10100008 CITY OF CUPERTINO '3UILDING PERMIT
BUILDING ADDRESS: 22106 RAE LN CONTRACTOR:ABC COOLING& PERMIT NO: 10100008
HE 4TING
OWNER'S NAME: FRANK CERVENKIA 3 1 f 45 HAYMAN ST DATE ISSUED: 10/01/2010
/NER'S PHONE: 408843000 HAYWARD,CA 94544 PHONE NO:(510)471-8181
YLICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class
3E C ZG Li,.# �'q L- 3 13 131 REMOVE AND REPLACE FURNACE 90,000BTU 95%AFUE
Contractor �',�tiJ� r Date -If C
1 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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3677
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:35607057.00 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 FROM 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 Is;ued bv' Date: < l LQ
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations er the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature to 1C / Al I roofs shall be inspected prior to any roofing material being installed.If a roof is
in:tailed without first obtaining an inspection,I agree to remove all new materials for
in;pection.
L1 OWNER-BUILDER DECLARATION C�
Si;nature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROO OVAPT
ASS"A"OR BETTER
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,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I rave read the hazardous materials requirements under Chapter 6.95 of the
C ilifornia 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(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 by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. w ill maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by ti a Health&Safety Code,Sections 25505,25533,and 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 shall
not employ any person in any manner so as to become subject to the Worker's CON UCTION 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 icreby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. µork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION 1 ender'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
n-on the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
anify and keep harmless the City of Cupertino against liabilities,judgments,
.s,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 I icensed Professional
9.18.
Signature Date
CITY OF CL PERTINO
FEE ESTIMATOR- BIUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: "VALUATION: 1$3,677
xPERMIT TYPE: Mechanical Permit PLAN C HECK TYPE: Alteration /Addition / Repair
PRIMARY �� f _ PENTAMATION
USE: SFD or Duplex ,t ;} �t.j- FURN/AC
PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $126
TOTALS: $126.00
Mech.Plan Check "00 $0.00
Fmech.Pennit Fee: IMPERMIT
Other Mech. Insp. 0.0 hrs $42.00 t - 1'it r_Inn
kc> i'r ��;�;. I e-�• l,iec_rr tp. I'cc'
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Elf FEE QTY/FEE MISC ITEMS
P/on ('11c :A VCC.
.S`lIpp1. PC 1:,",
F-T F- I
PME Plan Check: $0.00
sup/d, 11i'y Fc"
PME Unit Fee: $126.00
PME Permit Fee: $42.00
�Uli_ti'lt7tt`tlOi7 �tl.�
"fit"ilw)tIt'<`t! lit'1'If'1,
Work Without Permit? 0 Yes E) No $0.00
1'I czrtrr i tt�7 1'it e'.�
Travel Documentation Fee: ITRAVDOC $42.00
Strong Motion Fee: $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $211.50 $0.00 TOTAL FEE: $211.50
Revised: 9/29/2010
f
Sep 29 10 01 : 57p RBC COOLING & HEATING 5104718368 p. 2
Prescriptive Certificate of Compliance: Residential CP-I R-ALT
Resitlerrlial Alterations (1'arrc I of 5)
Project\'xn)c: ,— Climate Zone# #uf�tifuries
►ten 1�-
General Information
Site Address: hnrureement'q enc
• n LP �J � Y- h'nU Uatc: � 32
Iluilding Type f61191e Puntily ❑hlulli family Circle the Prov t Orientation:N,(�1a,W.or degrues
('()mliiinncd Iaour Area(CFA): 3�rvo Proiecl Type: Ahuralians ❑Envelope❑i:cncsttation 0 Ilc)ol' cgl IVt\C'
Replacement n Chan+e Out ❑ Ducl Ile)lacement ❑ Wtltet•I leatcr
NOTE. This form is nnl to he nsed,fir Newly Con.clrrrcled Buildings lir Alit,ilirnls
In.rulalian Vulaes For Opaque Snrfrrccs//iw Furring use the it lass and Purr 4t,�,Su/!zi C'orrsU rtcriOu fuhle hehnv)
Assembly Mteratiun
❑Openiii-of fr:inecl eaviiyalone :Ihc'ruliirr that imarlue the opaninrr n/dte•/ian)ed cutin'ufu troll•c<'Nint�,ur./luir uuccl inslcrl!the
mandifor;y mini illun hrsuAllio»value per,ss'150.lbl-/lie ullered usxenlbll' Vill,n Columns:i••Ccmd enter nujuk•11rn-i•itIsvtleWon vu/le in l'ahmur l/.
❑Replace met'(of caths xsscmhly llcpinccnun!a%uu entire mer//,cei/intr,ir,/luor ucs'c'nrhly rrrprirca lilt insvullulion r1%('um/runcrtl
1'ue11•a,:;e-1)hrivhnhut Vilhies•1n Tuhle l.il-('. pig in
Opaque Surface Details Pnr the Iirrred portioned or kl)lss Walls see Purring Strips Constructiuu'Tattle below.
A 13 c 1 1) b: li 1 (: 11 1 1 1 .I
I'ropused,"`not', Standard Values From.I1\4 T-lible
Framing' ihtckness. - Framed � Comitlllous JA-4 P)%)])n.ccl
Tug/ Assembly Name tvl:del-ial Splicing, l;- ,IA4'I'able Cavity lnxulatiun Asscmbly Assembiv
I I)' or I'�lie and Siic- ot•Other` luetort Number R-vuliter' R-Vulue7 Cull Vatluc l t 1-111ctor l
A'nte:1-tirArred asseurhlies.ucc•ouninq forC'ontinuous hatibliton 11-value.rce Page.b 4-3 and liqualion 4-1. For cuh-uJutiuq,(ulred walls un,the Aluss and
Furrirr•C onslrnctimi table below.
1.For•ifg.'ll)indk'cae rhe irlcni{11cnlion name deal ntalches the huildingplans•
2.hrdic•ule the ds•.rumhly iVamu or hire:/loof7('eiling, Wal/s.Floors,Slabs,Cr nvl Space,Doors and etc...indicate the 1 i cane lVpe ut7el.e:1•n1•
il'ood,d lelrr/, Xletal Buildings.:1/ass•,enter• 1Y4,?s(,or etc...see Ja•l for o her possible frame!ype ax.ve nrhlies.
3. linter the thickness_%r mass in inches ur Spacing heltveen•fivining meinher•i enter: 16"lir 24"0(':lir Other fir all other(INS01101v descriplion
such rr.s Collerele,Sanchvich Panel.Sj)crndrel Panel.Jogs,Sti-mv!tale Panel and etc....
•J. !lased on file(7inrute;'011e.-enter the Standard I/-favlor•/i•om Table/.i 1-li, .^or D fru•each d;'[%stent cesa emh/t'rvcune or It��c.
i./:
Sep 29 10 01 : 57p RBC COOLING & HEATING 51047183GS p. 3
Prescriptive Certificate of Compliance: Residential CF-1 R-ALT
Residenfirt/A/terat'iana• (Page c{ of S)
1'rujcct r\ami, Climate Zone N
LAn;5toric.v
IIVAC SYSTEMS-I IE,ATING
�d ininuttn Duct or firing C'nnl igurrttiun
I Icnlin�fiquipntcnl lil7icicnc)' Disllibutiun Insulation 'I'bcrmostut (Central.Split.
"v to and Ca unci! 7 t 1 (Al l II?ar 11SPI�) '•vine anti Loeation4 R-Value l'Y 7cS rtcc.I'nckuge or I fsdrnnic}
1.hrdicalle/l/culin,C'Type K entrel Furnace. IN111/'lrrncrce,Had pomp,lioi/e r,!ilectric Resislunce,etc.)
?./:/ecn)c resistance ht+crfin/;is'allrnred atilt'in(:v»tpunen!1'aelrage C.vp c«ep!a+!rete eteclric hentin�i.c s'tyrplenrenlnl(i,r., r/'!tiler!c u/?ar ih
KIPor 7.000 8f7alr,•cleefric heating is conuo/led Inv a lime-limiting c Yvice nut exceeding 30 nr/ncrles). See§15/(h).i cx.wv1dlOn.
3./tc,/i!r to the//ERS I•'erificuliun.ceNiun un Yage /gfthe C'1=/R-%I/T/'nrn7 fir addil/uncr/rrquircunenls'and chec/c crpp/iccrh/e hn.res.
1. lrrrlivate l vpe or l.ncation(Ducts,1•4velronic in 1•Yuor•, Radlettorn',etc.)
MVAC SYS'T'EMS-COOLING
Minimum
Ffficiency Duct or Piping Configuration
Coaling Equipment (S1ifiIZ/til 12 or Distribution Insulation I'hcrmnstal
Type and C'a nein 7" , Wenlntl.Split.
I Y C'UP) Tvpc and Localion' R-VIlluc I'vpo S rtt c.Pukape or 1 1pdronic)
I.Incllcal,Cooling 7i/1"0 V.Ileal pl»»p, lirup.Cooling,etc)
'. Re.A,fa the!//iR.S'J'cri/icuriun sc cviou nn Page a ul•lha C'1-1 R-;Il.%'1 i>rnr 1br tit filional reepir•c-rnc als and chock upplic able ho.sc+s•.
3./nclicote lil'i(,or bwfilirin tljucrs.lh--rlraoic•in Floor. Radiurnrs.ell.)
WATER HEATING
/.ist u:uler healers and hili/er:.1bl•hath du»re'stic•hat a+tiler(/)//lf%)hetoe+rw un)hudra»ic•s/rnrc+heating. hrdit idua(r/trc•Iling DHIIin+rrh•rs rrrrrsr he I
gav or•prupune•/irer%and wilt'nut em.-rud O gill/nnr. Ilol tnuler•pipe in ultm an from the Ulltl•'healer-to the kilchen(ay and utt cr//tinder;,+rnuurl u
1701 u+nler pipc.v is required ill all runt rune+tit pac.'kuge.+'in cr!!c 1/nurle=ones.
Miter IJeater'kpc/Fuc1 Dislribmion'1\pc NumbcrIn Tank Lner-,, lixtcrn;tl f;utk
y 1'ac:un'or ItsulUion
I)'pc7 (-%mdard.Rucirculaling)= Sysh n C'u acilY(gni) 'I'hcrmal Ef,icicncv IZ-V;tlut'
/.Indicate TIM iStorgZe Grix.Heat Puny).hula»lonevrrs,ele.J
'./leeitcrrluliugsi:.rrernsnervingmultiple dive//hkqunilsshallmeettherec)ren!titianregrriremevrrro/�ti'/.i0(nj. %%te /'rescriptnvc regrrircwern.rr/n
nol n/lov the irrelulhnion r;/'a recite atoning u:n/rrbenf/ng.ct',rlCnr fur single rltvclling units.
3. 17re esleri7ul+t+nlcr hcidinh rank crud�i.res shall he/nstrlalrclfo tinge!the rec uiren7entc v'4150(j).
SPECIA L FE,AT RES'['he err�rrcewr til ergenrr should pr(t+Spec•ial all rnt)un fu the Special Putilrrrer speci/iect illl/,i.r c•/recklirf lhelum•
M
1071».rti/-union and ducumenlvtion unrl S)eeial t'.,jgT•anion.
At-se llC'Ir1J'rnnl'rCr/air a
\P,1V RUM' ASS1al•i131.Y-Radiant Ilnrricr
The radiant barrier rc uircment al'§151(1)2 does nota Iv to rool'alturulinns,
Slab I-Age(Perimeter)Insulation --0 VES 0 NO
1'E:S:In C:lintutc Zone IG in C'ompullunt Packages 1). R-7 insultlion is require.!.
Heated Slab Insulation 0 I,I.'S 0 NO
1'I:S:Slab edge insululion nuc uircd fior u[I Iutt(ed slabs in all Climme Zone,. pec details in'I'able I I8-A ol'lhe standards.
Raised Slab Insulation 0 PICS 0 NO
YES: In Climate%ono, 1,2. 1 I. 13. id K IG.R-8 insulation is ret uircd:in C'li nate Zones 12& 15.IZ-41 is required undor cont oneml Nackup,c 1).
Thermal Nlass
To obtain C'omilih ee Credit lin•the installution ol'ihcrntal nutsS.Ilse the Pt:rlir,-mance Ap pronto.
.M
Regisfroliort Registration Ucrle,1htre: .S'Praridc�r:
2008 Residenfiul C'oarpliur7ve Forms "---'"' "' '
Jtr,ivrst 2009
Sep 99 10 01 : 58p AHC COOLING & HEATING 5104718368 p. 4
Prescriptive Certificate of Com liancc: Residential CF-i R-ALT
Residential Allerations (Page 5 of a)
Project Name:\ V(— ` J,^— Climate Zone# H of Stories
H ERS VERIFICATION SUMMARY The enliu c enre»l nee»cr•.chef ld par s7xrlul erlrc olio»to the II/iRS 11•leu.+tn e.+a7lrciJic rl in this
Chechlisl helull... 4 completed and signed(•7•=./R 1•oin.for all[lie niecisuru. sne•eUied s•he7116e st(binilled lc;the building hmpeclor be.1bre Jural
inspection.
Duct ScalingA Testing 111;12.5'ueri/icrukur ix requircdlnr this me rs•ure.
❑YES M NO YES:In Climatc Zones 2 and 9-I6.if niorc than 40 li tear feet ol'new or replacement ducts are instllllcd in unconditioned
space.the duets arc to be sculed per§152(h)ID i and the newly installed ducts are to be insulated per§I51(I)I0.
❑ !:\('I;P'1'IQK: !•:xislin);duct systems that arc extcuded,which arc causlrucled,inset.iletl or sealed frith.isbes(os.
❑YES dNO 1'liS:in Clinical:Zones 2 and 9-16.if the existing spa:e-umditioning system(I IVAC cquipnlcnl stmt dueling)is replaced.Ilse
ducts are In be sealed per§152(b)l Di.
❑YES 17!NO YES:In C'liniale%ones 2 0111,19-16.il'lht:mis(ing I IV 4C equipment is replaced(including,the replacement ol'lhe air handler.
outdoor condensing unit of I split systvill.coolit,g or heating coil,or the lin•nacc heat exchanger)the duels are to he
seuled per§152(h)11'.
❑ h\('l.,,lvrm:Duct systems that are documci,ted to have becu previously scaled confirmed Ihrou�gh iIFRS
veri4rtliun in accordance+with procedures in the 1Zefcrence 12csidentiai Appendix RA3.
❑ KX('iSPTIOV: Dnct systems with less than 40 linear feet in unconditioned space.
❑ 1?XCF.P770V: Existing duct systems constructed,insulated or sealed with ashestos.
Refrigerant9harge-Split System I11•.RSver•ific•aliunLcr•egirir dfnrthsinreasare.
❑ YES 6d VO 1'1:5:]n C'linuuc Zoiics 2.incl R-15.when the e%isting i IVAC equipment is replaced(inciuding the replacement ul'thc fir
handler,outdoor condensing unit ofn split syslc nl A/C or hcut pump.cooling or heating coil.or the lurnaec heal
exchanger)a relrigerani char a measurement sha I he verified per§152(h)IF.
Central Fan Integrates!(CFI)Ventilation System and Fan Watt Draw
The ventilation re uironlcnls of§150(0)do not apply to existin a residential homes.
Ducted Split. -stems-Air Conditioners and Heat Pumps:Aird)w HERS herr•'Jlccdinn U required fur this ineus•ure.
❑ YES 0 NO us:in Clinurie Zones 10 through 15,when the existing space-conditioning system(HVAC:equipment and ducting)is
replaced.the nirflow and fan wall draw shall Ix ,crilied per 152(h)I Ci to mcct the requirements of§15)(1)713.
Documentation Author's Declaration Statement
• t ccrlifr that this Certificate ol'Com rlitlnce documentation is accurate:tn c m tete.
Milne:'
C'onlptulyl I 1 Date:
Address: ��^.. , t �l 1('Applicahlc❑CTA or❑C'I{pl:
`� (CcrtilicaliulllG): �[ p
(D_
Responsible lluildi esigner's Declaration Statement
• 1 ani eligible under I)ivision 3 ol'thc California Ilasinessand 1'rol'essicns Code to accept responsibility for the huildine d"ig.n identilicd oil
this Cerlillenit:of l:tnnpliance.
• I ecrtilj.that the energy li:ululns gild pu(nrnutnce spceilicatious lirr the huilding design identilicd on this Cvnificute ol'Cunlpliance cotilbrnl
to(he requirements of"fills 24.!'arts I and 6 oflhc Cnlilurnia Cotle of Regulations.
•_ The building design li lures identified un this C:etiilicatc ol*Compliin(:c-urc consistent with the hillormulion provided to document this
huilding design on the other applicuble compliance(urns.worksheets,caleulutions.phots and specificutlonS SLIb111itted it)the ellibreetllent
agency filr a i roval With this huildin� ermit a 1 lication.
Wants: 5 ign:liurc:
Company: Dale:
Address: License:
C'il}JSlale//.ip: I'honc:
Fur alsi.sttlulce or gteea'tiulis regarding the F-nergy Standards,cantos r the EncWt,Hullbie at: 1-800-772-3300.
Registrutiun;Vniuher: _ _ - ReeistraliU»1111c".77.lie: 111..Ws Provider:
2008 Residential C'nniptiunce!•'arm.+• August'009
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 / SUB(:ONTRACTOR LIST
JOB ADDRESS:2-Z 10 RAE 4A) PERMIT# SDG'
OWNER'S NAME: c c)-z o e Jr-, 4 PHONE# 40*9-
JIN -3 Or-D-0
GENERAL CONTRACTOR: fArF, G ,,J- ,.J-• BUSINESS LICENSE#
ADDRESS: • 1 eJ 57. CITY/ZIPCODE: 94S
*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 ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signd Date
Please check applicable subcont ors an c mplete the following information:
V 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
/_'Z'11111�ontractor Sig ature Date
CITY OF CUPERTINO
5 ITEMS OF 8 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35607057 . 00
DATE ISSUED. . . . . . . : 10/01/2010
RECEIPT # . . . . . . . . . BS0000I1613
REFERENCE ID # 10100008
SITE ADDRESS . . . . . : 22106 FAE LN
SUBDIVISION . . . . . .
CITY CUPERTI NO
IMPACT AREA . . . . . .
OWNER FRANK C:ERVENKIA
ADDRESS 22106 FAE LN
CITY/STATE/ZIP . . . : CUPERT-NO, CA 95014
RECEIVED FROM JEFF RliINEY
CONTRACTOR GERALD UNRUH LIC # 24643
COMPANY ABC COOLING & HEATING
ADDRESS 31845 HAYMAN ST
CITY/STATE/ZIP . . . : HAYWARD, CA 94544
TELEPHONE . . . . . . . . : (510) 4'11-8181
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
____ ----- ----- ------
------------- ----------
1BCBSC VALUATION 3, 677 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 3, 677 .00 0 . 50 0 .00 0 .50 0 . 00
1MFR=<100 UNITS 1 .00 12-6 . 00 0 .00 126 . 00 0 . 00
1MPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 -----42_00 ------0_00
---------- ----------
TOTAL PERMIT 211 . 50 0 . 00 211 . 50 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -----
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF
CITY OF CUPERTINO
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
0 { �
APN # J`� Date: q/f,30//o
�
Building Address:
� Z-2- ( oE7 � aC
Owner's Name: Phone #:
Contractor: Phone#: 510 471-8181
ABC Cooling and Heating Inc.
Fax #: 510 471-8368
Contractor License #: 382383 Cupertino Business License #:
Contact: Brenda Phone#: 510 471-8181
Fax #: 510 471-8368
Building Permit Info:
Elect A/ Plumb �� Mech ]
Residential Ff] Commercial ❑
Job Description: t't)12,c)A-r C iZt _-iYr.CJ,,r�,J7 ���� b 'i�J) (7�j e7ei
C- A-7 i o,,
For Residential Installations:
Attic ❑ 1St floor ❑ 2"d floor ❑
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation []
New installation Planning Approval Required ❑
Cost of Project: 6 -77
-7 _7 Type of Const-uction(Usage Class):
V�g
Strapped ❑ On Platform ❑ BondedE] New Location ❑ Replacement F]
Project Size: Express D Standard ❑ Large ❑ Major❑
Valuation:
Green Building: Please complete relevant portion of-:he Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 01/07/09
-------------
CITY OF CUPERTINO BUILDING PERMIT 1
CONTRACTOR:REC SOLAR,INC.
PERMIT NO:09120079
BUILDING ADDRESS: 21608 RAINBOW DR DATE ISSUED:03/03/2010
775 FIE RO LN STE 200
OWNER'S NAME: LOUIS&PHYLLIS LAU PHONE NO:(888)657-6527
SAN L AS OBISPO,CA 93401
"NER'S PHONE:
J
OBESCRIPTION: RESIDENTIAL COMMERCIAL
LICENSED CONTRACTOR'S DECLARATION
SOtg 4 INSTALL GROUND MOUNTED SOLAR P.V.SYSTEM,4.2
License Class GAO Lic.tt / OWATTS,20 PANELS/UNITS.
Contractor .�`• Date
1 hereby affir that 1 am licensed under the provisions of Chapter 9
'2010-REVt#1-PANELS CHANGED FROM 215 WATT TO 235
(commencing i hla cta is 000)o lice and of f theBusiness&ProfessT PANELS—ISSUED 10/20/10
Code and thaty
t.
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:$28000
performance of the work for which this permit is issued.
[APN
by
Floor Area:
1 have and will maintain Worker's Compensation Insurance,as provided for this
Occupancy Type:
Section 3700 of the Labor Code,for the performance of the work for which this Number:36638031.00
permit is issued.
APPLICANT CERTIFICATION PERMIT EXPIRES IF WORK IS NOT STARTED
I certify that I have read this application and state that the above information is WITHIN 180 DAYS OF PERMIT ISSUANCE OR
correct.I agree to comply with all city and county ordinances and state laws relating 180 DAYS FROM LAST CALLED INSPECTION.
to building construction,and hereby authorize representatives of
g
this
ity to to saver
upon the above mentioned property for inspection purposes. (We)
indemnify and keep harmless the City of Cupertino against liabilities,judgments, �--� Date:
costs,and expenses which may accrue against said City in consequence of the Issued
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
( C� RE-ROOFS:
9 18
Date �( ! All i oofs shall be inspected prior to any roofing material being installed.If a roof is
Signature insu lied without first obtaining an inspection,I agree to remove all new materials for
insr ection.
OWNER-BUILDER DECLARATIONDate:
Signature of Applicant:
1 hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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) HAZARDOUS MATERIALS DISCLOSURE
1,as owner of the property,am exclusively contracting with licensed contractors to
I h Ave read25533,and 25534. 1 will
construct the project(Sec.7044,Business&Professions Code). California Health&Safety Code,the hazardous Sections 25505s under Chapter 6.95 oft e
al
er 9.12 and
1 hereby affirm under penalty of perjury one of the following three Health,&Safety Code,Section 25532(a)should Iliance with the Cupertino s toreoor handle thazardous the
declarations: sent to
ch emit hazardous
1 have and will maintain a Certificate of n 3700 of theConlLaborrCodevfor the Worker'se for ail contaminants as defined by the Bain.terial. Additionally,should I use yArea eAir Quality Mant or devices nagement District 1
Compensation,as provided for by Sect will maintain compliance,with the Cupertino Municipal Code,Chapter 9.12 and
performance of the work for which this permit is issued. th:Health&Safety Code,Sections 25505,25533 and 25534. 1���
I have and will maintain Worker's Compensation Insurance,as provided for by Date:
Section 3700 of the Labor Code,for the performance of the work for which this O Hner or authorized agent:
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 w� b fortwhich this rm that hpermere it is issued(Sec.3097,Ca construction lending iv for the performance o
forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Name
APPLICANT CERTIFICATION I ender's Address
-
I 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 ARCHITECT'S DECLARATION
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 I understand my plans shall be used as public records.
sting of this permit.Additionally,the applicant understands and will comply
a all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional-
9.18.
SignatureDate --------------