13020041 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 810 SEPTEMBER DR CONTRACTOR:ATLAS-TRILLO HVAC PERMIT NO:13020041
OWNER'S NAME: VUAY&V MITA GANPULE 1965 KYLE PARK CT DATE ISSUED:02/082013.
OWNER'S PHONE: 4089751550 SAN JOSE,CA 95125 PHONE NO:(408)286-8931
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIALO COMMERCIAL
License Clas �s, Lie.N REMOVE AND REPLACE FURNACE IN SAME LOCATION
Contractor f TY(. J 10 AL ate,
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 fora and effect.
I 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:$2200
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 iN Number:36214023.00 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 0 DAYS OF PERMIT 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 DA OM LAST CALLED INSP ION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issued by: Date-
granting of this permit. Additionally,the applicant understands and will comply
with all non-poin tfit regulations per the Cupertino Municipal Code,Section
9.18. //
Q RE-ROOFS:
Signature Da ,J 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date: -
I hereby affirm that I am exemptfrom the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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(Sec.7044,
Business&.Professions Code)
1,as owner of the property,am exclusively 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. 1 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 Code,Section 25532(x)should I 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,Sec r ,25533,and 25534. nn
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Dat L
permit is issued.
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 CONSTRUCTION LENDING AGENCY
Compensation laws-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 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 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 accrue 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
n
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18..
Signature Date
Simplified Prescriptive Certificate of Compliance:2008 Residential HVA CAlterations CF-lR-ALT-HVAC
Climate Zones 1 and 3-7
SheAddress% , o EnforcementAgency: Date: Permit#:
V Conditioned Duct insulation
00"Ccther
ui rent Type' List Minimum Efficiency" Floor Area re ent Thermostat
ackaged Unit Over 40 ft of ducts
maw - ® ®COP_ Served by system added or replaced in [3 Setback
door Coil ER_ HSPF_ (Ijnot alreadypresent,must be
ondensing Unit ®Resistance sf unconditioned space Installed)
• ®R 6 (CZ 1,3-5)
1.Equipment Type:Choose the equipment being installed;if more than one system,use another CF-IR-ALT-HVAC for each system.
2.Minimum Equipment Efficiencies:13 SEER,78%AFUE,7.7HSPF for typical residential systems.
Contractor(Documentation Author's)13esponsible 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 Tide 24,Paris 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 forms,worksheets,calculations,plans and specifications submitted to the enfor meat agency for approval with.the permit
a lica'on.
Name: Attaf - - to VAC Signature: i
Company:
' r- l
Address: /,i r_�^ � License: 1
City/State/Zip: CJ> O� Phon . qUD )P/ —05Y
2008 Residential Compliance Forms March 2010
GENERAL PERMIT APPLICATION M E p
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 Upa � '
CUPERTINO (408)777"3228•FAX(408)777-3333• buildin cuoertino.or : (
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EIPLUMBING ElviEcFAmcAL ELECTRICAL EIMISCELLANEOUS
PROJECTADDRESS Ge "°r'« .6z)
OWNER NAME /^ L/ PHO y((0 (F-y1 K R E-MAQ,
STREET ADDRESS CITY.S � (ZIPv ( t-,f� /, U /1/ FAX
CONTACT NAME PHONE - E-MAIL
STREEr ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUDDER ❑ OwNERAGEM NTRACrOR ❑CONTRACTOR AGENT ❑ ARcm= ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMEY.11 10
1/1 ,�c LICENSE (� `I Ll BUS.LIC X
COMPANY NAME v u`ln -FAX
STP=AftV CITY,STATE,ZIP (� PHO /�('
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS. % .JCC VJ L
COMPANY NAMEE-MAB. - FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SM or DUPLEX ❑ MULTI-FAMMY PROIECT IN WILDLAND ❑ YES PROJECT IN ❑YEB IS THE BLDG AN EI YES;
BUILIN
DG: ❑ MME
CORCIAL URBAN INTERFACEAREA [3 NO FLOOD ZONE [I No EICHLERHOMEt El NO
DESCRIPTION OF WORK
cu
TOTALVALUATION: , 1 RECEIVED BY:
By my signature bel w,I certify to each of the following: I am the property owntire or authorized agent to act on t perry owner's behalf. I have read this
application and the information III is ve read the Description of Work and verify it is ace . I agree to comply with all applicable local
ordinances and state laws relating to I g con wetion uthorize representatives of Cupertino to enter the above-i toff pro el�y for inspection purposes.
Signature of Applicant/Agent: Date: T/
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OYER-THECOUNTER
❑ EXPRESS
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❑ STANDARD
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❑ LARGE
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❑ MAJOR
MEPMucApp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 810 se
ow-ptember dr DATE: 02/ 8/201 3 REVIEWED BY: mendez
APN: BP#; *VALUATION: J$2,200
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION FURN/AC
USE: SFD or Duplex I PERMIT TYPE:
WORKremove and replace furnace in same location
SCOPE
P17.,'
h _
�,V%
Mech.Plan Check 0.0. hrs $0.00 Plumb. Plan Check Elec.Plan Check
Mech.Permit Fee: IMPERA11T Plumb,Permit Fee: Elec. Permit Fee:
-Other Mech.Insp. 0.0 hrs $45.00 Other Plumb Insp. Other Elcc.Insp.
.11ech. Insp. Fee: Plumb. Insp.Pee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments 0.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These&es are based on the preuminm in orntation available and are only an estimate Contact the Dept for addn'i info.
FEE ITEMS(Fee Resolution 11-053 E . 711 /1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Mechanical
Suppl.PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 $133.00 IA5R=<100 I Furnace,Forced-Air
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl.Insp.Fee.0 Reg. O OT0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Constmetion Tac:
Administrative Fee: IADA9N $42.00 0
Work Without Permit? 0 Yes Q No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure
Strong Motion Fee: 1BSEISA1ICR $0.50 Select an Administrative Item
Bldg Std s Commission Fee: IBCBSC $1.00
$133.50 $133.00 � '; TOLEE $266.50
Revised: 01/01/2013