12080331 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10481 E ESTATES DR CONTRACTOR:ATLAS-TRILLO HVAC PERMITNO: 12080331
OWNER'S NAME: JOHNSON JACQUELINE J 1965 KYLE PARK Cr DATE ISSUED:08/312012
OWNFR'S PHONE: 4083661776 SAN JOSE,CA 95125 PIIONF NO:(408)286-8931
❑ LICENSED C0N`fRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIAL.
License Class Lie.# W p)�M- REMOVE AND REPLACE FURNACE UNIT IN SAME
�� Jt
Contractor llt /fir rY1/IO t(VA-C Date LOCATION
1 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 full force and effect.
hereby alarm under penally of perjury one of the following rao declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of die Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2500
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
ANN Number:36926039.00 Occupancy'I"ype:
permit is issued.
AI'1'LICAN'I'Cl?R'1"IFICA'I'ION
I certify that 1 have read this application aid 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 state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon die above mentioned property for inspection purposes. (We)agree to save 180 DAY5,FIROM LAST CALLED INSPE TION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses wdiieh may accrue against said City in consequence of die
granting of this permit. Additionally,the applicant understands and will comply Issued Date:
with all non-point sour c ulatims per the Cupertino Municipal Code,Section
9.18.
nn RF-ROOFS:
Signatur Date 1 K 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-RUILDF.R DECLARATION
Signature of Applicant: Date:
hereby affirm that I am exempt from the Contractor's License Law fur one of
the following two reasons: ALL ROOF COVERINGS TO RF CL\SS"A"OR BETTER
1,as owner of the property,or my employees with wages as their sole comyrnsation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to IIAZARDOUS MATERIALS DISCLOSURE
construct the project(Sce.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California llcalth&Safety Code,Sections 25505,25533,and 25534. ["ill
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: 1lcalih&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain o 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 Section 3700 of die Labor Code,for the air contaminants as defined by the Ray Area Air Quality Management District
performance of the work for whichthis 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 Ilealth&Safety Code,Sectio x•25505,25533,and 25534.
Section 3700 of the Labor Code,for die performance of tie work for which this (� 7[
Owner or authorized agent• Date:
pcnnil is issued. G/ J .2
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation Imes of California. If,after making this cenificate of exemption,I CONS'1'RUC`I'ION 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. w'ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPI.ICAN'7'CIiR'1'IPICA"I'ION Lender's Address
I certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city,and county ordinnnces 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 ,\RCII I"I'E(.T'S DFCL.\R.\TION
indemnify 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
Simplified Prescriptive Certificate of Compliance: 2008 Residential HVACAlterafions CF-IR-ALT-FfVAC
Climate Zoo"I and 3-7 -
Site Address: Enforcemem Agency: Dore. Permit 0:
Conditioned Duct insulation
G i mens i List Minimum Efficiency Floor Area requirement Thermostat
Packaged Unit Over 40 B of ducts
Furnace AFUE B COP_ ❑Setback
Served by system added or replaced in
Indoor Coil EER , HSPF sf unconditioned space (If^a alreadyprramr,mutt be
Condensing Uni[ EER_ ❑Resistance R 6 (CZ 1,3-3) irvtal!<dJ
Other
/. Equipment Typc:Ch ose the equipment being installed;if more than one system,use another CF-1 R-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)
• 1 certify that this Certificate of Compliance documentation is accurate and complete.
• 1 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 of Compliance conform to the
requirements of Title 24,Pans 1 and 6 of the California Code of Regulations. ,
• The design feamres identified on this Certificate of Compliance are consistent with the information documented on other applicable
compliance forts,worksheets,calculations,plans and specifimtions submitted to the enforcement agency for approval with the permit
application.
Name: /U Signature:
Company: ILI 1G a 3
Address: V L:icenSe: r
City/State/Lip: 2. Phone• 4�os
2005 Residential Compliance Forms.doc revised 04110112
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10481 E ESTATES DATE: 0813112012 REVIEWED BY: MENDEZ
APN: BPH: 'VALUATION: $2,500
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK REMOVE AND REPLACE FURNACE UNIT UNDER 100 BTU'S
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $133
TOTALS: $133.00
Mech. Plan Check 0.0 1 hrs $0.00 Plumb.Plan Chcek Elec. Plan Check
Mech. Permit Fee: IMPERMIT 1Yumh. Permit Fee: I Flec.Permit Fee:
Other Mech. Insp. 0.0 hrs $45.00 Other Plumb Insp. El
Other Elce.brsp.
Mech.bap. Fee: Plumb. hcrp. Fee: Elec.Insp. Fee:
NOTE: This estimate does not include jeer due to other Departments(i.e. Planning. Public If orks, Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prelitninarl information available and are adv an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 EB' 7/1/111 FEE QTY/FFE MISC ITEMS
Plan Check Fee:
Supp 1. PC Fec
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $133.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: /ADMIN $42.00
Work Without Permit? O Yes Q No $0.00
Advanced Pluming Fees:
Travel Documentation Fee: ITRAI DOC $45.00 A
Strong Motion Fee: /BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $266.501 $0.001 TOTAL FEE: $266.50
Revised: 07/01/2012
GENERAL PERMIT APPLICATION E
COMMUNI7r DEVELOPMENT DE'-AR iii 1EN7 • BUILDING DNISION l
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 O/} p mg I ,/� c
CUPERTINO (408) M-3228 • FAX(408)i77-3333 • buildinGG�Guoertino.orD � m ��1
❑PL'U'NGING LI•CC:P.SIICAL IJ=LEC !CPi 1 ❑!.TSC=t a.NE0U5
PR0JZC7ADDR:,-S i L-� I AIN. (Q 2 (x V�
OWNER NAME SIA Uel I • 0 F'3GN_'-j`C ^I [ I E-MAP
STREET ADDRESS (1 iy LI C,,-Y. STAJ=,a? (Vj,0-11 FAX
CONTACT NAME ?NONE _MIz U
STit=",ADDRESS GT!,STA—1� Z FAX
❑owNER ❑ OVNER'-EV=ER ❑ Owfr..R Ac_ DNTRAC,-DR ❑MN, CTOR near, ❑ ARc—er ❑E rYEZ� ❑ DEv- p_ - ❑ TLN N,,
CONI MOOR NAME N ,CEN E NUF3 aU� LI c c-L`�7 I BUS.LC p
CON FA.NY NAM' ///// /,` E-MAII. �f I FAX
SZ. —,ADDRESSYJL J j(� ! Q ` / C4 . I C,.y.STAT 2: `IU -L� I
ARC`vT�!a'GU( tiA.aG ` r I LIC="ISE NuNe uZ I �us.LC i
COMPANY NAME' I E-MAL. FAX
STREET ADDRESS CITY,STAT;LR
PHONE
USE OF ❑SFu.DUPLEX ❑ MUL,.FANCLY PROJECTN WIIDLIND ❑ YS I PROfE(-D1 ❑YE 175 I?m SLOG AN ❑ YES
BUT-DING: E]cow-l . uL 'k2AN UMERFAr AREA NO FLOOD ZONE 0 N EIC�NOME'. No
DESC?=1 ON OF WORK
TOTAL VALUATION: I RECEIVED BY:
Gy my sig a a e below,I c^� ach oI e` lowcg: I e a he p opery owner or zu horzed agent;o act on he propery owce.'S behalf i have r_ad h S
applieadon znd the iaiorLnacon I v ed is or_r I have rmd the Duriodoa o:Work and ve=ry it is acn:.ze. I agree,o comply with all applicable local
ordinances and sate laws mlat;r.g• sm:ccm I SllihoilZ'repmsg3CVc5 of C1mmm_:C mer Lhe c-1 cd5ed oe •for insnecdoa ap poses.
Sigaarv.-e ofAppticant/Agcnc
SUP PL0k1EN-rAL?`rORMAT?ON REQL7RED OFFICE USE ONLY
❑ OVER-THE-COUNTER
❑ EXPRESS
V
m ❑ STANDARD
U
z ❑ LARGE
❑ AIAJOR
- IfcPMsc!pp_:011.dac r�visad 06/?J/11