12090187 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1160 ELMSFORD DR CONI'RACI'OR:POWER EDWARD R AND PERMIT NO: 12090187
MILDREDI
OWNER'S NAME: POWER EDWARD R AND MILDRED 1 1160 ELMSFORD DATE ISSUED:09/202012
OWNER'S PIIONE: 4082523538 CUPERTINO,CA 950144950 PlIONENO:
❑ LICENSED CONIRACFOR'S DECLARATION' BUILDING PERMIT INFO: BLDG C ELECT r PLUMB C
License Class Lie.N
p1ECH r RESIDENTIAL r COMMERCIAL
Contractor Dale
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE AND REPLACE FURNACE LIKE FOR LIRE
(commencing with Section 7000)of Division 3 of the Business& Professions
Cade and that my license is in full farce and effect.
hereby affirm under penalty 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 the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3800
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
permit is issued, ANNNumber:36209012.00 Occuponey'I)pe:
AI'PI.ICAN I'CER'I'IPICA'f10N
I certify that I have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of This permit. Additionally,the applicant understands and will comply /�
with all non-point source regulations per the Cupenino Municipal Code,Section Issued by: llq Date: 9'C-f
9.18.
Signature Date
RE:ROOFS:
❑ OWNER-RUILDER DECLARATION All roofs shall be inspected prior to my roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation. Signature of Applicant: Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penally of perjury one of the following three IIAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Ilcalth&Safely Code.Sections 25505,2.5533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&
perfommnce of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Ray Area Air Quality Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued.I shall Itealth&Safety Cade,Sections 25.505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Own e_r 99JJ aulh99((iz�e,d ag$ent:
Compensation laws of California. If,after making this certificate of exemption,I hate: ZS('r—,
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY
I hereby affirm this there is a construction lending agency for the performance of work's
APPLICAN"1'CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence ofthe ARCIIITECI"S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. /�, —Q n g� Licensed Professional
l
Signature L�Io '�'�f'�/'"Pl Date ( G C)Z
Simplified Prescriptive Certificate of Compliance: 2008 Residential HVACAIterations CF-IR-ALT-HVAC
Climate Zones I and 3-7
Site Address: Enforcement Agexgv Date: Permit N:
Conditioned Duct insulation
Equipment Type] List Minimum Efliciency
r Floor Area requirement Thermostat
TT-Packaged Unit kR
40 fl o chs
Furnace AFUE Imo- ®COP Served by system placed in Setback
indoor Coil SEER_ HSPF_ Qfnw alrmdvprenet,mum be
Condensing Unit ❑EER_ ❑Resistance y� sf ditioned space huralled)
(CZ 1.3-3) ,
❑Other
L Equipment Type:Choose the equipment being installed;if mom than one system,use mother CF-I R-ALT-ItVAC for each system.
2.Mioimum Equipment Efficiencies: 13 SEER,78%AFUE,7.7HSPF for typical residential systems.
Contractor(Documentation Author's/Responsible Designer's Declaration Statement)
• I 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 femures and performance specifications for the design identified on this Certificate of Compliance conform to the
requirements ofTitle 24,Pans 1 and 6 of the California Code of Regulations.
• The design features identified on this Certificate of Compliance are consistent with the information documented on other applicable
compliance fomu,worksheets,calculations,plans and specifications submitted to the enforcement agency for approval with the permit
application. '
Name: =--)_) 1) ,Q0 ILI 12 Signature: .
Companyi Date:
Address: //U LC'�/4� 5'-p /2 p License:
City/State(Lip:r ,& / t A/C C /9 0 ✓O!!f Phone: q n
2008 Residential Compliance Forms.doc revised 04/10/12
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228 • FAX(408)777-3333• buildinancuoenino.ora
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS // 2 APN BP#/ate 9 %
OWNER NAME / (O OWNER ADDRESS
DESCRIPTION OF WORK: /✓i7rG� /j/✓
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
W1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder"building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. 1, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
4�2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
The construction and are not hiring a licensed Contractor to assume this responsibility.
2W3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
e114. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
+ " 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars($500), including labor and materials, I may be
considered an"employer" under state and federal law.
6. 1 understand if I am considered an "employer"under state and federal law, I must register with the state and
Federal government,withhold payroll taxes, provide workers'compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
�mse�to serious financial risk.
79�- 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
2pe8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised04114110
}j�. I understand I may obtain more information regarding my obligations as an"employer"from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed
contractors.
-0 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
V—//—l1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
IZ12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying whether or not,
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's si nature.
Property Owner's Signature: A � , Date:
---------------------......................----- ------ ...............................----------------------- .................. ------
(NOTE., The following Authorization Form is required to be completed by the property owner only when designating an
agent of the'property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
0u,nerBndderForn] 2010.doc revised 04/14/10
i2ogo ( k -7
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE -CUPERTINO, CA 95014-3255 A '
sc
GUPERTINO (408)7773228• FAX(408)777-3333• buildinafcDcuoertino.ore '\s/'
[]PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROIECTADDRFSS r /0 q,=�lr a-roa/� C) R ' AFN4 1517 - o 1'�
OWNER NAME A_/,/�..2 V (J�Wp� n PHONE F p rJ/_pl ..J�S�y EgMAIILL
STREETADDRFSS rrnW/,.� I[/��/. ly.�.fFD Y7 iTY. STATE ZIP Uc..cl tit-"' (AI4 .G4 6j)q I FAX
CONTACT NAME /-f'OAU C• l! �rl [/ PHONE E-MAR
STREET ADDRESS CTTY,STATE IIP FAX
OWNER ❑ OWNER-BUIUDER ❑ OWNTJt AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEE]k ❑ DEVELOPER ❑- ANT
CONTRACTOR NAME I LICENSE NUMBER LICENSE TYPE BUS.LIC✓f
COMPANY NAME E-MAIL FAX
STREETADDRESS CITY.STATE IIP PHONE
ARCHITECT/ENGIN=NAME I LICENSE NUMBER I BUS.LIC p
COMPANY NAME' I E-MAR I FAX
STREET ADDRESS CITY.STATE,ZIP I PHONE
USE OF ❑SFDwDUPLEX ❑ MULT[-FAMILY PROJECT IN WILD A ❑ YES PROJECT IN ❑ YES ISTHEBLDGAN ❑ YES
BUILDING: E]CON.MERML URBAN INTERFACE AREA NO I FI-001)ZONE ❑NO EICHLER HOME? ❑NO
DESC=ON OF WORK '
Aj2e GAGE K/iTiNG Fo�C��P �7r� /=U2/rfl�
TOTAL VALUATION: U a RECEIVED BY: I V
By my signature below,I certify to each oI the[allowing: 1 am the property owner or au[horized agent.o ac:on the pmperry owner's behalf. I have read this
application and the information 1 have provided is correct. I have read the Description of Work and verity it is accurate. 1 agree to comply with all applicable local
ordinances and sate laws relating[o b ��ildding c_onsr't(j�don. i authorize mesentatives of Cupertino to enter the above
C-Iden' edpropem,:for inspection put�oses.
Signawre of Applicant/Agenzi' �/� ` �
SUPPLEMENTAL INFORNLATIGN REQUIRED OFFICE USE ONLY
y 'ER-THECOUNTER
r
- ❑ EXPRESS
Y
U
❑ STANDARD
V
a ❑ LARGE
❑ MAJOR
MEPJ1&cApp_1011.doe revised 06131111
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 1160 ELMSFORD DR DATE: 09/20/2012 REVIEWED BY: SYLVIA
APN: BP#: 'VALUATION: 1$3,800
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD Or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK REMOVE AND REPLACE FURNACE LIKE FOR LIKE
SCOPE
Mech. Plan Check 0.0 hrs $0.00 Plumb. Plan Cited Elec. Plan Check
Mech. Permit Fee: l AIPERMIT Plumb. Permit Fee: Fwc•.Permit Fee:
Other Mech. Insp. 0.0 hrs $45.00 Other Plumb Insp. Other Elec./nap. Lj
.1•le.ch.buy. Fee: Plumb.bill). Fee: FIce.buy.Fee:
NOTE: This estiorate does not ineludejees due to other Departments(i.e. Planning, Public I Parks• Fire,Sanitary Sewer District,School
District, etc.). These fees are baser/an the prefintinan information available and are only an estimate. Contact rite De t or addn'I info.
FEE ITEMS (Fee Resolution 11-053 Eft: 7/1/1 U FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Mechanical
Suppl. PC Fee: (j) Reg. O OT0.0 hrs $0.00 $133.00 IMFR= 100 I Furnace, Forced-Air
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee0 Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Consnwclion Tux:
Administrative Fee: !ADMIN $42.00 Q
Work Without Permit? O Yes Q No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential 17
Travel Documentation Fee: ITRAItDOC $45.00 Building or Structure 0
A
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $133.50 $133.00 TOTAL FEE: $266.50
Revised: 0710112012