11090074 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21876 BYRNE CT CONTRACTOR:SERVICE CHAMPIONS PERMIT NO: 11090074
OWNER'S NAME: HENRY DAVID G AND BEVERLY S 7020 COMMERCE DR DATE ISSUED:09/12/2011
QWNER'S PHONE: 4084460144 PLEASANTON,CA 94588 PHONE NO:(925)444-4444
LICENSED CONTRACTOR'S DECLARATION
�j BUILDING PERMIT INFO: BLDG� ELECT r PLUMB�
License Class C� Lie.# l7 I ) 4
Contractor�e f Uj v
tzi (iki,C(I/.�(PIDY1SDate MECH RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE EXISTING FURNACE&A/C UNIT&COIL
(commencing with Section 7000)of Division 3 of the Business&Professions SYSTEM
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 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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$10854
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION APN Number:35716142.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
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. Issued by: Date:
(,�t�,__2i x'-1 2 -!
Signatu /�� Date
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons:
inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. 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
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Ow r Pr, utl ri d a eat O,j �l I
become subject to the Worker's Compensation provisions of the Labor Code,I must �;t !�Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
casts,and expenses which may accrue against said City in consequence of the
ting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
ji all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Signature Date Licensed Professional
Simplified Presc ' five Certificate of Co fiance:2408 Residential BV4CAllerations CF-JR-ALT-HVA
Climate Zones 10 to 15
Site Address: ew
L. �"'-7' -�c _/ 7FAuipme _�/ Peranit iR
Conditioned Floor
rtt T ' List Minimum E�ci Duct insulation reguftement Area Thermostat
❑Packaged Unit
l 11 Furnace AFUF-��`� O COP Over 40$of ducts added a st sw-ack
10 Indoor Coil ®SEER nFlacco im rmccndi6oncd ,� (ff"M dnady
1l Candeming Unit O EER O Rcsistace OR 6 (CZ 10-13) f pmt naw be
O Other OR 8 (Q 1445) bu%dteo
1.Eq&Vmew Tip=Choose the equTmeit bemg i uWUedifmore than one systerb nae another CF-IR-AL T-HY-4 Cfor each system.
2.Af7mmam EquVftsent 491ckncies:13 SEER,7896 AF7JF 7 77LSPFfor""cal mode ad syrre s_
HERS VERIFICATION SUMMARY listed below are four HVAC alteration Options. The installs decides what work is being done and
picks one of the appropriate Options. Each Optica fiats the HERS mmures that must be conducted.A dopy of the forms shall be left on site for final
inspection and a copy given to the bomeownta. At fmai,the impaxor verifm that the work listed on this form was in fact the work completed by the
idler. The inspector also verifies that each appropriate CF-6R and registered CF-4R farms(no band filled CF-4R.c allowed)are filled out and
signed, nim October 1,2010,a rtzktered copy of the CF-IR std CF-6R sW also be an site for final hupectiolL
I.HVAC Chan art Required Forms:
• All HVAC Equipment replaced CF-6R Rr nsr MECH-04,ME(11-21 HERS and(for split systems)MECH-25-HERS
CF-4R fin= MECH-21 and for lit N ECH-25
• Condenser Coil and/or CF-6R Ams- MECH-2I-HER,S sad
• Indoor Coil and/or (for
spm syr)MECH-25-HERS
• Furnace CF-4R hams: MECH-21 and(for split systems) MECH-25
For.Split Systema:Duct leakage<15 percent; RC,CCA>300 CFMAton(Mutintum Air Flow Reilui ement),TMAH
For Packaged Units: Duct leakage<15 percent
Exempted from duct leakage testing if! r�
O 1.Duct system was doted to have bora previously sealed and eonfinned through HERS verification,or
O 2.Dad systems with less than 401utear Sent in unconditioned spm ce,Or
P3. duct an ,finulated or sealed with asbestos
HVAC Systems Required Forms:
r Changeout with new . CF-6R frrrrns MECH-04,MECH 204WM for
all new ducxing sIl •�( �0 sY )MBCH-22-11ERS,and MECH-25-11ERS
CF-411 foams MECH 20-,and(S)r split sydems)M ECH-22,and MECH 25 .
Systems:Duct leakage<6 percent,RC,CCA>350 CFM/ton,FWD,TMAH,STAS,and.cither HSPP or PSPP,
Unhs:Duct fouler <6 t
Ducts with Replacement R fired Forms:
rtplaciag or installing all rewdnctioag CF-6R items MECH-04, BC'-t-ZO-I II�RS,sad(for 80 systems)11¢,Q.I-25-HERS
and/or outdoor cmxknsimg unit and/or indoor CF-4R forms:MECH-20 and(for split systems)M13M25
coil and/or furnace. Not all equipment changed.
For Split Systems:Dud leakage<6 percen4 RC,CCA>_300 CFMAton,TMAH
For Packaged Units:Duct leakage<6 percent
O 4.New Do over 40 feet Reavired Forms:
• Includes adding or replacing more than 40 Cr-61Z forma MECH-04,MECH 21 Ants CF-4R forms: MEM-21
linear Set of duct in unconditioned spam I
For split system or packaged units: Duct leakage<15 percerrt
12 EXCEPTION: ' dud rystems constructed,insonated or scaled with asbestos.
Contractor(Documentation Author':/Respousibk Designer's Declaration Statement)
• I certify abet this Cgtifrate of Compliaum d0cummution is aocmate rad complete.
• I ata eligible cmdas Diviaea 3.od8ie Cafiforaia Basil and Profession;Code to accept req oner'bitity for ate design kkatifiod ap this Certificate of Compliance.
•. .I coiffy!hd the ewW fesunes aad.paimmance qwcfficadans for the desega idea ifW oa Haus Catigcdc ofComp8moe eonfaan to the ralairernentr.of-rgk 24,
Porta 1 and 6 eBre CiHfarpia.Co*&ofRegulations..:
• The design fiat=ideattified an die Carti0eate ofCompliaoee are eousistentwith dw infocmadan documented an ot6cappliabk eonpliamoe forms,worksbeas,
calculafin fiat arid' i4=ift d to the ceforameot yeacy for W tb the
I3ame~ MARINE BROOKS - Signaaore: ,��
CO�10y' SERVICE CHAMPIONS Die: _
Addreaa: (Z
x,4 ch arc.®t /-lU-- 817040
' 5An JC9 5e- L q 5l 3 1 kaS 94ti - 93w q,
2008 Residential March 2010
�v
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35716142 . 00
DATE ISSUED. . . . . . . : 09/12/2011
RECEIPT #. . . . . . . . . : BS000014728
REFERENCE ID # . . . : 11090074
SITE ADDRESS . . . . . : 21876 BYRNE CT
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : HENRY DAVID G AND BEVERLY S
ADDRESS . . . . . . . . . . : 21876 BYRNE CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1156
RECEIVED FROM . . . . : IE INC
CONTRACTOR . . . . . . . : KEVIN COMERFORD LIC # 31833
COMPANY . . . . . . . . . . : SERVICE CHAMPIONS
ADDRESS . . . . . . . . . . : 7020 COMMERCE DR
CITY/STATE/ZIP . . . : PLEASANTON, CA 94588
TELEPHONE . . . . . . . . : (925) 444-4444
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1. 00 41. 00 0. 00 41 .00 0. 00
1BCBSC VALUATION 10, 854 . 00 1. 00 0. 00 1 .00 0. 00
1BREMAIRRA NO.UNITS 1. 00 65. 00 0. 00 65 .00 0. 00
1BSEISMICR VALUATION 10, 854 . 00 1. 09 0. 00 1.09 0. 00
1MFR=<100 UNITS 1 .00 130. 00 0 . 00 130. 00 0. 00
1MPERMITFE FLAT RATE 1 .00 44 . 00 0 . 00 44 .00 0. 00
1TRAVDOC FLAT RATE 1 .00 44 . 00 0. 00 44 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 326 . 09 0. 00 326. 09 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 326. 09 #10679
---------------
TOTAL RECEIPT 326 . 09
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255
CUPERTINO (408)777-3228 •FAX(408)777-3333•buifdinaaacupertino.or° MISC
❑PLU-NMING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS ^ I j7 ApN
n � 1q2_
OWNER NAME
PHONI;
(1. ,.>;h '�L!'zS �y G, 'c)/K'j
STREET ADDRESS ?� CITY,STATE,ZIPS. AX Cu
CONTACT NAM"
ckkc�l �°�U y E-MAIL
srREEr ADDR.1_a` l`��Vi l�r AU-e— Com'��1� ,1 V J� 64 �,51� FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 4
CONTRACTOR AGENT ❑ ARCHTrECT ❑ENGRIEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME l C�I V (�A LICENSE"N"ER(3`"761 /\ LICENSE 7fy,Z�� BUS.LIC#
COMPANY NAME E-MAIL ( [V FAX
STREET ADD ATE,ZII_ p PONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC 9
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE.ZIP PHONE
USE OF 't SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ❑ Commercial URBAN[NTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ NO
DESCRIPTION OF WORK
Cuc CLArn - c� 4 L,u l4, 5-u-V
TOTAL VALUATION: V g 5-q,( c)
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. I have read this
application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to b c ction. 1 autho rep 1eNatives of Cupertino to enter the above'denatified pro rty for inspection purposes.
Signature ofApplicantlAgent: /�vUUV�- Date: 4 7
SUPPLEMENTAL INFORMATION REQUIRED T -_
MEPMiscApp_201 1.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 21876 byrne ct. DATE: 09/12/2011 REVIEWED BY:
APN: BP#: „'VALUATION: 1$10,854
PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: PERMIT TYPE:
WORK replace existing furnace/a/c unit and coils stem.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $65
Furnace, Forced-Air 1MFR=<100 1 # $130
—7 TOTALS: $195.00
Mech.Plan Check0.0 hrs $0.00I T
Mech.Permit Fee: 1MPERMIT
Other Mech.Insp. 0.0 hrs $44.00
Ll
NOTE: This estimate does not include fees due to other Depts(i.e.Public Works,Sanitary Sewer District,School District,etc.).
Theseees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn7 info,
FEE ITEMS (fee Resohition 11-053 Ef ?'1,/11) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $195.00
PME Permit Fee: $44.00
Administrative Fee: IADMIN $41.00
Work Without Permit? Yes Q No $0.00
Travel Documentation Fee: ITRA VDOC $44.00
i
Strong Motion Fee: IBSEISMICR $1.09 Select an Administrative Item
Filch Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $326.09 $0.00 TOTAL FEE:'` $326.09
Revised: 09/02/2011
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