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12020017 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: I 1140 SANTA TERESA DR CONTRACTOR:SERVICE CHAMPIONS PERMIT NO: 12020017 OWNER'S NAME: CONWAY JILL,l TRUSTEE 7020 COMMERCE DR DATE ISSUED:02/06/2012 OWNER'S PHONE: 4082573377 PLEASANTON,CA 94588 PHONE NO:(925)444-4444 /LICENSED CONTRACTOR'S DEC,LARATION BUILDING PERMIT INFO: BLDG ELECT t u PLUMB License Class ✓ Lic.# -1040 MECH RESIDENTIAL ' COMMERCIAL Contract r Date 1'(9I Z JOB DESCRIPTION:REPLACE FURNACE ONLY 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 frill force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 37/00 of the Labor Code,for the performance of the work t6r which this permit is issued. Sq.Ft Floor Area: Valuation:$5411 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. APN Number:35617025.00 Occupancy Type: 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 acrd 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 DA S FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply �J with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date• 71 ( 9.18. rr//�� /n� ^�' � Signatur0 .;��1� Date RE-ROOFS: ❑ OWNER-BUILDER DECLARATION All roof.-,shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for I hereby affirm that I am exerupt from the C'ontractor's License Law for one of inspection. the following two reasons: L as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will dig the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) L 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 3',•00 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(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by .additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,f6r the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 certify that in the pert6rmance of the work for which this permit is issued,I shall not employ airy person in any manner so as to become subject to the Worker's O e Compensation laws of California. If,after making this certificate of exemption,I Date: t��CDM 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.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 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, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulatio€rs 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 356170:5.00 DATE ISSUED. . . . . . . : 02/06/2012 RECEIPT #. . . . . . • • • : BS000015932 REFERENCE ID # . . . : 12020017 SITE ADDRESS . . . . . : 11140 SANTA TERESA DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER CONWAY JILL J TRUSTEE ADDRESS . . . . . . . . . . : 11140 SANTA TERESA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4767 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 5,411 .00 1. 00 0 . 00 1.00 0. 00 1BSEISMICR VALUATION 5,411 .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 #13052 --------------- TOTAL RECEIPT 260 .54 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C O P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: j I)-1 C: -�c�,,�l'3�t:�. PERMIT# V Com` c> I OWNER'S NAME: PHONE# `cA GENERAL CONTRACTOR: ,rt; ('�itC3� is ytS BUSINESS LICENSE # ADDRESS: 7CZv ' :A-,,,4tt,&j 0/ CITY/ZIPCODE: 1c �rc�ta *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. I 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 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION °' ADDRESS: 11140 Santa Teresa Dr. DATE: 02/06/2012 REVIEWED BY: A. Salvador APN; BP#: "VALUATION: 1$5,411 ®� PERMIT TY'PE: Building Permit PLAN CHECK TYPE: Alteration /Repair PRIMARY" PENTAMATION FURN/AC USE: SFD or Duplex PERMIT TYPE: WORK Replace Furnace Only SCOPE Mech7PIanCheck 0.0 hrs $0.00 h.Perrnit Fee: 111PERMIT Other Mech.Insp. 0.0 hrs $44.00 Li NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These ees are based on the g=EaLaLifornwtion available and are only an estimate. Contact the De t or addra't info. FEE TY/FEE MISC ITEIVIS FEE ITEMS Q Plan Check Fee: $0.00 = # Mechanical Suppl.PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $130.00 1MFR=<100 Furnace,Forced-Air PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-.0 Reg. Q OT Q,Q hrs $0.00 PME Unit Fee:: $0.00 PME Permit.Fee: $44.00 Administrative Fee: 1.4DMIN $41.00 0 Work Without Permit? 0 Yes 0 No $0.00 G $0.00 Select a Non-Residential Q Building or Structure Q Travel Documentation Fee: ITR.4vaOC $44.00 +;rare LI 1 f1tFee: IBSEISMICR $0.54 Select an Administrative Item v<i .( ornigiissio r eee IBCBSC $1.00 SUBTOTALS: $130.54 $130.00 TOTAL FEE: $260.54 Revised: 1/19/2012 Simplified Prescriptive Certificate of Co Bance:2008 Residual HVACA&eratiorrs CF-IR-ALT-HVAC Clim:h Zones 10 to 15 S&e A �Vl� Enjbricanent'gew-7'_ Data Pervi t#. Conditioned Floor EquipmentTyle! List Whilman F.fiici Duct insulation requirement Area Thermostat Q Packaged UnitOver 40 ft of ducts added or Ig Setback IF Furnace it AR `T`� Q COP replaced in u xemclitionod spar Swvc d by system (Yfnm olracdy Q Indoor Coll QSm Q MPF_ Q R 6 (CZ 10-13) sf prem must be Q Condensing Unit Q EM Resistance Q R 8 (CZ 1445) 1 D Other L EquWasod Tye Chancre the eguWM=t being usstalleaC lfJnwe than one sjw4w4 ure another CF-1R-A-LT-HVACfor'each rysrew 2.Mbri mm EquWasart Effackocim 13 SEEN.78%AFW 7.7hWFfor 0VAcd raidantial s)wvvM HERS VERIFICATION SIJI(MARY Listed below ate Seta HVAC altaatim Options.The installer decides what work is being done and picks one of the appropriate Options. Each Optica lists the HERS measures that mast be conducted.A copy of the forms shall be left on site for final inspection and a copy given to the bomewmer. At final,the inspects verifies that the work listed on this form was in fact the work completed by the installer. The inspector also vedfies that each appropriate CF-6R and registered CF-4R forms(no hand filled CF41ts allowed)are filled out and si October 1,2010,a registered copy of the CF-IR and CF-6R shall also be on s11e for final bapecdoiL 1.HVAC Chian at Re9ns ed Forms: t replaced CF4R I MECH-�MECFb21-HERS and(far split systems)MECH-25-HERS • Ali HVAC Equipment CF-4R trans: MELM-21 and for split MECH-25 • Condenser Coli and/or CF-6R fomw MI3CH-21-HERS and(for split systems)WM-25-HM • Indoor Coir and/or CF-4R farms MECH-21 and(for split systems) MECH--25 • Furnace Fer.Spat Systema:Duct leakage<15 perceait; RC,CCA>300 CFMAon(Migittsuun Aa Flow Requirement),TMAH For Packaged Units.- Duct leakage<15 pezvent Exempted fiotn dud leakage testing ii: Q 1.Iaoct-system was documented to haw been previously sealed and confirmed through ITERS verfcabon,or Q 2.lard systems whit less than 40 liner Seat in unconditioned space,or Q 3.Existingduet are ,insulated or sealed with asbestos O 2.New HVAC System Required Forms. a. Cot in or Changed with new - CF-6R foams: MECH-04,MECH 20-HERS,and(for split systems)M WH 22-HERS,and MECH-25-HERS duds:(all new dactinggd aft CF-4R 6 M SCE120-,and(for split systems)MEM-22,and MECH 25 . new For Split Systems:Duct leakage<6 P RC,CCA>_350 CFM/toa,FSHD;TMAK STV�S,and either€ISFP or ME For Packaged Units:Duct kala <6 t ❑3.New Ducts with Replacemew ReVired Forms: • Includes replacing or hi alling all new ducting CF-6R farms: MCH-04,IvBC%-20->TIF2tRS,*nd(for split systems)N E H 25-HERS and/or outdoor condensing unit and/or indoor CF-4R forms:WCH-20 and(fret split systtma)NMI-25 coil and/or furnace. Not all went changed- For Spat Systems:Dad leakae<6 percent;RC,CCA>_300 CFMAon,TMAH For Packaged Unft Duct leakage<6 ❑4.New Dn over 40 feet 'red Forms: • bscfides adding or replacing more than 40 CF-6R fpttas: MECH-04,MECH-21 HIR.S CFAR farms: MECH-2 E linear Sod of duct in unconditioned space. I- For spat system orpaclaged units: Duct leakage<15 percent Cl EXCEMON:Emsting dot qsb=w w=lrncb4 insaiated or waled with asbestm C�tractor(Documentation Anther`s/Responsible Desiner's Declaration Statement) • I certify dot this Cadfieate ofConspilmce doewnentstim is awwata sad complete. : -I am elignWnaderDivicicn 3-of ft Cd fomk Business and Professions Cade to accept responsibility for the design;doffed as this Catilicate of Compliaom I ccs ft*9 Me encu aod.pufb mtmce apaaficatiow for the design ideatifwd m this Certificate of Cmupliance conform to the ro*rcmenU of Tide 24, 'Parts J and 6�the(atifiorn`ta•Cade-of$egalatioas... • The design feawmideatifmd m Ens Orl cam of Compliance are crosk mtwith the infotmstim doemented on other applicable compliance forms,wodmhees, ins andspecil5caiians std 0 the 06mensat av=M for aMwmlw with the gooGcatioa N.mc IMAXINE BROOKS - Srgae: i Com' SERVICE CHAMPIONS Dam: Address: "t 1 0,Z O ��/)') "' ��8170410 tty/State2ipc f�f� Se+vd`) �C7� LJ �Y7-`_Y"` 2008 Residewid Compliance Forums Murch 2010 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION �a 10300 TORRE AVENUE,CUPERTINO,CA 95014-3255 MISC(408)7T7-3728- FAX(408)777-3333-buHding(c7cupq no_orc, CUPERTINO ❑PLUMBING ' q MECHATTICAL ❑ELECTRICAL ❑NUSC r I ANEOUS F S (1 1 {L) ' �.4 `r/� T�i e`�,� ✓� AFN# `J 1-1 0�5 t` / PHONE E'MAI j, G ;S-7- 3 7 7 srxEsr ADDRESS ,STw�. it� !� �AV1{'�Ft�.-✓`�-�'� �� ✓�C 'T PHONE E-MAIL CONTACT DER CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT 0 ARomECT 13 Et+GR7 ❑ DEVELOPER ❑TENAw LICENSENUMBER jCWM TYPE BUS.LIC$ CONTRACTOR NAME ,ZU FAX COMPANY NAMF)6 �r, j&# E IL Q p�j STREET wDDRESS J CITY.STATE.ZIP�GL L s� 1 LI)� jj�� yyy-�ryy L � k fC �� [l� I ARCHITECT/ENGINEER NAME LICENSE N�Fx US.Btic# E44AIL FAX COMPANY NAME CIPHONE STREET ADDRESS TY,STATE,ZIP SFD err DUPLI7t [3MULTI-FAMILYPROJECT IN WILDIAND 13 YES PROJECT IN ❑YES USE OF IICHLIIt HOMfi? E3 No BUIL D WCt ❑COM ERCIAL URBAN INTERFACE ARF ❑No FLOOD ZONE ❑NO DESCRIPTION OF WORK `4?' 07A—RECEIVED BY: TOTAL VALUATION: "� By my sigaatttce below,I certify m each of the fiollowing: I am the property owner or anthorized agent to act on the propary ownces behalf I have ream this application and the information I have provided is correct,j have read the Description of Work and v=jfy it is=MLA f I agree to eon�lY Wide all applicable local ordh=ces and State laws relating m g cons; I anthori=representatives Of Cupertino to=ter the above-ideudfied property for inspection pUP=S. Date: z 5ignatirre of ApplicaadAgeat- STJPPLENiE`1TAL INFORMATION REQU= OFFICE USE ONLY ea ❑ OVER-THE-COUNTER ❑ EMPRESS x U rr ❑ STANDARD T U < ❑ LARGE J G ❑ M.UOR MEPMucApp Z011.doc revised 06121111