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13010071 CITY OF CUPERTINO BUILDING PERMIT CONTRACTOR ffffll �+� PERMIT NO:13010071 BUILDING ADDRESS: 1165 ELMSFORD DR , 1 S _1 � I DATE ISSUED:01/11/2013 OWNER'S NAME: BEDELL WILLIAM N AND ELAINE T AI F �Cvl'l PHONE NO: OWNER'S PHONE: 4088972955 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIALJX COMMERCIAL REMOVE AND REPLACE FURNACE IN SAME LOCATION License Cl Lie.# 61 pe. �t ` Contractor "" `.J e 23 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: 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 Valuation:$6100 performance of the work for which this permit is issued. Sq.Ft Floor Area: 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 APN Number:36208022.00 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 construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS O LAST CALLED 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 Issued by: Date: ZO&I nall the applicant understands and will comply i e rt. Additionally, app of s Y, with granting p Code Section with all non- oint s ice regula' s per the Cupertino Municipal 9.18. RE-ROOFS: Signature rV�"� Date 'r I 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. OWNER-BUILDER DECLARATION Date: Signature of Applicant: thereby 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) HAZARDOUS MATERIALS DISCLOSURE 1,as owner of the property,am exclusively contracting with licensed contractors to 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,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)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 the ay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance wit the C pertino u icipal Code,Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec' 5 ,2 3 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent. Date: permit is issued. I certify that in the performance of the work for which this permit is issued,I shal I not employ any person in any manner so as to become subject to the Worker's CONSTRUCTI N LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,I 1 hereby affirm that there is a construction lending agency for the performance of become subject to the Worker's Compensation provisions of the Labor Code,I must work's for which this permit is issued(Sec.3097,Civ C.) forthwith comply with such provisions or this permit shall be deemed revoked. 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 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 1_icensed Professional 9.18. Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•buildingecupertino.org MISC i PLUMBING MECHANICAL IVOIELECTRICAL MISCELLANEOUS PROJECT ADDRESS VA� I C �1 rP APN# OWNER NAME lQ J v�,PH E-MAIL o STREET ADDRESS �/ CITY, wa FAX l rCA q�;bF4 CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER 13OWNERAGENT CONTRACTOR 11 CONTRACTOR AGENT 11 ARCHITECT ❑ENGINEER 11 DEVELOPER ❑ TLNAl \ �I CONTRACTOR NAME N 1 f LICENSE NUMBER q`(, Gbq LICENSE TYPE/' BUS.LIC# COMPANY NAME 'P--F\� E-M D��}�� FAx fol-R yll i,?_ 'A ( STREET ADDRESS II, S� CITY, A ZIP J V}�y C G� PHO LLLu y_ ARCHITECT/ENGINEER NAME LICENSE NUMBER l BUS.LIICC# 0 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OFFD or DUPLEX ❑ MULTI-FAMILY I PROJECT IN WB.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA PONO FLOOD ZONE ->p NO EICHLER HOME? NO DESCRIPTION OF WORK I �jg, a/J Y16L(Q r lX" ^.l,/) 1'�V yLcC� ` l ) TOTAL VALUATION: RECEIVED By my signature below,I certify to ch of the followin . I am the property owner or authorized agent to act on a pro owner's behalf. I have read this application and the information I hav rovi i corr . I ve read the Description of Work and verify it is accurat . agree to comply with all applicable local ordinances and state laws relati to it ' stntc to ��riiz7e,representatives of Cupertino to enter the above entified property for inspection purposes. Signature of Applicant/Agent: � V (/"�— Date: I I� SUPPLE7 INFORMATION REQUIRED OFFICE USE ONLY W OVER-THE-COUNTER�� a I" ❑ EXPRESS .< I U x ❑ STANDARDI U ❑ LARGE 4 i ❑ MAJOR MEPMiscApp_201 1.doc revised 06/21/11 CITY OF CUPERTINO IFFEE ESTIMATOR—BUILDING DIVISION ATDDRESS: 1165 Elmsford Dr DATE: 01/11/2013 REVIEWED BY: Mendez PN: BP#: "VALUATION: $6,100 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY PENTAMATION FURN/AC USE: SFD or Duplex PERMIT TYPE: i WORK Remove and replace furnace in same location SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UMTS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $133 TOTALS: $133.00 hrs $0.00 Phunb.Plan Check Ele4,Plan Check Mech.Plan Check Rol Mech.Permit Fee: 1MPERMIT Plumb. Permit Fcc: Dec. Permit Fee: Other Mech.Insp. 0.0 hrs $45.00 Other Plunab Insp. ID—L— Other Elec.Insp. Insp. Fcc: Phmrh. E=F-L- h1s)). Fer: Eke.Insp.Fee: NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the preliminary information available and are only an estimate. Contact the Dept-for addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee. A PME Plan Check: $0.00 Perinit Fee: Suppl. Insp Fee PME Unit Fee: $133.00 PME Permit Fee: $45.00 T= Conswuction Tax: Administrative Fee: IADMIN $42.00 Work Without Permit? 0 Yes Q No $0.00 Adyancecl Planning Fees Travel Documentation Fee: ITRA VDOC $45.00 Strong Motion Fee: IBSEISMICR $0.61 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.001 L SUBTOTALS: $266.611 $0.00 TOTAL FEE: $266.61 Revised: 10/01/2012 Simplified Prescriptive Certificate of Compliance:2008 Residential HVACAIterations CF-IR-ALT-HVAC Climate Zones 1 and 3-7 Sit Enforcement A e n : D Permit#: "tS�(Abf— - 1'1 Conditioned Duct insulation Equipment T el List Minimum Efflciency2 Floor Area requirement Thermostat Packaged Unit ��p� Furnace EfAr UA65D ®COP Over 40 ft of ducts Served by system added or replaced in Setback Indoor Coil ®SEER HSPF (If not already present,must be ®Condensing Unit ®EER ®Resistance sf un nditioned space ,,,stalled) 0 Other a R 6 (CZ 1,3-5) 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. 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 forms,worksheets,calculations,plans and specifications submitte to the elbrcement agency for approval with the permit application. Name: tkvSignature. 4 MY Company: Date: Address:/f� '1 License: o City/State/Zip: O Phone: I I 2008 Residential Compliance Forms March 2010 II Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: (p 5 L� r�i PERMIT# ( 0/C OWNER'S NAME: PHONE# GENERAL CONTRACTOR: !1-( BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND A SU CONT TORS HAVE OBTAINED A C TY OF CUPERTINO BUSINESS LICENSE. I�� I am not using any subcontractors: Signature Date Please check applicable subcontractors a d 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 Date Owner/Contractor Signature