12050133 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21745 COLLINGSWORTH ST CONTRACTOR:ATLAS-TRILLO HVAC PERMIT NO: 12050133
OWNER'S NAME: GEORGE YANO 1965 KYLE PARK CT DATE ISSUED:05/162012
OWNER'S PHONE: 4082531862 SAN JOSE,CA 95125 PHONE NO:(408)286-8931
LICENSEDCONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U CODINIERC1AL
License Class ic.q
b ?)e3i 3- REMOVE AND REPLACE A/C IN SAME LOCATION
Contractor
1 hereby affirm that I am - ensed 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.
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.F1 Floor Area: Valuation:$5000
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:35617068.00 Occupancy Type:
permit is issued. -
APPLICANT CERTIFICATION
I certify that I 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 stale laws relating WITHIN 1 0 YS 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 ISO DAYS M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the / 2�
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: — p
with all non- oint soureeTegul nto Cupertino Municipal Code,Section
9.18. F-
.C_ R -ROOFS:
Signature ---- —Dale—v ��s.� / 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
1 hereby affirm that 1 em exempt from she Contractor's License Law for one of Signature of Applicant: Date:
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) -
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS 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. 1 will
1 hereby affirm under penally 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
Are 'SQuality Management District l
performance of the work for which this permit is issued. will maintain compliance with the Cuper no M nfcipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S ti s 2 5 ,25 ,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this S
permit is issued. f 6 I
Owner or authorized agent: Dale:
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 as to become subject to the Worker's
Compensation laws of Cal ifomia. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,1 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 stale 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 ARCHITECT'S DECLARATION
and keep harmless the City of Cupertino against liabilities,judgments,
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 Date
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: counter
COPY # 1
Sec: Twp: Rng: Sub: Elk: Lot :
APN . . . . . . . . : 35617068 . 00
DATE ISSUED. . . . . . . : 05/16/2012
RECEIPT #. . . . . . . . . : BS000016840
REFERENCE ID # . . . : 12050133
SITE ADDRESS . . . . . : 21745 COLLINGSWORTH ST
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : GEORGE YANO
ADDRESS . . . . . . . . . . : 21745 COLLINSWORTH ST
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4708
RECEIVED FROM . . . . : ATLAS TRILLO
CONTRACTOR . . . . . . . : TRILLO, STEVE LIC # 4269
COMPANY . . . . . . . . . . ATLAS-TRILLO HVAC
ADDRESS . . . . . . . . . . : 1965 KYLE .PARK CT
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 286-8931
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, 000 . 00 1. 00 0.00 1.00 0. 00
1BREMAIRHA NO.UNITS 1 .00 65 . 00 0.00 65 . 00 0. 00
1BSEISMICR VALUATION 5, 000 .00 0 . 50 0. 00 0. 50 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 195 . 50 0 .00 195. 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
------- --------------- -----------
CHECK 195.50 5340
---------------
TOTAL RECEIPT 195. 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- --------------- ---- -------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 mamI S C
CUPERTINO (408)777-3228 FAX(408)777-3333• buildina(dCuoertino.org 2 2
El PLUMBING NICAL EIELECTRICAL MISCELLANEOUS 1 50�33
PROJECT ADDRESS APN n •� O / ry
OWNERNAME -MAIL W V
5 T D CITY, S FA%
CLuj, IV 6S[A JA-krt4-
CONTACT NAME PHONEEMAIL
STREETADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BURDER ❑ OWNERAGEN CON, CTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑E1GNEER ❑ DEVELOPER ❑TENANT
.T T R N17Q LICENS NU LICE.' ' BUS.LIC e
AD SS k&e 29 Y—
AR 11TECT/ENGINEER. ME LICENSENUMBER BUS.LICK �V�7
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ FRILTIFAMILY PROJECT P'WILDIAND ❑ YES PROTECT LV ❑NuIS THE BLDG AN ❑ YESBUILDING: ❑COMMERCIAL URBANINTERFACEAREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
—
Al
TOTAL VALUATION: < RECEI\'ED BY
By my signature below,I certi to each o e follow g: 1 am the operty owner or authorized agent to act on the property owner's behalf. 1 have read this
application and theinPortnatio 'have ro-id cl. 1 ha• e Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and sate laws relati g to ilding co tuon. on sentatives of Cupertino to rnter the above-id ifif a rop "four inspection pulposes.
Signature of ApplicanUAgem: Date: V 1 ��J
SUPPLEMEN L INFORMATION REQUIRED OFFICE USE ONLY
OPER-THE-COUNTER
❑ EXPRESS
Y
U
❑ STANDARD
U
< ❑ LARGE
c ❑ MAJOR
AIEPA1iscApp_2011.doc revised 06121111
_I .
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 21745 Collingsworth DATE: 05/16/2012 REVIEWED BY: gs
APN: BP#: 'VALUATION: $5,000
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK replace a/c unit in existing location.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $65
TOTALS: $65.00
Meeh. Plan Check 0.0 Ins $0.00 Plumb. Plan Check Elec. Plan Chrck
Meeh. Permit Fee: IMPERMIT Plumh. Pel mil Fac: tiler. Permit Fee:
Other Mesh. Insp. 0.0 hrs $44.00 Other Plumb Insp. Lj
Odter Elen hnp. El
.I lac h. Iny. (','e: Plumb. ht.ep. Fre: filo. perp. Pec:
NOTE: This estimate does not includejees due to other Departments(ie. Planning,Public Works,Fire,Sanitary Sewer District,School
District,ere). Thesefees are based on the prelimina information available and are only an estimate Contact the De 1 or addn 7 info.
FEE ITEMS (Fee Resalution 11-053 E1I 71111ll FEE QTY/FEE MISC ITEMS
l'lun Check Fee:
.1uppl. PC Fete
PME Plan Check: $0.00
Pertnir Fee:
Sapp/. trap Feu
PME Unit Fee: $65.00
PME Permit Fee: $44:00
Cunsvrurtion Tas.
Administrative Fee: IADMIN $41.00
Work Without Permit? O Yes 0 No $0.00
Advatrced Phu mirW Pecs:
Travel Documentation Fee: ITRA VDOC $44.00
Shrong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $195.50 $0.00 TOTAL FEE: $195.50
Revised: 04/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3229
C U P E RT I N O Fax: 409-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: S -PERMIT#
OWNER'S NAME: PHONE # Leff) 31
GENERAL CONTRA TOR. BUSINESS LICENSE
ADDRESS: CITY/ZIPCODE:
*Our municipal code requirks all businesses working in the city to have a City of Cupertino us ess licen,e.
NO BUILDING FINAL OR FINAL OCCUPANCY I ECTION'(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALLUB ON C RS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
1 am not using any subcontractors: ( C�
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 Roc
Tile
i
i
Owner o tractor Signature Date
c —
Sipled Prescriptive Certificate of Conip 2008 Residential HVA C Alterations CF-3R-ALT-HVAC
mifi
Climate Zones I and 3-7
Enjorcemenr Agency: ar Pm rnir N:
LJ Conditioned Duct insulation
Equipment T e List Minimum Efficiency' Floor Area requirement Thermostat
O Packaged Unit Over 40 it of ducts '
O Furnace O AFUE O COP Served by system added or replaced in Setback
El indoor Coil BER .O HSPF-_ (foot aL eadl:yrerenq mart be
❑Resistance sf unconditioned space installed)
ndensing Unit _ ❑R 6 (CL 1,3-5)
O Other
/.Equipment Type: Choos the equipment being installed,if more than one system,use another CF-IR-ALT-HVAC for each system:
2.Minimum Equipment Efficiencies: 13 SEER,78%AFUE,7.7HSPF for typical residential systems.
Contractor(Documentation Author's/Responsible Designer's Declaration Statement)
ccrtify that this Certificate of Compliance documentation is accurate and complete.
• I am eligible under Division 3 of the California Business and Professions.Code to accept responsibility for the design identified on this
Certificate of Compliance.
• I certify that the energy features and performance specifications for the design identified on this Certificate o ompliance conform to the
requirements of Title 24,Parts l and 6 of the California Code of Regulations.
• The design features identified on this Certificate of Compliance are consistent with a information cumented o other applicable
compliance forms,worksheets,calculations,plans and specifications submifttotikerforcemen envy for app oval with the permit
implication.
Narc: Signalul
Com p'nnY' Date:
E�
Addre r _ License: J�
CiIY/Stale/Zip: Phone:
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