09070151 CITY OF CUPERTIN D BUILDING PERMIT
BUILDING ADDRESS: 10128 IMPERIAL AVE CONTRACTOR:BLUE MOUNTAIN AIR PERMIT NO:09070151
OWNER'S NAME: JOAN ANDRUSKO "07 ALDRIDGE RD STE B DATE ISSUED:07/21/2009
ER'S PHONE: 4088739616 VACAVILLE,CA 95688 PHONE NO:(707)451-8111
❑ LICENSED CONTRACTOR'S DECLARATIONL----
Q / WILDING PERMIT INFO: BLDG ELECT PLUMB
License ClassCi dC� Lic.#
MECH RESIDENTIAL COMMERCIAL
Contracto JQ �/`' Date �—�'L` 2�s
1 hereby affirm that I am licensed under the provisions of Chapter 9 IOB DESCRIPTION:ADD A/C TO HV SYS 3 TON BSEER CONDO ON
(commencing with Section 7000)of Division 3 of the Business&Professions 'ATIO
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. 3q.Ft Floor Area: Valuation:$2680
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
permit is issued. 1PN Number:35722040.00 Occupancy Type:
APPLICANT CERTIFICATION
1 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 no int source regulations per the Cupertino Municipal Code,Section Issued Date:
9.18.
Signat Date
RE-ROOFS:
CJ OWNER-BUILDER DECLARATION all roofs shall be inspected prior to any roofing material being installed.If a roof is
nstalled 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 two reasons:
1,as owner of the property,or my 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).
1 hereby affirm 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. 1 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.
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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,1 shall
not employ any person in any manner so as to become subject to the Worker's 0.14r author' age p
Compensation laws of California. If,after making this certificate of exemption,I Date:���� !
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked. CTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work'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
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
i• iify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
c. 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 no -7pnt source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
n
Signat re 7
Oq 0r7 01 t
CITY OF CUPERTINO
FUP2iACE/AC
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
.� � � oL
Building Address-__,
/a/Z�, � /- ✓e- 0 t4 mac,l l
Owner's Name: Phone#•
Contractor: Z /,C- /I-40,t, 4,4 C,�`,� X) ,,, 7� e- Phone#:
l Fax#: l� o rb-7'� 2 b
Contractor License#: Cupertino Business License#:
Contact: Phone#: 7d 7- ,S-�
Fax #:
Building Permit Info:
Elect/61Plumb'o Mech 10
Residential W zCommercial
Job Description:
4 � (-'
For Residential Installations:
Attic ❑ I"floor [] 2"d floor ❑
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of CDnstruction (Usage Class):
Strapped 0 On Platform ❑ Bond,;d New Location ❑ Replacement
Project Size: Express ❑ Standard Lar e [] Major❑
Valuation:
6 lcD
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, incl ide in plan set& the sheet index.
Revised 01/07/09
CITY OF C UPERTINO
s FURNACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
AIR FURN/AC
CONDITIONING
1BCAIRHAN Commercial A/C Units <= 10k CFM B
1MCRAA Commercial Mech Repair/alt/add M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICO Seismic Commercial B
1PGASCOM Commerical for e gas piping System P
1-4 outlets
1 PGASRES Residential for ea gas piping system P
of 1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet. C omm/Resid
1BREMAIRHAN Residential A/C units<= 10k CFM B
1 MRRAA Residential Mech Repair/alt/add M
r 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
I TYPES
( 1BSEISMICR Seismic Residential B
1 EPERMITFEE Electric Permit E
' 1MPERMITFEE Mechanical Perm,t M
1 PPERMITFEE Plumbing Permit P
I 1 TRAVDOC Travel Document ition B
1BUSLIC Business License B
Green Building Plan Check
Index of Green Building Points/Categories
A. Category Example of an Index or Table of C reen Plan Sheet or Page Points
Building Points Categories that mL st be
shown and referenced on the Prc ject
Plans See below
_-
NVAMEXIM
B. Site 9. Install H.E. Irrigation, (details/sp.;c)' L-1 2 points
11. Permeable Paving, Note L-1 2 points
C. Foundation 1. Use 15 % Flyash Concrete, (not:) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) S-2 2 points
6. B. OSB Sheathing, detail S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spec.) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec. A-4 2 points
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11. A 2500 Gal. Tank, (Note/Spec L-1 10 oints
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (Note/.3pec.) A-3 1 point
3. Energy Star Refrigerator, Note/3 ec. A-3 1 point
P. Other 1. List Green Features on Plans A-1 1 point
TOTAL POINTS 40 points
Plan Review Process Work Book Page-12-Revised 3/25/0 3
INPUT Rescwrus
a I.Windows Energy '
1 1.Install Energy-Efficlent Whdows
a.Double-'aged I Energy pt y=yes 0
b.Lowaniissiivity(Lor-q i Energy pts Y--yes 0
c.Low.Conduct+vity Rum 2 Energy pts y=yes 0
2.Install Low Heat Transmission Glazing I Energy pt y=yes 10
■
J.Heating Ventilation and Air Conditioning 1 1 1
1•Use Duct fustic on AM twat Joints ?Energy pts y=yes 0
2.Install Ductwork within Conditioned Space 3 Energy pts y=yes 0
3.Vent Range Hood to the Outside IAQ/Health pt y=yes 0
4.Clean all Ducts Before Occupancy 'IAQ/Health pts y=yes 0
5.Install Solar Attic Fan Energy pts y=yes 0
6.Install Attic Ventilation Systems Energy pt y=yes 0
7.Install Whole House Fan t Energy pts y=yes 0
8.Install Sealed Combustion Units
a.Furnaces ;3IAQ/Health pts y=yes 0
b.Water Heaters 3 IAQ/Health pts y=yes 0
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEER/11 EER or higher AC with a TXV 3 Energy pts y=yes 3 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts y=yes 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace ?Energy pts y=yes 0
13.Retrofit Wood Burning Fireplaces
a.Install EPA certified wood stoves/inserts IAQ/Health pt y=yes 0
b. InstalVReplace Dampers Energy pt y=yes 0
c.Install Airtight Doors Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating :3 Energy pts y=yes 0
15.Install High Efficiency Filter 4 IAQ/Health pts y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) "IAQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes 0
E1 1 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts y=yes 0
2.Install Solar Water Heating System 1 1)Energy pts y=yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation I Energy pts y=yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=18 points) Up to 18 Energy pts 0
6.Select Safe and Durable Roofing Materials 1 Resource pt y=yes 0
7.Install Radiant Barrier :3 Energy pts y=yes 0
■ 1 1 1
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts y=yes 0
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts y=yes 0
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y—yes 0
■ f 1 1
Community Development
ii 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
tin Of Fax(408)777-3333
,-.-UPEkT1N0
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: A k PHONE # i
GENERAL CONTRACTOR'j3j I 1A r FAX #
I am not using any subcontractors: 7
Si:,,nat4e 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 7
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
j Sheet Rock
Tile
2 ,4 c)-k)
-�Ur
Owner/tontract6r Signa e Date