13030035 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20578 CEDARBROOK TER CONTRACTOR:CALIFORNIA DELTA PERMIT NO: 13030035
MECHANICAL INC
OWNER'S NAME: LIN PI Y AND MAO H 6056 E BASELINE RD STE 155 DATE ISSUED:03/072013
OWNER'S PHONE: 4088395763 MESA,AZ 85206 PHONE NO:(866)692-5273
E3 LICENSED CONTRACTOR'S DECLARATION 30B DESCRIPTION: RESIDENTIALD COMMERCIAL -
License Class C- 2 U Lie.# Y/��� _ REPLACE(E)FURNACE,SAME LOCATION
Contractor,, �J! / ��"l�c'�CI�i�Date
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:
Il 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
performanceof the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3349
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 jN Number:32345048.00 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 OF PERMIT ISSUANCE OR
to building concoction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, /�
costs,and expenses which may accrue against said City in consequence of the Issue te:
granting of this permit Additionally,the applicant understands and will comply
IZ
with all non-point source regulatiQm;_V&the Cupertino Municipal Code,Section
9.18.
.ate ? 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
6 inspection.
❑ OWNER-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,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,Sections 25505,2553 ,a 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: DatezJ
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)We 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
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature . Date
�A
GENERAL PERMIT APPLICATION OM4 MER
p
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION"r!O
.10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 � '
CUPERTINO (408)777-3228• FAX(408)777-3333• buildina(a?cuoertino.org �0
SC
[]PLUMBING MECHANICAL CIELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS A" Z O
N a� moo/ ci��l c
PHOTS E-MAR
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STREET ADDRESS CITY, STATE,IIP FAX
C OC e Cc
CONTACT NAME h
STREEFAD RESS CITY,STATE,IIP FAX
ry
❑ OWNER ❑ OWNER-BUBDER ❑ OWNERAGENT T}1 CONTRACTOR ❑CONTRACTORAGEhrr ❑ ARCIDTECI ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACT RNAME LLCSF�NUMBE�/ LCENSE72 BUS.L1Cz
77
MP NAME
E-MAIL FAX
S ADD Ss CITY,STATE,ZIP O PHONE ,O,O'
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LJC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFDwDUPLEX ❑ MULTI-FAMPROJECTA'WB.DLAND [3YES PROJECT IN ❑YFS ISTHEBLDGAN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZOI.'E ❑NO EICHLER HOME? ❑NO
DIscRTPnoN of wonx wi G e- _ / c
TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the property owner or authori agent to act o grope owner's f I have read this
application and the information I have provided' w t. III read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bvildin coon. I aufi=representatives of Cupertino to enter the above-identified propeft'y for inspection purposes.
Signature of Applicant/Agent: Date: S _
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OVER.THE-COUNTER
❑ EXPRESS
U
❑ STANDARD
'O
5 ❑ LARGE
❑ TIAJOR
MEPD1acApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20578 cedarbrook ter DATE: 03/07/2013 REVIEWED BY: MELISSA
APN: 323 45 048 BP#: *VALUATION: $3,349
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD Or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK REPLACE E FURNACE SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE H) QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $133
TOTALS h ' $133.00
♦F,{(. 4, iY MITI i
$i1�T
�b Q Nn
Meeh.Plan Check 0.0 hrs $0.00 Plumb.Plan Check Elee.Plan Check
Mech.Permit Fee: IMPERMIT I Plumb.Permit fee: -lec. Permit Fee'
Other Mech.Insp. 0.0 hrs $45.00 Other Plumb Insp. Li 0ther Elec Insp.
Li
;Mech. hasp. fee I Plumb. Ins).Fee: Elec.Insp.Free
NOTE:This estimate does not ineludejees due to other Departments(Le,Planning,Public Works,Fire,Sanitary Sewer District,School
District eta). These ees are based on the prefintdina in ormation available and are only an estimate. Contact the Dept for addn't info.
FEE ITEMS (Fee Resolution 11-053 Eh LL 21 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee,
PME Unit Fee: $133.00
PME Permit Fee: $45.00
Consiruction Tar:
Administrative Fee: (ADMIN $42.00
Work Without Permit? Q Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VDOC $45.00 A.
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$266.50 $0.0022wwE'., $266.50
Revised: 01/01/2013
Simplified Prescriptive Certificate of Compliance:2008 Residential HVA C Alterations CF-IR-ALT-HVAC
Climate Zones 1 and 3-7
Site Address: EnjorcementAgency: Date: Permit
Conditioned Duct insulation
i meat Type' List Minimum Efftcien Floor Area requirement Thermostat
Packaged Unitp
®.Furnace ®AFUE / ®COP_ Over 40 ft of ducts
Served by system added or replaced in E3 Setback
®Indoor Cod ®SEER HSPF (7not alreadypresent,must be
Condensing Unit ®EER_ Resistance sf unconditioned space installed)
Other ®R 6 (CZ 1,3-5)
1.Equipment Type:Choose the equipment being installed;ifmore 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/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 forts,worksheets,calculations,plans and specifications submitted to the enforcement agency for approval with.the permit
application.
Name:. .�G�, /D a v o - Signature:
Com - Date:
Oess:Tl� i�` - License:
City/State/Lip: C O 2 6 Phone: ,v
2008 Residential Compliance Forms March 2010