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12120014 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19811 PRICE AVE CONTRACTOR:SERVICE CHAMPIONS PERMIT NO: 12120014 OWNER'S NAME: ADAM JOEL F AND SHARON M TRUSTEE 7020 COMMERCE DR DATE ISSUED: 12/04/2012 OWNER'S PHONE: 4082522966 PLEASANTON,CA 94588 PHONE NO:(925)444-4444 I� LICENSED CONTRACTOR'S DECLARATION � � � �7 /-� BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C Zv Lic.# �� 6U�V �"` � � /� MECH RESIDENTIAL COMMERCIAL Contractor V�C.k��T(��ate ��"�' I hereby aftirm that I am licensed under the provisions of Chapter 9 �OB DESCRIPTION:REMOVE AND REPLACE FURNACE (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. [hereby af7irm 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:$5778 [have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of ihe work for which this permit is issued. APN Number:36905017.00 Occupancy Type: APPLICANT CERTIFICATION [certify that I have read this application and state that the above information is corcect.I 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 entec upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmiess 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 Cupertino Municipal Code,Section Issued by:t /'��/✓ �— �1 �� Date• %�'`�'l . 9.18. Signature Date �� 1�� RE-ROOFS: ❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material beng installed.If a roof is installed withoirt first obtaining an inspection,I agree to remove ali new materials for I hereby atlirm that I am exempt from the Contractor's License Law for one of �nspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, S�gn�ure of Applicant: Date: wiil 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). I hereby affirm under penalty of perjury one of the following three HAZARDOUS NIATERIALS 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 Health&Safety Code,Sections 25505,25533,and 25534. I 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 Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. [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 Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,SecNons 25505,25533,and 25534. 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 Worker's Oy�e� uth ri �I ay�n� / Compensation laws of California. If,after making this certificate of exemption,I �� .L ___Date:`�V��'� 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 1 hereby affirm that there is a construction lending agency for the perfortnance of Hork's APPLICANT 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 cottect.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 hazmless the City of Cupertino against►iabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the 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. Licensed Professional Signature Date � Z ( ��LC� ��> � � GENEF�AL PERIt1(fT APPLlCAT[ON � � � � COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �UPERTENO ��8� 7n'3228• FAX(408)777-3333• buildinQ(a�cuoertino.orq � '�C ❑PLUMBING 'MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS � PR�.TECI'ADDRESS l ( l ��- V �U �.PNn �- � L�� — �) / �� .� � OVTNER NAME '� �i �� ,PHONE j�v D '7 r Z_�CJ��(„ E M/'II, i <A WW sr�nDDxFSS �`� � (� �P.l L� crcY, sTnrF�z� � �, �� U�� I F.�.x U-- CONTACT NAME PI-]ONE E-MAlI. STtt_:.e"TADDRESS CIIY,STATE, ZIP FAX ❑ OM'N'rA ❑ OVTNER-BL'IIDER ❑ OVdNER AGENT �CON7RAC1'OR ❑CONfRACTOR AGrT'T ❑ ARCF�7'IFCf ❑ENGAtE�t ❑ DEVELOPER ❑ 7`Tr,IANT CANTRACtOR I.'AME I.10EN SE NUMBER �1 l U u(\ LICr�..TSE 7`�?Z O BUS.LIC,� � ( J COMPANY NAN�,� � �C G� � I v`►'� S t MAIL ' FAX .:dl/� 5�� ,� . � � ��,-�,sTA�� c��5�� /yy—�/yy� ARC.T-II'IsCT/ENGIIdEr.'FtT1P.M_E LICENSE NUMBER ( BUS.L1C R COMPANY NAME' E-MAII. FAX STREET ADDRESS CI1Y,STATE,ZIP PHONE USE OF r"�or DUPL.F�C ❑ M111.77-F/.T2iLY PROTcCT A7 WIIDLAND ❑ Y'rS PROJECf IN ❑Y'rS � IS 7'tiE BLDG nN ❑ Y=S . BLJII�ING: CAMAgRCW. URBAN A'7"cRfACE ARFA NO FLOOD ZOT'E 0 EICHI.IIt HON.ET 0 DESCRIPTION OF WORK � i�c,-� �u-rn�G� ox, TOT?.L VALUA170N: � �� U I RE[EIVED BY: '7 r � By my simzture below,I certify to each of the followine: I azn the property ocrner or zuthorized zgent to act on the prope;ty oc,mer's behzif. I have read this application uzd the in;o�mation I'�zve provided is correcC I have rezd the Description of Work and veri,"y it is accunte. I zgrce 7o comply�;�ith a11 applicable 1oca1 ordir.�.�ces and sate laws relating to t}ui di_� nstrvctio . I zu onze representarives of Cupertino to enter the above-idenufiedp:vpe.^.�ior inspection pu;�eses. Sieaatw-e of ApplicanUAgenY. �l 'W�-� Date: �" `v' ��I ^! � SUPPLEMEN'TAL INFORMATION REQUIRED OFFICE USE ONLY , OYER-THE-COUNTER F ❑ EaI'FESS U � ❑ S'C.�TDAFD V ; ❑ L4RGE ❑ Rt.4J0R 1L�'PAT'ua4pp_�011.doc revised 06/21/II S� �fied ' tive Ce�cate of Co liance:2008 Resid�xdal HVACAlt�ratio�rs � CF-IR-ALT-HVAC c�z�ia to is Si�e.l�dira: I Gi g � � a L�i � ��8��_ ��1 Z Perr�iti�: Camdi6a�cd F7oar T t List M'�mm�an Fffi ' " Duci iamtatia� Area Tha'most� �� '' (�� Over 40$of�added a - �SetbacY AF[JB ❑CQP �placed 'm�ditionod bpa�x Savad bY sys� lff�t af+ffidy ' ��OOi CO� �� g— C7 R 6 (CL 10-131 � �'Q1�"�� ❑CaodeacmgF3nit ��R �R�e ❑R 8 (fZ 14-15) . �1 ❑Otha I_Eqs�e�ewt Typc(�ioa�e tlre aqrap�toit beneg Da7alled:f mose thmr rnu systa�me miaaho CF-1R-.iLT-FfVACfweach systenc Z Miwiw�a Eqa�ps�nt E,�daade�l3�789i�lFYTE,7.7FLTPFfor rypfcal resido�tial systsau. HERS VERIFICATION SUMMARY Iiffiai bdoav ace Saa HVAC aitesatioa Optia�. T��e installer daadex wl�t wotk is bemg dcme atd picl�ous af the ap�napriat�Optiona. Fach Opticn Sa�s tbe AER4 mas�es fl�at mnst be c�dac:tod.A capy of the focros shsiI be teft oa site far final impection and a copy given to ihc haaneuama At Sns1.fbe�spocxa va�es fl�at tbc wa�listed ao 9iis fam was m fad the work completed by 8�e i�taller_I3e mspax��1so vaii5es tbat each�CF-bR md n-�CF�R fams(no Lmd fi11cd CF-�ts allowod)are filled oat md Oember 1,2Qld,: c af t6c GF-1R aad CF-6R shaD ako�e os s�c for fi�i os. I.HVAC Cl�an ot Re4ased Fsrms= . • AII HVAC lsood CF-bit� MECii-Q4.MEQ�2]-f�RS�d jfor ap�t systems)ME�Fi-2i-IiE-RS F4�t''�P CF-4R faar� MT�CfI-21 md fo� lit MECH-25 • c�a�c�t�a ia t;F-sx� a�si-�s ma��M�y�s)MEc�r-as-�s • �oor c��Q c��x s� �-si�a�f��n�} �x zs • Fmnsce Fer_�Ifit Syat�ma:Dud leakage<i5 perceat; RC,CCA?300 C�7btftan{Mmimum Air Flow Req¢iranent),TMAH Fer Packaged IInils� Dact leakage<l5 peremt � Exemptal5romn aacx I��g i� O i.DucE-aystem�vat do�d tobave baa p�sriwsly sealad ad oam5rmed thr�agh HERS ve�catiao►.or - . •- Cf 2 F)mct syatmis w�!e$tlmn 4�16�ar 5xt in tmcmdmo�d spaoe.ar - Q 3. ' ' duct ae woa�ncDed.m�alatal a�seaiad witL as�os - o Z x�svAC sy� R«�a�a��: . � . �c m�c��c we�� . cr�sx��-0a,a�-zo-�xs.�a cf�s�n sy��a�cx-rz-�xs.�r�cx-as-r�.s aa��eu�a�g�en cF�t s�: MEc�r za.�a(t�r��t�)�-�,aoa MEcx u . � F��t System�Dud leakage<5 pa+ee�itC,CCA>_35Q C�M/Mn,FWD;TMA$ST14�5,amd eitha�iSPP or PSFP. For Psc Q�ts:Dnct �6 � ❑3.1�Ie�e Dncls witit Repheement ired Farms: - - • �aa�,�or�tuag.n�a�g cF-��: MEcx-oa.�i-20-F�RS.�ad(frn'spiii systems)MECH-25-fiERS mdtor oetdoar emdea�g�it md/ar� CF-4R faam�MECI��md(fta split syst�)I��S - cavl�dlor furasa. Nd aIl oq�cl�Sed For Sp�Ft S�*stana:Dad leakaSe<6 Pe�+ce�itC,CCA>_30Q CFMft�n,'TMAH . '_ Fer P e�II�Dnct 1 e<{ - O 4.New Du over 4A feet Ferms- . • 7n�h�da sddiag ar r�g mare�40 CF-6R fg� MECH-04.MECI�21��RS CF-4R facros: �-2 i }iaeat�t ofdnctm �� F.w'��t system er gael�ged m� Duet leaicage<15 per�cffi . Q ECCEPTlON: " ' � u�misle�ar�w'sh asb� � C�tractor(DoeumKOtatioe Ant6er`:/RespenaiWe Desiper's Dedaritioo Statemmt)� . .• I eatity t6�t mis Cadfiata a�cor�i'�ee aoe�eantimis aavnte�a�e. . .• .I�e6g�bk;�der,Dieisian 3 ad�e Cstifmnia Baeimas md Ft�o�ioa Code m auxpt�u'6ihry fa t6e desgn id�aa thie Ca�Scaoe of Compii�ce �• i ea6fy tl�tbe eoaB3r tqmaes and pa��fa tLe d�ig�idmrified an ffiis Caffia6e of CompHmx cougacm to t5e raZmraneats of Tide 24, �PuEC I�ad 6�fhe Catlfloeai�,Code.ofRe�ulttioo�... .. . . • T6e d��aidmti5ed m 8ris Cati�1e af Campliaoee ate wasictmtait�9�e im[ozmetim doc�eamd�otheappiimbk ccanpiimae fotms,worla6oets, imt�d sa6moded b 8!C Ca�a1+ImIDmt 'f� �1 the � MAXINE BROOKS - s'�' � . C°�`'SERVICE CHAMPIDNS � � o�J��j� Eia�se: Add�c.• � �Z p �1�/YI L:/`L f�' ..�1i� . $17040 �s� 1��5c�,� �v� G��_ y J�:� �,°°«�Z5 �IYY-`.'��' � 2UD8 Resia�entral Compliance Foe�rs Marrh 2a10 ' CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 19811 PRICE AVE DATE: 12/04/2012 REVIEWED BY: Sean APN: BP#: ''VALUATION: $5,778 xPERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: wORK REMOVE AND REPLACE FURNACE. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $133 TOTALS: $133.00 M0C}l.Plari CIIOCIC 0.0 �ll'S �V�.�� t'Ir+!tih 1'!ct�t t�ttc`r6� f:ic;' r'�czf:C.it<<k � MeCh.PermitFee: IMPERMIT ' ,�%rl�. � � r��'"t I�_c: t�i�t�- F'tr�r�it I��.�a� Other Mech.Insp. �0.0 hrs $45.00 t?rl�� t'I�rr�at,In.t�> l)t,'��-= l;ier�_It�r��. bk.°c:i�./rt.;Ez I.�,t,� p�zrrrth_ tit�j;. I��c��: I;�ie<�. Errsp, l��e� NOTE:This estimate does not include jees due to other Departments('�e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc . These ees are based on the relimina in ormation available and are onl an estimat� Contact the De t or addn'1 in o. FEE ITEMS (I'ee Resolution 11-053 E�'. 7i1;'12� FEE QTY/FEE MISC ITEMS ��UI'} (.'jte.'C�i /`E'E': .S'lt�tjll. I'{_�!`�'E, PME Plan Check: $0.00 Pef�trrit f��c�: Su��l. In.i1�I�'ee PME Unit Fee: $133.00 PME Permit Fee: $45.00 (:nrt.sta�rrct`ion 2�x.r: Administrative Fee: IADMIN $42.00 Work Without Permit? � Yes � No $0.00 f �G7�1'Uili'E'c ��(t1��ii1P1,4�I'eE'S: Travel Documentation Fee: ITR,4vDOC $45.00 � Stron�Motion Fee: 1BSEISMICR $0.58 Select an Administrative Item Bld� Stds Commission Fee: 1BCBSC $1.00 SUBTOTALSc $266.58 $0.00 , TOTAL FEE: $266.58 Revised: 10/01/2012 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19811 PRICE AVE CONTRACTOR:SERVICE CHAMPIONS PERMIT NO: 12120014 OWNER'S NAME: ADAM JOEL F AND SHARON M TRUSTEE 7020 COMMERCE DR DATE ISSUED: 12/04/2012 OWNER'S PHONE: 4082522966 PLEASANTON,CA 94588 PHONE NO:(925)4444444 I� L[CENSED CONTRACTOR'S DECLARATION gUILDING PERMIT INFO: BLDG� ELECT� PLUMB r License Class C Zv Lic.# ��j�ZU�U , /� MECH� RESIDENTIAL� COMMERCIAL � Contractor U L��f'J�l�I(Jyl�ate +D�"�' I hereby af'firm that I am licensed under the provisions of Chapter 9 �OB DESCRIPTION:REMOVE AND REPLACE FURNACE (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: [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:$5778 [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. APN Number:36905017.00 Occupancy Type: APPLICANT CERTIFICATION [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 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 Cupertino Municipal Code,Section Issued by t �� 1 �� Date: `�'`�'� , 9.18. Signature Date �� 1�� RE-ROOFS: ❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material beng 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 �nspection. the following hvo reasons: [,as owner of the property,or my employees with wages as their sole compensation, Signature of Applirant 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). [hereby aftirm under penalty of perjury one of the following three HAZARDOUS 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 Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 912 and the Health& performance 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 Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 25505,25533,and 25534. 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 Worker's O�e}� uth ri �d ag�� /��r/,�� Compensation laws of Califomia. If,after making this certificate of exemption,l �d�� '(�fl�.� Date:6 �a 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 that there is a construction lending agency for the performance of Hork's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) [certify that I have read this application and state that the above information is Lender's Name corcect.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this ciry 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 of the ARCHITECT'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 regulatirns per the Cupertino Municipal Code,Section 9�18� I.icensed Professional Signature Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: �� '�' I I /'1 C,� �(}� PERMIT# OWNER'S NAME: ,] Z.I I'Y� PHONE# �� ✓�Z-2{�F�lv GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: '��Z.() �G{u��/�, ` CITY/ZIPCODE: ��'ISQ./'�C�f'1 Q�fs�� *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. ;1 I am not using any subcontractors: � "��t��-� �v�' `�'l � Signature Date Please check applicable subcontractors and complete the following information: �/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date