12090227CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11106 LINDA VISTA DR CONTRACTOR: VALLEY HEATING & PERMIT NO: 12090227
COOLING
OWNER'S NAME: BOWER KEITH D AND IILLVIA B 1 1171 N 4'1'11 ST I DA'Z'E ISSUED: 09262012
OWNER'S PHONE: 4082537480 ISANJOSE,CA 95112 I PBONF. NO: (408)294-6290
T� LICENSED CO\ TRACTOR'S DECLARATION
License Class C-20 L ie. q 250 -C-4tO
Contractor V P L /u ,:,
Date (/�r,
hereby affirm that 1 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.
1 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.
I 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.
AI'1'LICANI' CERTIFIC, %'1'ION
I certify that I have read this application and state 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 die 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 of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Sectiom
9.18.
p n
Signature .Ziboe( �� Date C /G[.(
❑ OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 (Scc.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (See.7044, Business & Professions Code).
hereby affirm under penalty of perjury one of the following three
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.
I 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.
I certify that in the performance of die 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 Col ifnnim. If, alter making this cenificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this pemnit shall be deemed revoked.
APPLICANI'CF-RTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city nix] county ordinances wad 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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 Cupertino Municipal Code, Section
9.18.
Date
BUILDING PERMIT INFO: BLDG I— ELECT r PLUMB r
MECH r RESIDENTIAL 1J COMMERCIAL r
JOB DESCRIPTION: REMOVE AND REPLACE FURNACE IN CLOSET, EXISTING
LOCATION
Sq. Ft Floor Area: I Valuation: $4860
ANN Number: 35616020.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DA 'S FROM L ST CALLED INSPECTION.
Issued by: � / _/ Date:
y
RE- ROOFS:
All roofs shall be inspected prior to any roofing material beiig installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS NI\TFRIAI -S DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Scetinns 25505. 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health &
Safety Code. Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Jlunicipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505. 25533, and 25534.
Oi�l1 ner r(r auth�fuze� aagen,V�� n /2�
Ifii+6�(�lls ti)a": -t
CONSTRUCIJON LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of cork's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCIIITECI "S DECLARATION
I understand my plans shall be used as public records.
Licensed
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildingickupertino.oM
n PLUMBING YIIMGCIIANICAL n1iL1iCTRICAL -MISCELLANEOUS
MEP
MISC
PROJECT ADDRESS r 'A /Ci V-5 rG
LJ (� T
APNtl 2 � ( f O � T
\� C/V
PHO"z165- Z53 -'7g6d
OWNER NAME v I�
E -NIAIL
$IREET ADO0.[SS GI/'16(4 C/r'S �(�
GO'Y, STATE. ZII'�uP / 'r5a /Lr
I FAX
CONTACT NAME V 1 a J/ PHONE
/
E -MAIL
STREET ADDRESS
ClT.STATE -ZIP
FAX
❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHrTECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAM t
uQ/! Nee ,r
LICENSE NUMBER 5 �S�O LICENSE ell 6
BUS. LIC u /� f
COMPANY NAME J - t r
E -MAIL
FAX
STREET ADDRESS %17/ Al, qf� 5A.
—I
CITY,STATE, ZIPS ` / TL //2
7 J J L
/
PHONED O$—ZQN -( ,7?
ARCHITECUENGINEER NAME
LICENSE NUMBER
BUS. LIC14
COMPANY NAME
E -NIAIL
FAX
STREET ADDRESS
CT'. STATE. ZIP
PHONE
USE OF ❑SFDwDUPLEC MULTI- FAMILY
BUILDING', ❑COMMERCIAL
PROTECT IN WILDLAND ❑YES
URBAN OTERFACE AREA ❑ NO
PROIECTIN El YES
FLOOD ZONE ❑ NO
IS THE BLDG AN ❑YES
EICHLER HOMER ❑ NO
DESCRIPTION OF WORE: -
�,� �1rsc4�c J� c %sef
TOTAL VAI.UATION: G,d O
RECEIVEDBY:
By my Signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property wmer's behalf. 1 have read This
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildingconslmciam. I authorize epresenlatives of Cupertino to enter the abovve identifi /ed property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMA'T'ION REQUIRED
OFFICE USEONLY
❑ OVER -TIIE- COUNTER
L
'1
❑ EXPRESS
L
U
❑ STANDARD
5
❑ J. \RGE
❑ MAJOR
,l1EP,tfiscApp_2011.dac revised 06/11111
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
JAFADDRFSS:
11106 linda vista
DATE: 09/26/2012
REVIEWED BY:
UNITS
APN:
BP #:
*VALUATION: $4,860
*PERNIIT TYPE: Mechanical Permit
PLAN CIiECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: SFD or Duplex
#
PFNTANLYTION
PF.RM ITTYPE: FURN /AC
WORK
remove and replace furnace in closet existing location
SCOPE
�d
APPLIANCE/ EQUIP TYPE
FEE ID
Plumb. Plan Check
QTY
UNITS
BP FEES
Elec. Permit Fee:
Furnace, Forced -Air
1MFR = <100
Oder F•Ice, bnsp. El
1
#
$133
Permit Fee:
Sapp/. Insp Fee
PME Unit Fee:
$133.00
PME Permit Fee:
$45.00
Consnvtction Tax
Administrative Fee: IAD,t/IN
$42.00
Work Without Permit? O Yes E) No
$0.00
TOTALS:
A
Travel Documentation Fee: ITRAVDOC
$133.00
Strong Motion Fee: IBSFISAIICR
NOTE: This estinmte does not includejeev due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These feev are based on the orelintinary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolalion 11 -053 Efl' 7/1/11)
Mech. Plan Check 0.0 hrs $0.00
Plumb. Plan Check
Elec. Plan Check
Mech. Permit Fee: 1AIPERAIIT
Plamh. Permit Fee:
Elec. Permit Fee:
Other Mech. Insp. 0.0 hrs $45.00
Other Plumb Insp.
Oder F•Ice, bnsp. El
161ech. Insp. Fee:
Phaeb. losp. Fee:
Elec. Insp. Fee:
NOTE: This estinmte does not includejeev due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These feev are based on the orelintinary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolalion 11 -053 Efl' 7/1/11)
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check:
$0.00
Permit Fee:
Sapp/. Insp Fee
PME Unit Fee:
$133.00
PME Permit Fee:
$45.00
Consnvtction Tax
Administrative Fee: IAD,t/IN
$42.00
Work Without Permit? O Yes E) No
$0.00
Advanced Phvming Fees:
A
Travel Documentation Fee: ITRAVDOC
$45.00
Strong Motion Fee: IBSFISAIICR
$0.50
Select an Administrative Item
131d4 Stds Commission Pec: IBCBSC
$1.00'
SUBTOTALS:
$266.50
$0.001
TOTAL FEE:
$266.50
Revised: 07/01/2012
Simplified Prescriptive Certificate of Compliance: 2008 Residential HVACAIterations CF -IR- ALT -F VAC
Climate Zones 1 and 3 - 7 -
Sire Address: //I0& L V51',
Enfertemem Agency:
Damn /2 /
7 (r
Permir p:
a
Conditioned
Duct insulation
Equipment Type
List Minimum Efficiency r
Floor Area
requimment
Thermostat
Q,Packaged Unit
Fumace
ff AFUE I% l
B COP
Served by system
Over 40 ft of ducts
added or replaced in
�, l
LySetback
Indoor Coil
SEER_
HSPF_
sf
unconditioned space
{If nor already present mutt be
Condensing Unit
❑ EER _
❑ Resistance
Lmalled)
❑ Other
L Equipment 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)
• 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.
• 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, Parts I and 6 of ibe California Code of Regulations.
• The design features identified on this Certificate of Compliance are consistent with the lnfonnntion documented on other applicable
compliance forms, worksheets, calculations, plans and specifications submitted to the enforcement agency for approval with the permit
application.
Name: Br,Q,t 'J its 61,
_
Signature:
Company:
Date: ^/2
Address:
71 N, Nth 54.
License:
25$$YV`
City /Stwelzip: SJ g5ll2
Phone: qOF
2008 Residential Compliance Forms.doc revised 04110112