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12050111
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23350 SERENO CT V26 CONTRACTOR:SANDIUM PERMIT NO: 12050111 OWNER'S NAME: RER'rHOLD,JOHN R TRUSTEE ASSIGNEE 4223 VERDIGRIS CIR DATE ISSUED:0511 1 201 2 OWNS 'S PHONE: 6509657801 SAN JOSE,CA 95134 PHONE NO:(408)894-9072 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL. LicenseClassC2--v Lic.N &Sk l j REPLACE FURNACE AND A/C AT SAME LOCATION Contractor SaNnr u 7 Date S- / I. 12 I hereby affirm that 1 am licensed under the provisions of Chapler 9 (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 penally 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 3700 of Elie Labor Code,for the performance of work for whichthis permit is issued. Sq.FI Fluor Area: Valuation:$9500 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 APN Number:34255011.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I ccnil}'that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I aunt 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 7 LAST CALLED INSPE TION. indemnity and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the �, / granting of dais 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. q Rf:ROOFS: Signmu �iV V Date ` y 2 All roofs 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 inspection. ❑ OWNER-BUILDER DECLARATION I hereby affirm that I em exempt from the Contractor's License Lew for one M Signature of ApplieanC Date the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BF.7TER I,as owner of the property,or my crployces with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sce.7044, Business&Professions Code) 1,as owner ofthe property,am exclusively contracting with licensed contractors to ILAZARDOUS MATERIAL S DISCLOSURE: construct the project(Sec 7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code.Sections 25505,25533,and 25534. I will I hereby affirm under permit} 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 I use equipment or devices which emit hazardous Compensation,as provided for by Section3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District l 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 Health&Safety Code,See ' s 5505,25533,and 25534. Section 3700 of the labor Code,for the performance of the work for which this permit is issued. Owner or authorized agent: Date: I certify Thal in the performance of toe work for which this permit is issued,I shall not employ any'person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGE:NCV 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 perlbm,ance of forthwith comply'with such provisions or this permit shall be deemed revoked. w'ork's for which this permit is issued(Sec.3097.Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify Ihm 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 of Cupertino against l iabilitics,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the 1 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 Date Simplified PrescriptiveCertificate of Complinnie:2008 Residential HVACAIterations CF-IR-ALT-HVAC Climate Zones I and 3-7 Sire Address: EnforeemewAgency: Date: Permit p: 23SS� Se3ru� G-E . Conditioned Duct insulation cm T u List Minimum Efficien Floor Area requirement Thermostat Padraged Unit --ff Over 40 it of ducts ornate AFIJE ®COP Served by system added or replaced m Setl>a<k Indoor Col SEER HSPF (lfrmr ahmdypresmr.murr be lensing unit 0 EER ©Resistance sf unconditioned space aumaeo 13 Other [31L 6 (CZ 1,3-5) . 1.Equipmeat Type:Choose the equipment being btstalled;if more than one system,use another CF-1 R-ALT-HVAC fm each system. 2.Minimum Equipment Efliiclencies:'13 SEER,78%AFUE,7.7HSPF far typical residential systems. Contractor(Documentation Antbor's/Responsible Designer's Declaration Statement) • I certify that this Certificate of Compliance documentation is accurate and complete. • I am eligible under Division 3 of the California Business and Pro ssiom Code to accept responsibility for the design identified on this Certificate of Compliance. • 1 certify that the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the requirements of Tide 24,Parts I and 6 of the California Code of Regulations. • The design lbanaes identified on this Certificate of Compliance are consistent with the information doamented on other applicable compliance forms,worksheets,calculations,plans and specifications submitted to the enforcement agency for approval with the permit application. Name: Signehae: Company. _ 1 . _ Datc CJ�p/p�Ql 1 I Z Address: 423 l : . ' /'.N' License: Ciry/Slateaip: '_ Gam(• Phone: 2008 Residential Compliance Forms.doc revised 04/10/11 CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Secl Twp,: Rng: Sub: Blk: Lot: APN, 34255011. 00 DATE ISSUED. . . . . . . : 05/11/2012 RECEIPT #. . . . . . . . . : BS000016796 REFERENCE ID # - . . : 12050111 I SITE ADDRESS . . . . . : 23350 SERENO CT V26 SUBDIVISION . . . . CITY . ... . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER BERTHOLD, JOHN R TRUSTEE ASSIG ADDRESS . . . . . . . . : . : 23350 SERENO CT V26 CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : SANDIUM CONTRACTOR . . ... . . . : MICHAEL LEE LIC # 28867 COMPANY SANDIUM ADDRESS .1. . . . . . . . . : 4223 VERDIGRIS CIR CITY/STATE/ZIP . . . : SAN JOSE, CA 95134 TELEPHONE . . . . . . . . i (408) 894-9072 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- lADMIN HOURS I 1 .00 41. 00 0. 00 41 .00 0. 00 1BCBSC VALUATION 9, 500 .00 1. 00 0. 00 1 . 00 0. 00 1BREMAIRHA NO.UNITS 1 .00 65. 00 0. 00 65.00 0. 00 1BSEISMICR VALUATION 9, 500 .00 0. 95 0..00 0 .95 0.'.00 1MFR=<100 UNITS 1 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 325. 95 0. 00 325 .95 0. 00 METHOD OF PAYMENT 1 AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 325.95 VISA --------------- TOTAL RECEIPT 325.95 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION 1"NADDRESS: 23550 Sereno Ct DATE: 05/11/2012REVIEWED BY: Sean OMNI APN: BP#: -VALUATION: $9,500 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: WORK Furnace and A/C replacement same location. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAIR 1 # $65 Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: $195.00 Meeh. Plan Cheek 0.o hrs $0.00 Phiwh. Plan Check Mech. Permit Fee: IMPERMIT Plrurrh. !'crn,ir l4 " hart. l\v... I —LOther Mech. Insp. 0.0 hrs $44.00 a;her!'h,mh ln,p. Urh lClc _ b: a. llrrh hr y;. h2r Phrurh_ Ah", lrr,n. 14'... NOTE: This estimate does not include fees due to other Departments(Le. Planning, Public IVorks, Fire,Sanitary•Sewer District,School District.etc. . Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addr;7 in o. FEE ITEMS (tics Kcsolalion 11-053 E!L 71111l/ FEE QTY/FEE MISC ITEMS Phoe ('11ce k l'er: PME Plan Check: $0.00 l'crrni! l',rr: PME Unit Fee: $195.00 PME Permit Fee: $44.00 C'nr>.w)lo lion To..%: Administrative Fee: 1ADMIN $41.00 Work Without Permit? O Yes (F) No $0.00 ,Lhsurt"d lVunnirh Vccs: Travel Documentation Fee: ITRAVDOC $44.00 Strong Motion Fcc: IBSEISMICR $0.95 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $325.95 $0.00 TOTAL FEE: $325.95 Revised: 04/01/2012 GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DNISION I 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 I A CUPERTINO (408)7T7-3228•FAX(408)77773333• buildinGfa.cuoertino.orG /v_ ZZ 0 ) PLUMHINNG ❑MECHANICAL ELECTRICAL ❑MISc a�US I PAOIER ADDRESS �y " I a'- . Gam+. /Z C J o l ! OWNER NAME K' .I - �,r}{,`'�1d CNSo _` PHONE EMAIL STREET ADDRESS 5, • L CITY.STATE4 ZtP -1I rV FAX CONTACT NAME PHONE I STREET ADDRESS CITY,STATE, ZlP FAX ❑OWNER ❑ OWNER-aum.Om ❑ OWNERAGFNT NTAACTOR ❑CONTRACTORAGENT ❑ AItCIc= ❑PNOpIIDt ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME 1./�•- Q _ ( UA, LICENSENA LICENSE TYPE BUS.LICA COMPANY NAME I E-MAIL _ FAX STREETADDRESS L SM .Cv� QTY.STATE,ZIP C! Q F1� PHONE 4AtTi-%-z Z ARCHTTECTIENGTNEFR NAME LICENSE NUMBER BUS.uC a COMPANY NAME E-MAB. FAX STREETADDRESS CITY.STATE,Z@ PHONE USE OF mOrIPlFJr ❑ MULTI-FAMB.Y -PRDIFLTINWBDLAND ❑ YES PROIECTIJ ❑YES ISTIIESLOGAN ❑YES BUILDING: ❑COWMaAL URBAN INTERFACE AREA Er* FLOOD ZONE [3 NO ER]IJ:R HOMET ❑NO DESCRIPTION OF WORK } TOTAL VALUATION: Sop RECEIVED BY: Sy my signauue below,I certify to each of the follloowing. I am the pmpelty owum m amhorized agent m act on the property awner's bchalE I have read this application and the iffbrmation I have provided is canrocLj have read the Description of Work and vetify it is accurate. I agree to comply with all applicable local ardmarDces and state Taws rtJatmg to coustruetio0. o^+^represeatatives of Cupertino to enter the above-ideadD9e property for inspection pu@jDases. Signature of ApplicaoVAgeaD Date: SUPP AL INFORMATION REQLMtED OFFICE USE ONLY m OVER-THE-COUNTER 6 ❑ CRESS Y u ad ❑ STANDARD u 3 ❑ LARGE ❑ MAJOR MHPMtrcApp_2011.doc revised 06/21111