13020052 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22696 ROYAL OAK WAY CONTRACTOR:ONE HOUR HEATING PERMIT NO:13020052
AND AIR
OWNER'S NAME: SHILPANAIK 1400 PETALUMA HILL RD DATE ISSUED:02/122013
OWNER'S PHONE: 6502455347SANTA ROSA,CA 95404 PHONE NO:(707)545-1800
- LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class CZ-0 Lic.it 7'4.0"q REPLACE(E)FURNACE&AC UNIT,SAME LOCATION
Contractor OJZ H&*7 r-G Date 2-- j2 13 -
I hereby affirm that I 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.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain acertificate 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:$9498
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:34232128.00 Occupancy Type:
permit is issued. _
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS QUERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS F T CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 1
costs,and expenses which may,accrue against said City in consequence of the Its Date:
2' 1
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.
- 2--./ 2 l 3 RE-ROOFS:
Signature." Date 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
inspection.
❑ NER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,of my employees with wages as their sole compensation,
will do the work,and the structure is not intended'or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property, m.sexclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Cade,Section 25532(a)should 1 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 Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent• Date: Z/I z-
permitis-issued.
I certify that in the perfomrance 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 CONSTRUCTION LENDING AGENCY
Compensationlaws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that 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
APPLICANT CERTIFICATION Lender's Address
I certify that 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 the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accme 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
GENERAL PERMIT APPLICATION o'er M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 0
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 O A
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinalaakuoertino.ora ' MISI
PLUMBING MECHANICAL ELECTRICAL
❑MISCELLANEOUS
PROJECT ADDRESS 7ZC7O 'ZOYAI / K ,W/ � APNM 2� I
OWNERNAME ,
Z
P ONE �� J E-MAIL
STREET ADDRESS7 2�Q/ A KW' I Com,ST�v�7 f D C Q}/O/4 FAX
CONTACT NAME L_ l(O v PHONE /E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OwNER ❑ OwNER-BUILDER O OwNERAGENI' �(CONFRACIOR OCONIRACTORAGENT ❑ ARCHITECT ❑ ENGINEER O DEVELOPER O TENANT
CONTRACTOR NAME LICENSENUMBER'7,jc7 j LICENSE TYPE BUS.LIC N
COMPANYNAME E-MAIL /`fV / FAX
IF vUK IF SIJ 707 2 - I O3
STREETADD BSSCITY,STATE,ZIP PHONE
,LLaAs 1�c A�zf �5h c,1 . S�fb�F 67. 5 40a
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC a
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX O MULTI-FAMILY PROJECfINWILDLAND O EPROIECFM O YES ISTHEBLDGAN ❑ YES
BUILDING [3CommERCLV. URBANBJTPRPACEAREA O NO FLOOD ZONE O NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK I �I
1 Ser,2
TOTALVALUATION: 7.47q
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 have read this
application and the information I have provided is correct. I have read the Description of Work and verify itis accurate. I agree to comply withal]applicable local
ordinances and state laws relating to building constructio ze presentativALaLCa=rtirm to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: l
PLEB O TION REQUIRED OMCE USE ONLY
OVER-THE-COUNTER
❑ EXPRESS
RI: ❑ STANDARD
El V
LARGE
❑ MAJOR
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 22696 ROYAL OAK WAY DATE: 0211212013 REVIEWED BY: MELISSA
APN: 342 32 128 BP#: VALUATION: $9,498
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE: At
WORK REPLACE E FURNACE&AC UNIT SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $133
TOTALS: trete} i4 $133.00
y�t 'mak"+ .
@�
T
Mech.Plan Check 7WERMT
Phunb. Plan Check Elec.Plan Check
M¢Ch. Plumb.Permit Fee: Ele.c. Permit Fee:
Other Mech.Insp. 1 0.0 hrs $45.00 Other Plumb Insp. Other Elce.Insp.
ED
Hech.Insp. Fee: - Phunb. /nap.Fee: Elec.Insp.PFee.
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District eta). These ees are based on the prellmina in ormation available and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 711/121 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
T-77 A
PME Plan Check: $0.00
Pennit Fee:
Suppl. btsp Fee
PME Unit Fee: $133.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: IADMIN $42.00
Work Without Permit? 0 Yes 0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRavDOC $45.00
Strom Motion Fee: IBSEISMICR $0.95 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
yiIMP,p ,
$266.95 $0.00[, r ,, TUTAI FtE ,t $266.95
Revised: 01/01/2013
Simplified Prescriptive Certificate of Compliance:2008 Residential HVACAlterations CF-IR-ALT-MVAC
Climate Zones 1 and 3-7
Site Address: EnforcementAgency: Date* permit#:
Z2 6
96 'KO YA I OA-t` 1,)A- 4'UP67Z-T(,J 0 2- I!-/o
Conditioned Duct insulation
ui rent Type' List Minimum Efficiea Floor Area requirement Thermostat
Packaged Unit ,/
Furnace �AFUE 96ro ®COP Over 40 R of ducts
12 Indoor Coil ®SEER I HSPF Served by system added or replaced in Setback
-� sf unconditioned s (ljnot dreadypresent,must be
Condensing Unit ®EER_ ®Resistance un R 6 (CZ 1,Spapace immlled)
Other
/.Equipment Type:Choose the equipment being installed;ifmore than one system,use another CF-1R-ALT-HVAC 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.
• I 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 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 fomes,worksheets,calculations,plans and specifications submitted to the enforcement agency for approval with the permit
application. -
Name: St F F SR I nI8 - Signature:
Company:
(9jE !-I cVe- cn-7r r A-,2 . � 2//2- 13
Address: I Iwo W 1 ?44
J I �� License: 44 G 9 a g
E?A-ftJ /
City/State/Zip: !�yi AJ'A ILC-5A eh . 9 S,..f o c.I Phone: 70'7 5-/ S • l �ZTo
i
2008 Residential Compliance Forms March 2010