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11100089I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10140 PASADENA AVE I CONTRACTOR: TBD - TO BE DETERMINED I PERMIT NO: 11100089 OWNER'S NAME: GEORGE OMEN I I DATE ISSUED: 10/12/2011 OWNER'S PHONE: 4089962487 1 . I PHONE NO: I L �LI'CENSED CONTRACTOR'S DECLARATION License Class C ��Lic. # l C ✓ ` Contractor&,G �; U C DateZd l? ` A"" I hereby affirm that 1 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. 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. 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. APPLICANT CERTIFICATION certify that I have read this application and state that the above information is correct. 1 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, costs, and expenses which may a rue ag st 'd City in consequence of the granting of this permit. dditi ally, t ap cant understands and will comply with all non -point so a re lation er t Cupertino Municipal Code, Section 9.18. Signatur _ Date O D OWNER -BUILDER DECLARATION 1 uy affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three 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 Section 3700 of the Labor Code, for the performance of the work for which this 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 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 forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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, costs, and expenses which may accrue against said City in consequence of the g' 1. of this permit. Additionally, the applicant understands and will comply N I non -point source regulations per the Cupertino Municipal Code, Section 9.1,). Signature Date BUILDING PERMIT INFO: BLDG F ELECT I— PLUMB MECH RESIDENTIAL F_ COMMERCIAL JOB DESCRIPTION: REPLACE FURNACE AT EXISTING LOCATION Sq. Ft Floor Area: I Valuation: $2750 APN Number: 35717094.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by ` Date:,,- / 2 - 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 inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as define by the Bay Area Air Quality Management District I will maintain corpplianc ith the Cupertino Municipal Code, Chapter 9.12 and the Health & fety We, Sections 25505, 25533, and 25534. Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 7 ITEMS OF 7 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35717094.00 DATE ISSUED.......: 10/12/2011 RECEIPT #......... BS000015030 REFERENCE ID # 11100089 SITE ADDRESS .....: 10140 PASADENA AVE SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER ............: GEORGE OMEN ADDRESS . 10140 PASADENA AVE CITY/STATE/ZIP CUPERTINO, CA 95014 OPERATOR: suew COPY # : 1 RECEIVED FROM DUNRITE HEATING CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS CITY/STATE/ZIP TELEPHONE ........: FEE ID UNIT QUANTITY AMOUNT PD -TO -DT ---------- THIS REC -- --- NEW -BAL- -------- lADMIN ------------- HOURS ---------- 1.00 ---------- 41.00 0.00 41.00 1.00 0.00 0.00 1BCBSC VALUATION 2,750.00 1.00 0.00 0.00 0.50 0.00 1BSEISMICR VALUATION 2,750.00 0.50 115.00 0.00 115.00 0.00 1BUSLIC FLAT RATE 1.00 1.00 130.00 0.00 130.00 0.00 1MFR=<100 UNITS 1.00 44.00 0.00 44.00 0.00 1MPERMITFE FLAT RATE 1.00 44.00 0.00 44.00 1TRAVDOC FLAT RATE ------ --- ---------- - ---- ---------- 375.50 0.00 375.50 0.00 TOTAL PERMIT METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 375.50 --------------- 375.50 VOICE ID DESCRIPTION -------- ------------------------ 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- 1072 VOICE ID DESCRIPTION -------- ---------------------- 507 FINAL PLUMBING GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION MEP 14300 TORRE AVENUE • CUPERTINO, CA 95014-3255 MISCCUPERTINO ISI (408) 777-3228 • FAX (408) 777-3333 • building(5cupertino.org PLUMBING L'J ��ZCAL ELECTRICAL ❑/MISIf(,/CELLANEOUS PROJECT ADDRESSZZ e OWNS 6 0-7 PHONE ?6 _ Z V k7 E-MAIL STREET ADDRESS CITY, STATE, ZIP C, r(` - FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME J LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS/J CITY, a a X- g -C S'+ 7'o s�' f STATE, r . a f o /�, ! C' /� 3 PHONE yo? - 3 S2 -- c/Foci ARCHTI'ECTIENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME ' E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE SE OF SFD or DUPLEX ❑ MULTI -FAMILY BUILDING. ❑ COMMERCIAL PROJECT IN WI DLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN FLOOD ZONE ❑ YES ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK /� G fi h �j / G `- R s ` TOTAL VALUATION: 2 7 S Q. cr RECEIVED BY: L By my signature below, I certify to each of the following: 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 con � have d e Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building c on: I a ori r s tatives of Cupertino to enter the above -identified` property for inspection pu{poses. Signature of ApplicantlAgent- Date: ` d �` 2 tel/ SUPPLETB AL tORMATION REQUIRED OFFICE USE ONLY n -07;;;; -THE -COUNTER c Y U W T_ U ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR MPPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10140 pasadena ave. DATE: 10/12/2011 REVIEWED BY: bobs. APN:� j , BP#: ��O "VALUATION: $2,750 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition /Repair PENTAMATION FURN/AC PRIMARY SFD or Duplex PERMIT TYPE: USE: WORK replace furnace at existing location. SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced -Air 1MFR=<100 1 # $130 TOTALS: I 1 $130.00 Mech. Plan Check 0.0 I hrs $0.00 SUBTOTALS: $260.501 $0.00 TOTAL FEE: 1 $260.50 Revised: 10/01/2011 Mech. Permit Fee: 1MPERMIT Other Mech. Insp. 0.0 hrs $44.00 = Lj NOTE: This estimate does not include fees due "to other Departments (i. e. Planning, Public Works, Fire, Sanitary Sewer District, School information available and are only an estimate. Contact the Dept for addn'1 in o. District, etc.. These fees are based on the preliminary MISC ITEMS FEE ITEMS (I- ee Resolution 11-0WEJ Q TY/FEE PME Plan Check: PME Unit Fee: $130.00 PME Permit Fee: $44.00 $41.00 Administrative Fee: 1ADMIN Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Blda Stds Commission Fee: 1BCBSC $1.00 LLL=_= SUBTOTALS: $260.501 $0.00 TOTAL FEE: 1 $260.50 Revised: 10/01/2011 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: ' C) 1 (U = a S4 d 2 G U PERMIT # a� OWNER'S NAME: g /o f- Ore- PHONE # Y77- f''7GENERAL GENERALCONTRACTOR: ,Q c. •./1, T ,/v �. BUSINESS LICENSE # ADDRESS: 2 61,oc� 5e,. �� 1�/ CITY/ZIPCODE: C 'I- 9-v 3 -"ur municipal coae requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY I SPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL 'Up AC RS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: S gnature Date Please check applicable subcontractors and complete the following information: / C:�p - / Z- - /Contractor Signature Date 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 / C:�p - / Z- - /Contractor Signature Date INSTALLATION CERTIFICATE CF-6R-MECH-04 Space Conditioning Systems, Ducts and Fans (Pagel of2) Site -Address:_ Enforcement Agency: Permit Number: � �oi5!o �s Ate. so/� 7A161 // D 0 v, -F9 Space Conditioning Systems Heating Equipment F I L Equip Type (package- heat um) CEC Certified Mfr. Name and Model Number ARI Reference Number 2 # of Identical Systems Efficiency (AFUE, etc.)• 3 (zCF-111 value ° Duct Location (attic, crawl- space, etc.) Duct R -value Heating Load Btu/hr Heating Capacity Btu/hr (30S ,C: wSM04 PG?'A o1 (A1Ae A P o S01 N '� 6 c.00ttng t;qutpment Equip Type (package heat um CEC Certified Mfr. Name and Model Number ARI Reference Number' #of Identical Systems Efficiency (SEER- and EER) 1'3 (zCF-IR value) ° Duct Location (attic, crawl- space, etc. Duct R -value Cooling Load Btu/hr Cooling Capacity (Btu/hr 1 IVo AC t. y project is new construction, see rootnotes to wandaras /able 1.)I -Band /able 151-c Jor duct ceiling alternative compliance. 2. ARI Reference Number can be found by entering the equipment model number at hap:lAvww.aridirectory. org/ari/ac.php# 3. Listed efficiency on this page must be greater than or equal (>_) to the value shown on the CF -1 R form. 4. When CF -1 R is reference it is also applicable to the CF -1 R, CF -IR -AA or CF -IR -ALT ALL BOXES MUST BE CHECKED TO BE A VALID FORM ❑ § 110-§ 113: HVAC equipment is certified by the California Energy Commission. ❑ § 150(h): Heating and/or cooling loads calculated in accordance with ASHRAE, SMACNA, or ACCA. ❑ § 150(i): Setback Thermostat on all applicable heating and/or cooling systems meet the requirements of § 112(c). ❑ § 1500)2: Pipe insulation for cooling system refrigerant suction, chilled water and brine lines meets minimum requirements of Table 150-B and includes a vapor retardant or is enclosed entirely in conditioned space. 2008 Residential Compliance Forms August 2009 INSTALLATION CERTIFICATE CF-611-MECH-04 Space Conditioning Systems, Ducts and Fans (Page 2 of 2 Site Address: Enforcement Agency: Permit Number: / d S><l��f! �Sd / of 0(Y 1410 0 0 0 Ducts and Fans § 150(m): Duct and Fans ❑ 1. All air -distribution system ducts and plenums installed, sealed and insulated to meet the requirements of CMC Sections 601, 602, 603, 604, 605 and Standard 6-5; supply -air and return -air ducts and plenums are insulated to a minimum installed level of R-4.2 or enclosed entirely in conditioned space. Openings shall be sealed with mastic, tape or other duct -closure system that meets the applicable requirements of UL 181, UL 181 A, or UL 181 B or aerosol sealant that meets the requirements of UL 723. If mastic or tape is used to seal openings greater than 1/4 inch, the combination of mastic and either mesh or tape shall be used; and ❑ 1. Building cavities, support platforms for air handlers, and plenums defined or constructed with materials other than sealed sheet metal, duct board or flexible duct shall not be used for conveying conditioned air. Building cavities and support platforms may contain ducts. Ducts installed in cavities and support platforms shall not be compressed to cause reductions in the cross-sectional area of the ducts. ❑ 2D. Joints and seams of duct systems and their components shall not be sealed with cloth back rubber adhesive duct tapes unless such tape is used in combination with mastic and draw bands. ❑ 7. Exhaust fan systems have back draft or automatic dampers. ❑ 8. Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually operated dampers. ❑ 9. Protection of Insulation. Insulation shall be protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind. Cellular foam insulation shall be protected as above or painted with a coating that is water retardant and provides shielding from solar radiation that can cause degradation of the material. ❑ 10. Flexible ducts cannot have porous inner cores. DECLARATION STATEMENT • 1 certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct. • 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction, or an authorized representative of the person responsible for construction (responsible person). • I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • 1 reviewed a copy of the Certificate of Compliance (CF -I R) form approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the CF -IR that apply to the installation have been met. • 1 will ensure that a completed, signed copy of this Installation Certificate shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. 1 understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: (Installing Subcontractor or General Contractor or Builder/Owner) l.A 2A Responsible Person's Name: Responsible Person's Signature• CSLB License: Date Signed: Position With Company �3C43 y - lZ -a01 a � ice • ��,v-�C 2008 Residential Compliance Forms August 2009