:r.1'14171 Cb cc/;
Meeh.Permit Fee: IMPERMIT round,.Permrt Fee: Dec. Pernik
• Other Mech.Insp. 0.0 hrs $44.00 Other Plweb be+p. Other ld&a:. imp, Ej
dirk.I n'p. Fee: Plumly. hrsp.Frc•: Glen.Imp. Fee.
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelinina Information available and are onip an estimate. Contact the Dept for addn'l Info.
FEE ITEMS flee Resolniion 11-053 E/T 7/1/11) FEE QTY/FEE MISC ITEMS
Plan ("heck Fec:
.Supp/. 11C'.Fce
PME Plan Check: $0.00
f'c rn it Fce-
,Suppl. lncp Fee
PME Unit Fee: $65.00
PME Permit Fee: $44.00
Construction 'l ire:
Administrative Fee: iADMIN $41.00
Work Without Permit? O Yes (j) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $44.00
Strong_Motion Fee: IRSEISMICR $0.51 Select an Administrative Item
•
Bldg Stds Commission Fee: IRCeSC $1.00
, :
SUBTOTALS: $195.51 $0.00 TOTAL FEE: $195.51
Revised: 12/04/2011
Shnsitified Prescriptive Certificate of Compliance:2008 Re"entlo!RVACAIrrradons CF-IR-ALT-HVAC
Clim b Zona 10 to 15
•
SAN Address;
� 1 �Ci C.•� 14U� Esfarvomd Agen7. Dore: -�-II Permit&
Conditioned Floor
Equipment n fiat 114immnon Ra'iei Dna Insulatian regultenteet Area Thermostat
O Packaged Ung creno 8 ofdaete added a
O Fmmce O APUii O COP_ O Setback
O Indoor Cott OSEE3 OHSPF coplaced in unconditioned apace Served by Vaim pf„aah--d
OCoademfmgUdt OF.Ot_ ORaketauce 13R6 ((Z 10.13) of parent mat be
OOtha ORS (CZ 14,15) lnrtaneg
1.Sga{pn eW 2)iav l2mere the equipment bob;htsadlaet•#Imm than one system,we another CF-IR-ALT-HFACJor'each",vac
2.MbrLmm Equlparnr Effichn wksc 13 MMX 78%AFUE,7 IhMPFfor Optical residiendatnyw=L
HERS VERMCA77ON SUMMARY listed below ere four HVAC altaetlon Optiooa. The installer decides what " done mid
pietr one of the approin am Options. Each Option line the HERS measures that must be conducted.A copy of the ftess 40ILTELIM site ft,find
impectian and a copy given to the homeawnc. At fink tho inspa torvedfics that the wait listed on this num Ms. fit t ygompletcd by tea
imtaliec The mspeeta also vaifics that each appmpdate CF-6R and registered CF-4R Emma(no hand filled CF4Ra allowed) Cdcd oat and
signed. October 1 2014,a registered copy of the CF-1R and CF4R sha0 deo be an site for final hantecdod�
O 1.HVAC Cbsuageout Required Forms:. 1
• AR HVAC Fgaipmest epiaeed CF-6R name MF3 H-K N ECII-21-HERS and(fbreplit systema)WET 25- _
CF-4R Cams: MECH-21 end 0br split a MECH-25 (:
• Condanstar Cil and/a CF-6R forme MEC8-21-ITERS end(fa split systema)MECH-25-FISS .
IaF��7 and/a CF4R forms: MEM-21 and fbr (�1
( tplh systems) MECff-75 \ O
For.SpNt Systeme:Dud leakage<15 percent RC,CCA>_300 CFMAo n(Minimani Air Flow Re4airaoent),')3"M\
"For Packaged Units: Duct leakage<15Percent �J
Ex=q ted from duct leelage testing if!
O 1.Doctsysean war doccumanted tohave been previously soled and confirmed through HERS verifiatioh,a 1
.. 132.Dad systema with las then 40 lioew fed In unconditioned space,of
O 3.Existing dust syvshanniemconstructed,moulded or smled with asbestos
O 2.New HVAC System Required Forma:
g tot is aCtangcour who d - CF-6R fame: MECH-04,MEM-20ZERS ..
• dace:(add new non"w" elk .end(for split systema)MBCFFi-22-}p•RS,and MFfl1-25-HEILS
new (]+4R forms: MF.CH 20.,and(fnrepFit ayesam)MECEI-22,and MECH 25 .
For Split Systems:Dud leakage<6 percent;RC.CCA?350 CFMltou.FWD,TMAH,SEMS,and either HSPP 2r4WP.
For Packaged Units:Duct leakagee<6 t
❑3.NewDutds with lRe hlcement Regullred Forma:
a lafides replacing or kmm0tsg all new ducting CF-6R 0arms: MWEE-04,MWW20•FIDtAnd(for split events)is�CF3 MARS
and/or outdoes cadencing unit md/or indoor CF-4R forms NECH-20 and(fa split sym®e)MECH-25 84 C p�
cufland/a5ana e. Notallegmpmeotchanged. Y
For Split Systems:Dud leakage<6 percent,RC,CCA?300(FMAon,TMAH .
For Packaged Units:Dud leabita<6 Percent -
4.Now Da over 40 feet I RequiredForms:
a batudes adding arepeemgmae than 40 CF-6R hams MECH-04.MECFf-21 11M CF-4R forms MKH-21
Iineerfrd of duct in oneonditionedspace. I
F.or spat system or packaged mots: Duct leakage<15 percent
Q EXCEPTION:Fidstion dadmens hsulatd or scaled with WiLSm9.
Contractor(Documentation Aothibei/Responsible Designer's Dedaration Statement)'
.. I madly the tINe Cgdfiam otCoupiimmm doemoeotedme aawete and complete. .
•a .Ism c6g3k alderlYvidmizfffteCWifW*Pwdzess eadProfasiom Coda to aceptretpom'6ility forthe deep Identified anthis Certificate of Compliance
a jccay WsthecuMfiantra md.pafa®regrcsifiatimu Pathe dedga idecti0d mtha Cea6mm ofCamydimro coafam to the mgcdmmne of Title 24,
FLe I ail dcif the Cihfmnya,Co4o"?fRgnleriooa..
a The design fia utesidatiged an m's Ccn$ce s ofCemplisaa fie emilacutwith Poe bdbrmtim doe®eated anotheraWiable compliance forms,No 1W ces,
ths andspeciAcedonicalianiftod to tlx mihra®t flw oval whh Oe t iimsaioa
NeaO MAXINE BROOKS
Com' SERVICE CHAMPIONS
Addma:
�5tr/Se+ p I t.'ti 5011 rbn Get tj --77 Phone qZ5 yY l yk y
• 2W8ResholantialCattpitanceFarmr March 2010
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
.U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: q q S 11 (P/-1 Gt' U e, PERMIT# 2 e
OWNER'S NAME: 7 e,l Aci0kV1j PHONE# yD(9 yea-OVS l
GENERAL CONTRACTOR: St✓rU tC>e� lMS BUSINESS LICENSIE.^#
ADDRESS:1020 L'ONdJtM rC'0— Or CITY/ZIPCODE: tea54 -t\tUbt gg5'9V
*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. c.{�
1 am not using any subcontractors: V"'a4�t� 1 S;_
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