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11100120 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 869 LONNA LN CONTRACTOR:VALLEY HEATING& PERMIT NO: 11100120 COOLING OWNER'S NAME: MATHIS ATHYLIN H TR AND CHARLE 1171 N 4 TH ST DATE ISSUED: 10/18/2011 WNER'S PHONE: 4082531450 SAN JOSE,CA 95112 PHONE NO:(408)294-6290 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL License Class e. ic.# REPLACE FURNACE SAME LOCATION Contractor ate I hereby affi a licensed under the provisio s of apter 9 (commencing S tion 7000)of Division 3 of the Business&Professions Code and that rcense 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. Sq.Ft Floor Area: Valuation:$2551 I 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. APN Number:35919029.00 Occupancy Type: 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 to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which ma rue against said City in consequence of the granting of this ermit. iti ly,the applicant understands and will comply Issued Date: with all non-po t ations per the Cupertino Municipal Code,Section 9.18. Signature G am. Date �© `? RE-ROOFS: 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 4�O ER-BUILDER DECLARATION inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,C pter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or andle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipm devi s which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay ea Air ua ty Management District I performance of the work for which this permit is issued. will maintain compliance with the erti i ' al Code,Chapter 9.12 an I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 5 5533, d 25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized agent: Date p�(J I certify that in the performance of the work for which this permit is issued,I shall 11 not employ any person in any manner so as to become subject to the Worker's J Compensation laws of California. If,after making this certificate of exemption,I CONS N T NDING AGENCY 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. ming 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 Building Department City Of Cupertino 10300 Torre Avenue [Lai Cupertino, CA 95014-3255 Telephone: 408-777-3228 C O P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: ONN PERMIT# L' OWNER'S NAME: p�Y— �� ���� PHONE # r 2 Z O GENERAL CONTRACTOR: SINESS LICENSE, ADDRESS: _ ���� CI Y/ZIPCODE: *Our municip 1 c4 r es ineps4w-working in the city to have a City of Cueertkabusines4 license. NO BUILDIN� FI L OR FI AL ODUPANCY INSPECTIONS O WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature 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 Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO 6 ITEMS OF 14 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35919029. 00 DATE ISSUED. . . . . . . : 10/18/2011 RECEIPT #. . . . . . . . . : BS000015072 REFERENCE ID # . . . : 11100120 SITE ADDRESS . . . . . : 869 LONNA LN SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MATHIS ATHYLIN H TR AND CHARLE ADDRESS . . . . . . . . . . : 869 LONNA LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4324 RECEIVED FROM . . . . : VALLEY HEATING CONTRACTOR . . . . . . . : ATKINSON, THOMAS LIC # 141 COMPANY VALLEY HEATING & COOLING ADDRESS 1171 N 4 TH ST CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 TELEPHONE . . . . . . . . : (408) 294-6290 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 2,551 .00 1. 00 0. 00 1. 00 0. 00 1BSEISMICR VALUATION 2, 551. 00 0.50 0. 00 0.50 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 260.50 0. 00 260.50 0.00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 869 lonna In DATE: 10/18/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$2,551 Y°PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION USE: PERMIT TYPE: WORK furnace replacement SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Select a Mech Item Furnace, Forced-Air 1MFR=<100 1 # $130 TOTALS: $130.00 Mech.Plan Check 0.0 I hrs $0.00 Mech.Permit Fee: 1MPERMIT Other Mech.Insp. 0.0 hrs $44.00 NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Theseees are based on the prelinina information available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS (I ee Resohition 11-053 i f '-1.%71) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 3 , PME Unit Fee: $130.00 PME Permit Fee: $44.00 -FT Administrative Fee: 1ADMIN $41.00 Work Without Permit? 0 Yes (F) No $0.00 Travel Documentation Fee: ITRAVDOC $44.00 A Strom,Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldiz Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $260.50 $0.00 TOTAL FEE': $260.50 Revised: 10/01/2011 Sim lified Prescriptive Certificate of Compliance: 2008 Residential HVAC CF-IR-ALT-HVAC Climate Zones 16 eAd es Enforcement Agency: Date: > #,• t.ii a Conditioned Equip ment Type' List Minimum Efficiency' Floor Area Duct insulation re T f1packaged Unit Over 40 ft of ducts added or ornate FUE COP erved b stem replaced in unconditionedSetback Indoor Coil gA EER HSPF_ y s ace Condensing UnitEER 8 Resistance sf R 8 (CZ 16) must be insta lled) jet sent, Other 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. HERS VERIFICATION SUMMARY Listed below are four HVAC alteration Options. The installer decides what work is being done and picks one of the appropriate Options. Each Option lists the HERS measures that must be conducted.A copy of the forms shall be left on site for final inspection and a copy given to the homeowner. At final,the inspector verifies that the work listed on this form was in fact the work completed by the installer. The inspector also verifies that each appropriate CF-6R and registered CF4R forms(no hand filled CF-4Rs allowed)are filled out and signed. Beginning October 1,2010,a registered copy of the CF-1R and CF-6R shall also be on site for final inspection. 1.HVAC Changeout Required Forms: • All HVAC Equipment replaced CF-6R forms: MECH-04 and MECH-2I-HERS CF-4R forms: MECH-21 • Condenser Coil and/or • Indoor Coil and/or CF-6R forms: MECH-2I-HERS CF-4R forms: MECH-21 • Furnace For Split Systems:Duct leakage<15 percent For Packaged Units: Duct leakage<15 percent Exempted from duct leakage testing if: 1.Duct system was documented to have been previously sealed and confirmed through HERS verification,or 2.Duct systems with less than 40 linear feet in unconditioned space,or 3.Existing ducts stems are constructed,insulated or sealed with asbestos 2.New HVAC System Required Forms: • Cut in or Changeout with new ducts:(all CF-6R forms: MECH-04 and MECH-2I-HERS new ducting and all new equipment) CF-4R forms: MECH-21 For Split Systems:Duct leakage<6 percent, For Packaged Units:Duct leakage<6 percent 3.New Ducts with Replacement Required Forms: • Includes replacing or installing all new ducting and/or outdoor condensing unit CF-6R forms: MECH-04 and MECH-20-HERS and/or indoor coil and/or furnace. Not all CF-4R forms:MECH-20 equip ment changed. For Split Systems:Duct leakage<6 percent For Packaged Units:Duct leakage<6 percent 4.New Ducting over 40 feet Required Forms: • Includes adding or replacing more than 40 CF-6R forms: MECH-04 and MECH-2I-HERS linear feet of duct in unconditioned space. CF-4R forms: MECH-21 For splits stem or packaged units: Duct leakage<15 percent EXCEPTION:Existing duct systems constructed,insulated or sealed with asbestos. 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' o tion ented qn other applicable compliance heets,calculations, Tans ands specifications submitted to the enforcement aal with the pennit application. Name: . 1� Signature: Company: 1 11 �- �(`� \ i I ate: �� Address: City/State/Zip: Phone: 2008 Reside ial cqmptzance Form March 2010 GENERAL PERMIT APPLICATIONMEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228 • FAX(408)777-3333•building(d)cupertino.ora MISC ❑PLUMBING &CHANICAL— ❑ELECTRICAL ❑MISCELLANEOUS I I I -0 PROJECT ADDRESS . APN ,n OWNER NAME PHONE STREET ADDRESS ITY, ATE, C \ FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CTrY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT IkONTRACTOP ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LI SE BUS.LIC# �` COWANYNAMEIt"k ` E-MAIL ' VV1 FAX LJ_C�� Z / STREET ADDRESS I STATE,Z '� P 0 ARCHITECT/ENGINEER NAME LICENSE NUMBER t BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE of SFD or Duplex Cl Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK %. TOTAL VALUATION: L g � a v ^e By my signature below,I certify to each ofo ng: I the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have51 �%,�j2,-= have read the Description of Work and verify it is accurate. I agree t comply with all applicable local ordinances and state laws relating to bauthorize ref Cupertino to enter the above entified roperty for in pection purposes. Signature of ApplicandAgent: Date: S PP ME INFORMATION REQUIRED MEPMiscApp_2011.doc revised 03116111