12090050 CITY OF CUPERTINO BUILDING PERMIT
BIJILDING ADDRESS: 11141 CI'IADWICK PL CONTRACTOR:ATLAS-TRILLO IIVAC PERMIT NO: 12090050
OWNER'S NAME:
SAN JOSE,CA 95125 Pl IONE NO:(408)286-8931
LICENSED CONTRACTOR'S DECLARATION .1011 DF-SCRIP`fION: RESIDE\PIAL El COMMERCIAL.
CI
�Li.seClassC.:2,Q Lic.4 O 1 37 REMOVE AND REPLACE FURNACE IN SAME LOCATION,
f(asTh 1& Date q loZ ADD
ContractorASC
hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business S 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 cent fate 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 whichthis permit is issued Sq.Ft Floor Area: Valuation:$9000
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:35617079.00 Occupancy Type:
permit is Issued.
APPLICANT'CERTIFICATION
1 certify that I have read this application and state chat the above informalion is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY F� OM LAST CALLED INSPECTION.
indemnify and keep hmmless the City of Cupertino against liabilities,judgments, /
costs,and expenses which may accrue against said City in consequence of die4 9
granting of this permit. Additionally,the applicant understands and will conhply Issued by: Z 7 Date:
with all non-poi source regulations per the Cupertino Municipal Code,Section
9.18.
y RE-ROOFS:
Signature (SZDate All roofs shall be inspected prior to any roofing material being installed.Ira roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
0 OWNER-BUILIIER DECLARATION
Signature ofApplicrm: - Date:
hereby affirm that I am exempt from the Contractor's License Law fnrpne of
the following two reasons: ALI,ROOF COVERINGS TO RE CLASS"A"OR BETITR
I,as owner of the property,or my employees with wages as their sole comprnsation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business d Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to IIA7.ARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business R Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth S Safety Code,Sections 25505.'_5533,and 25534. 1 will
hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth S Safety Code.Section 25532(x)should I 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 Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued will maintain compliance with the Cup'ertinccMunicipaf Code.Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code.Sec ' n. _ 505.25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this ,G.
Owner or authorized Ogen e
Dat
permit is issued
I certify thin in the perfomhonce 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 Inas of Califomia. If,after making this certificate of exemption,1 CONSI-RUCrION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm thin 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
APPLIC.S\1'CERTIFICATION Lender's Address
I certify that I have read this application mid state that the above information is
correct.I agree to comply with all city and county ordinances and state Ines 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 liabilities,judgments, ARCIIITEC`r'S DECLARATION
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 HVACAlterations CF-IR-ALT-HVAC
Climate Zones 1 and 3-7
Sitedddre ts. I • .r-i / Enforcement Ageng: Dale: Permit H:
Conditioned Duct insulation
Elpu meat Type' List Minimum Efficicncy., Floor Area requirement Thermostat
Packaged Unit Over 40 ft of ducts
FurnaceAFUE 8 COP Served by rystem added or rtphmd m ❑Setback
Indoor Coil SEER HSPF a(.&alreadvpresmt,mutt be
CondensingUnit EER ❑Resistor= sf unconditioned spam frutalled)
Other
❑R 6 (CZ 1.3-3) ,
1. Equipmeat Type:Choose the equipment being installed;if more than one system•use another CF.I R-ALT•FiVAC 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.
• 1 certify that the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the
requirements of Title 24,Parts I and 6 of the California Code of Regulations.
• The design featurcs identified on this Certificate of Compliance are consistent with the information documented on other applicable
compliance fonts,worksheets,calculations,plans and specifications submitted to the enforcement agency for approval with the permit
a lication. _
Name: T Signa
Company:
Address: ,r& L License: /3
City/sue/zip: O �5.� Phone: =7
2008 Residenlial Compliance Forms.doc revised 04/19112
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
2 ADDRESS: 1141 Chadwick pl DATE: 09/07/2012 REVIEWED BY: Mendez
APN: BP#: 'VALUATION: $9,000
*PERMIT TN'PE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK REMOVE AND REPLACE FURNACE IN SAME LOCATION ADD A/C
SCOPE
Mech. Plan Check 0.0 hrs $0.00 Plumb.Plan Check Flee.Plan Cheek
Mech. Permit Fee: I MPERMIT Numb. Permit Fee: F1ec. Permit Fee:
Other Mech. Insp. 0.0 hrs $45.00 Other Plumb Insp. El
Other Elec.hasp. Li
dIech.limp. Fee: Plumb. Lisp. Fee: Elec.imp.Fee:
NOTE: This estimate sloes not include jeer due to other Departments(i.e. Planning, Public IPorks, Fire,Sanitary Sewer District,School
District,etc.). These ees are based on the prelindnan information available and are only an estimate. Contact the Dept for addn'I info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Mechanical
SUppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 $133.00 /MFR=<100 I Furnace, Forced-Air
PME Plan Check: $0.00 F1 # Mechanical
Permit Fee: $0.00 $67.00 1BREMAIR 7 A/C Units (<=IOK cfm)
Suppl. Insp. Fee0 Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Consu•nction Tax
Administrative Fee: (ADMIN $42.00 O
Work Without Permit? C) Yes (j) No $0.00 0
Advanced Plannine Fee. -Residential$0.00 Select allon
Travel Documentation Fee: ITR.rnDOC $45.00 Building or Structure Q
Strong Motion Fee: 1BSF1SMICR $0.90 Select an Administrative Item
131d1;Stds Commission Fcc: IBCBSC $1.00
SUBTOTALS: $133.901 $200.001 TOTAL FEE: 1 $333.90
Revised: 07/01/2012
GENERAL PERMIT APPLICATION
,.- COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION c)�o MEP
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 p I
(408)777-3228 • FAX('408)7777-3333 • buiidindar—uoerinG.ora ��
SC
CUPERTINO \ CA' M
❑PLUMBING ❑MEC''12,FICAL ❑ELECTRICAL ❑&USCELLs.NEOUS
PROTECT ADDRESS ',^,
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SRi Ec'T ADDRESS (�C ��_� CJI-R GY n � CRY, SA 1� � FAX
CONTACT NAMEr
PHONE I E-MAR.
STREET,ADDRESS ��/ CRY.SCATc
❑OWNER ❑ OWNER-BIRL:)E2 CIO w, AGENT L'1 CONRUC70R ❑CONI CIOR AGENT ❑ ARCFGT7 ❑ENGINEER ❑ DevE-0 .R ❑ T^JANT
CONTRACTOR --r f 1, kV C I LICENSE, E19 �1� (1Cc'15E I Bas.LICI
COMPANY NAME L I E-MA:L 7 FAX
STREET S � L&'�, k-ell I CrY.STATE, _- O .00 I PEONS
ARCH=_CTlENGLYEr':R NAME LICENSE NUMBER BUS.LIC f
COMPA.NYNAME' I E-MAS. FAX
SCR=ADDRESS CRY,STA—,,ZIP PHONE
USE OF s mDUPLEt ❑ MULTI-FAMILY PROTECT IN WILDLAND ❑ YS PROTECT Pt ❑ YES IS THE BLDG AN ❑ YES
BU TNG: CO.' M ci L ( URSANNTERPACEAREA NO I FLOOD LANE ❑NO I EIOa.ER HOME? ❑ NO
DESCRIPTION OF WOR%
d
Ah-, .1
TOTAL 11UA1. RECEIVED BY:
By my signature below,I certify to each of the following: I=[he pmperry owner cr authorized agent to act on the ompe:ry cr ncr's behalf. I have read this
application and the information I have p vide cosr''.'�cL I have tad the Description at Work and verify it is accurate. I agroe(D comply with all applicable local
ordinances and state laws relating to buil cotssnuct3on- I authorize representatives of Cunerdze:c enter the above-i�5epmpe...y for inspection pu:'¢osu.
Signature ofApplica t/Agcnc Dae: 9 ,�
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SUPPLENENTAL INFORbLATiON REQUIRED OFFICE USE ONLY
y ❑ OVER-THE-COUNTER
❑ EXPRESS
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❑ STANDARD
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S ❑ URGE
❑ NWOR
dg'PMuc.4pp_2011.doc revised 06/21111 '