12110135 CITY OF CUPERTINO BUILDING PERMIT
BUI LDING AD DRESS: 1646JAMES TOWN DR C(INTRACI'OR:FLANDERS I[[,AT&AIR P ERMITNO: 12110135
SYSTEMS,INC
OWNER'S NAME: SIMMONS CHARLES N AND 13AR13ARA 555 PEITIiRS,IVE STE 255 DA'Z'E ISSUED: 11272012
OWNER'S PDONEI 4083577777 PLEASA11'01N,CA 94566 PHONE NO:(925)461-3333
❑ LICENSED.CON`FRAC`FOR''S DECLARATION BUILDING PERMIT INFO: BLDG F__ ELECT❑ PLUMB 0
License Class `0 Lie.N 677- 0 0IOr d r r
1 ! MECFI RESIDENTIAL r J COMMERCIALL
ContractraAr R " Flo�. EJ 5 Dale
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE&REPLACE EXISTING 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 penally 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.FI Floor Arca: Valuation:$2250
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of One work for which this
permit is issued APN Number:36610064.00 Occupancy Type:
APPLICAN I'CF.RTI FICATION
I certify that I have read this application and slate that the above inforonation is
correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EMPIRES 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 acerae against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source ren Inn er the Cupertino Municipal Code,Section Issued by: ���-/V !7%G Date: 'IV-/49-
9.18
Signature Dateff�
Rb:ROOFS:
❑ OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following'two reasons:
1,as owner of the property,ormy 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).
hereby affirm under penalty of perjury one of the following three IIAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials regniremenls'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 llcallh&
performance of the work for which this permit is issued. Safely Code,Section 25.532(a)should 1 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 Arca Air Quality Management District I will
permit is issued. maintain compliance wish the Cupertino Municipal Code,Chapter 9.12 and the
Ileakh&Sufrn Code.Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,L shall
not employ any person in any manner so as to become subject to the\Porker'sO aer n a uJ agent
Compensation laws ofCali(omia. If,after making this certificate of exemption, Date:
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. le7 CONSTRUCTION LENDING AGENCY
I hereby nflion that(here is a construction lending agency for the performance of work's
API'-LICAN'I'Cl,R"1'IF1CA'f1ON for which[Itis 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.1 agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives ofthis 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, ARCA 1'fFCf'S DECLARATIONcosts,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicam 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
01 -?D--�>
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 p '
sc
GUPERTINO (408)777-3228 • FPX(408) -3333 • builn /ci)
dinacuoerino.ora �`a/'
❑PLU:MBING ?+SC-r-AN'!C?! L=LECR!CAL � ❑M2SCELLLPNEOUS
,TS
PROADDRESS // q/ IC� ///�t-
1 I °.PN: / 6 - 10 — D
OW?: NAME pert I, PHO,- Z .MAB.
5 T RE-,ADDRESS FAx
CONT.4CT NAME
S .RJ=--r,0DRESS / Cr'TI,STA, Z? j FAX
❑ OW'- ❑ owT.SU'L`9ER ❑ OWhr'-R. AOrT.'i to}rtCTDR ❑CONTRACrDRAG= ❑ ARGTCT ❑ �_.'G].�t.-� ❑ D1rnzPzpt ❑ i7:AT-'T
n
CONTRACTOR N.U.0 f�� ^IA Q L1C"v'.'SE NUT3ER UCENSE�E I BUS.LIC'.
COI✓3 YNAMEFIa.�I�..S MAfT. FAX
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S-=7 C,TY.STAT-LP ?EON-
A.RC-7,-C71-�GIIvT_,-tNAM.E UL-ttSE NUMBER BUS.1JC%
COMPANY NAME' E.Y--JL FAX
ST= DDRESS CTTY,STA,-Z2 ?Ii Oh-
USE OF S�1, .DU?= ❑ MULn-FAMILY I PROT.C7IN WILDa\D ❑ YS I PROI=Cr AI ❑ ]TS IS Tk:.BLDG AN ❑ :S
BLII1DrvG: ❑CAMMER URBAN INTERFACE-AJL.A '�NO FLOOn ZON- .+.'O r74�30MEI NO
DESCRIPTION OF WORK L
TOTALVALUATION: /J' tel` PECEiv'BD BY: v�
By cry signarcre below,I cerdy to each of the following: Ian!the prooerty owner or mr.3orized agent to act on the pmper y`awrt-tr's bthaif. (have road this
zpplirzion and th — I ve is thave- d the Description of Woland verity is is zctwIay _ y plicable local- to comply nddll
ordinances ad sate Laws rozieg c aconI YL`iO..Ze representatives OICVJemnO
LO G1"_r the 2D0��:-idcnd5e3 pmpe,-,/for 5
nsnoci0.pu;�cses.
Sig-a=-of AppliczndA.genn Date: f/ 9
SUPPLE INFORMATION REQTj-aED OFFICE USE ONLY
n OYER-THE-COUNTER
❑ EXPRESS
u
❑ STANDARD
V
❑ LARGE
❑ AUJOR
J�=P.x.!ssc4pp_?011.doc revised 06/21/11 -
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 1646 Jamestown Drive DATE: 11/2712012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: 1$2,250
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTANIATION FURN/AC
USE: PERMIT TN'PE:
WORK Remove and replace existing furnace.
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 hrs $0.00 Plumb. Plan Check Elec.Plat Check
Mech. Permit Fee: I MPERMIT Plumb. Permit Fec: Elec. Permit Fee:
Other Mech. Insp. 0.0 hrs $45.00 Other Plumb Insp. Other Elce.Insp.Ll I
,I tech,hup. Fec•: Plumb. btsp.Fee: Eley.leap.Fee:
NOTE: This estimate does not include fees clue to other Departments(i.e. Planting, Public(Forks, Fire,Sanitary.Sewer District,School
District,etc.). These feev are baser(on the prelinninan information available and are onlr an estimate. Contact the De t or whin7 info,
FEE ITEMS (Fee Resohuion 11-053 ER 711112) FEE QTY/FEE MISC ITEMS
Pian Check Fee:
Snppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $133.00
PM Permit Fee`. $45.00
Construction Tax:
Administrative Fee: 1ADAHN $42.00
Work Without Permit? Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VDOC $45.00
Strong Motion Fee: IBSE/SAt/CR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $266.50 $0.00 TOTAL FEE: $266.50
Revised: 10/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 9501'4=3255
Telephone: 408-777-3228
C U P E RT I N O . Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS:/ S /` PERMIT#
OWNER'SNAME: HV-1,0, td ' .P PFIONE# T) SCI33
GENERAL CONTRACTOR: a i, w BUSINESS LICENSE#
ADDRESS: HC4 —
CITY/ZIPCODE:
*Our municipal code requires all husinesses 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 AL SU C 'T TORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
nature Date
Please check applicable subcontrtors andtplete 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
Simplified Prescriptive Certificate of Compliance: 2008 Residential HVAC CF-IR-ALT-HVAC
Climate Zones 2,9 and 16
Siteres � En{{��reemenlrA eqC;': Date�: Permit N:
� �
Va✓t1eS �o w ✓I I/( C`u 'e . .- _n..v 'FP6
Conditiunca
E ui mem Typet List Minimum EfticiencY2 Floor Arca Duct insulation requirement Thennostat
❑Packaged Unit �a ��yy Over 40 fi of ducts added or
R Furnace NLAFUE OD ❑COP Sensed by system replaced in fducts tided or back
❑Indoor Coil ❑SEER_ ❑ HSPF (l noralread);present,
❑Condensing Unit ❑ EER_ ❑Resistance sf spacO Heb (CL 2 and 9) mast be iastalled)
❑Other
1. Equipment Type:Choose the equipment being installed;if more than one system,use another CF-I R-AL f-H VAC for each system.
2.Minimum Equipment Efficiencies: 13 SEER,78%AFUE,7.711SPF for typical residential systems.
HERS VERIFICATION SUMMARY Listed below are four HVAC alteration Options. The installer decides what work is being
done and picks one of the appropriate Options. Each Option lists the Id ERS measures that must be conducted.A copy of the forums shall
be lelt on site for final inspection and a copy given to the homeowner. At final,the inspector verifies that the work listed on this fano
was in fact the work completed by the installer. The inspector also verifies that each appropriate CF-6R and registered CF-4R forts(no
hand Filled CF-4Rs allowed)are filled out and signed. Beginning October 1,2010,a registered copy of the CF-IR and CF-6R shall
also be on site for final inspection
❑ 1. HVAC Changeout Required Forms:
• All HVAC Equipment replaced CF-6R forms: MECH-04,N1ECIi-21-TIERS and(for split systems)MECH-25-ITERS
C17-411forms: MECI-l-21 and(fors lits stems) NIECII-25
• Condenser Coil and/or
• Indoor Coil and/or CF-611forms: NIECII-21-TIERS and(for split systems)MECI I-25-ITERS
• Furnace CF-4R forms: MECIi-21 and(for split systems) MECI I-25
For Split Systems: Duct leakage < 15 percent; RC,CCA>_300 CFM/ton,TMAI-I
For Packaged Units: Duct leakage< 15 percent
Exempted from duct leakage testing if.
❑ 1.Duct system was documented to have been previously sealed and confirmed through I1ERS verification,or
❑2.Duct systems with less than 40 linear feet in unconditioned space,or
113.Existin ducts stems are constructed,insulated or sealed with asbestos
❑2.New HVAC System Required Forms:
• Cut in or Changeout with new ducts:(all C17-6Rforms: MECH-04,MECI-1-21-TIERS and(for split systems)MECII-25-ITERS
new ducting and all r I CF-4R forms: MECH-21 and(for split systems) MECH-25
For Split Systems: Duct leakage<6 percent;RC,CCA?300 CFM/ton,TMAH.
For Packaged Units: Duct leakage<6 percent
❑ 3. New Ducts with Replacement Required Forms:
• Includes replacing o installing all new CF-6R forms: MECH-04,MECH-20-1 IERS,and(for split systems)MECFI-25-HERS
and/or indoor coil and/or furnace. Not all
ducting and/or outdoor condensing unit CF-4R forms:MECI1-20 and(for split systems)MUCH-25
equipment char ed.
For Split Systems: Duct leakage<6 percent, RC, CCA>300 CFM/ton,TMAH
For Packaged Units: Duct leakage<6ent
❑4. New Ductingrce
over 40 feet Re uired Forms:
• Includes adding or replacing more than 40 CF-6R forms: MECH-04,MECH-21-IIERS
linear feet of duct in unconditioned space. CF-4R forms: NIECI I-21
For split system or packaged units: Duct leakage< 15 percent
❑ EXCEPTION: Existing duct systems constructed,insulated or sealed with asbestos.
Conlrector(Documentation Author's/Responsible Designer's Declaration Statement)
I certify that this Certificate of Compliance documentation is necumte and complete.
1 am eligible under Division 3 of the Califomia 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 I and 6 of the Califomia Code of Regulations.
The design features identified on this Certificate of Compliance are consistent with the information documented on other applicable compliance
forms,worksheets,calculations,plan and specifications submitted to the enforcement agency for a r val with the DCriail application,
Name:'�?fe- f-, / N ir Signature:—
Compan}f^ /h� Date:
la�Id�4� Nom d �Ir S s e�
Address: License:
5 �le�ers 7` 502
City/State/zip: p a OA Phone: 4a i' FFG/� 3 33
2008 Residential Compliance Forms ,lfarch 2010