09050137 CITY OF CUPERTINO (I TI A�"TC?R I t? �T
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
21690 OLIVE ATLAS-TRILL PERMIT IssUEDATE
OWNER'S NAME:
Q r-
9 CONTROL NO.
7
(408) 286 BUILDING PERMIT INFO
ARC HIT_CT/ENGINEER: BLDG ELECT PLUMB MECH
u p a LICENSED CONTRACTOR'S DECLARATION Job Description
V
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RMV & RE P LC FURNACE
n=y in full force and eft & �
License CI L] LK•S
Date Contractor
3 ARCHITECTS DECLARATION
aI understand my plans shall be used as public records
A.
4 C y Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
t m which requires a permit to construct.alter,improve,demolish,or repair any structure
prior uh its issuance•also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
fret he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $2000 000
Yi-G (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
� that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant fox a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500). 3 5 7 2 10 0 6 . 0 0
❑1,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 Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a comractor(s)licensed pursuant to the Contractor's
License Law. B&P C for this reason
❑I am exempt under Sec
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
Ove and will maintain a Certificate of Consent to self"nsum for Workers Compen-
_./on,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
have and will maintain Workers Compensation insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workees_C/ompennsation rance ca er and Policy number am:
Carrier. �/ I Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cnis section need not be completed if the permit is for one hundred dollars($100)
or less)
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 Workcrs'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z h CONSTRUCTION LENDING AGENCY
F.o rA I hereby affirm that them is a construction lending agency for the performance of -
�, m7 the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
�Z Gender's Address
U 0 1 certify that 1 have ad this application and state that the above inform
reation is
LL"
sorters.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
mH,o to liabilities,judgments,costs and expenses which may in any way accrue against said City r ^ -70 y
V Z in consequence oC g of thls Ix rrthit. Date J L
►- APPLICANT�c ran As JILL COMPLY Wa7/71-7
NT Issued by:
sovecrGUi _ Re-roofs
�._
Signature of Applicant/Contractor ate T Of Roof
MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino un ipal Code.Chapter 9.12,and the Health and Safety
Code.
Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
E]Yes a If a roof s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
'L hazardous air contanu72ntS defined by the Bay Area Air Quality Management all new n materials for inspection.
strict?❑Ycs
___..
1have read the hazardous materials requirements under Chapter 6.95 of the Califon-
nia Health ty Code,Sections 25505.25533 and 25534.1 understand that if the building
does current have a tenant,that it is my responsibility to nouf the Occup t or the Date
ire mrM mel r to issuance of a Ccnificatc o cuyan • i Signature of Applicant
— (� All roof coverings to be Class"n"or better
Owner or authorized agent Date
v� 0L51
CITY OF CUPERTINO
FURNACE/AC
CUPCITYEf�TINO PERMIT APPLICATION FORM
APN # � n � � .
ate:
Building Address: t ,y
v j �/ it
Owner's ame: Phone
-;04
0_-Y O-01 _
Contractor: Phone#:
/,4 c Fax#:
Contractor License M Cupertino Business License#:
Contact: Phone#: ,ti
Fax#:
Building Permit Info:
Elect E3 Plumb Mech 0-------
Residential Commercial
Lj
Job Description:
For Residential Installations:
Attic El
floor [� 2°d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Pro" ct: Type of Construction (Usage Class):
X 6 6 0
Strapped On Platform BondedNew Location Replacement
Project Size: Express [�Standard ❑ Large 11] Major❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 01/07/09
CITY OF 4,UPERTINO
FURNA
CE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1MCRAA Commercial-Repair/Alteration/Add to M
ea heating appli ince,refrigeration unit,
cooling unit,abs:)rption unit,or ea
heating,cooling,absorption or
evaporative cooing system,incl
installation of controls regulated by this
code.
1 MCREPALT Commercial for the repair of alt/add to M
ea heating appEmce,refrigeration
unit,cooling unii,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of co rrtrols regulated by
this code.
1 MCSUSHTR Commercial Ins-:all/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted uait heater.
1 PGASCOM Commerical for ea gas piping System P
1-4 outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appliance vent
installed ¬ i:icl in an appliance
permit.
1BCBSC Cal Bldg Standa-ds Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
1 MRRAA Residential RepE.ir/Alteration/Add to M
ea heating appliznce,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,,Lb sorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
CITY OF CUPERTINO
FURNACE/AC
CUP TYOF O FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Grou
1 MRAPPVNT Residential for-he install/relocate/or M
replacement of-.a appliance vent
install ¬ incl in an appl permit.
FURNACE
FURN/AC
1PGASRES Residential for ea gas piping system of P
1-4 Outlets
1 BPGAS For each gas piping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Residential Seismic B
IMEr1MFR=<710)0
f-Fumace
l Plan Check M
yst<==100k BTU install or M
for:,ed-air/gravity type
rner, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
1 MFRN>100 Furnace Syst 100k BTU install or M
relocate ea foi ced-air/gravity type
furnace/burne incl ducts/vents
attached to su:,h appliance over
100,000 Btu/l.
/ 1 EPERMITFEE Electric Perm it Fee E
I 1MPERMITFEE Mechanical Permit Fee M
' 1PPERMITFEE Plumbing Peimit P
1TRAVDOC Travel Documentation B
1BUSLIC Business Lica;nse B
Community Development
10300 Torre Avenue
' --' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
TPEkTINO
Buildi[ng Department
JOB ADDRESS: PERMIT # N j I �
0 VQ- -e '
OWNER'S NAME: Ka {9AGL p PHONE #
GENERAL CONTRACTOR: a J, H VA C FAX#
I am not using any subcontractors: ------.--.- .- �
Signature Da e
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSI:vESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contrac or ignature Date
INPUT Rescwrces Energy 1AWHealth
I.Windows
1.Install Energy-Efficient Windows
a.Double-Paned 1 Energy pt Y--yes 0
b.Low-Emissivity(Low-E) 2 Energy pts y=yes 0
c.Low.Conductivity Frames 2 Energy pts y=yes 0
2.Install Low Heat Transmission Glazing 1 Energy pt y=yes 0
Em1 1 !
J.Heating Ventilation and Air Conditioning
1.Use Duct Mastic on All Duct Joints 2 Energy pts y=yes 0
2.Install Ductwork within Conditioned Space 3 Energy pts y=yes 0
3.Vent Range Hood to the Outside 1 IAQ/Health pt y=yes 0
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy pt y=yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
8.Install Sealed Combustion Units
a.Furnaces 3IAQ/Health pts y=yes 0
b.Water Heaters 3 IAQ/Health pts y=yes 0
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEER/11 EER or higher AC with a TXV 3 Energy pts y=yes 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts y=yes 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes 0
13.Retrofit Wood Burning Fireplaces
a.Install EPA certified wood stoves/inserts 1 IAQ/Health pt y=yes 0
b. Install/Replace Dampers 1 Energy pt y=yes 0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15.Install High Efficiency Filter 4 IAQ/Health pts y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes 0
■ 1 1 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts y=yes 0
2.Install Solar Water Heating System 10 Energy pts y=yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts y=yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=1 B points) Up to 18 Energy pts 0
6.Select Safe and Durable Roofing Materials 1 Resource pt y=yes 0
7.Install Radiant Barrier 3 Energy pts y=yes 0
1 t i
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts y=yes 0
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts y=yes 0
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y-yes 0
1 t 1