13050058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10169 S FOOTHILL BLVD CONTRACTOR:ORTIZ HEATING AND PERMIT NO: 13050058
AIR CONDITIONING
OWNER'S NAME: HUI TAN 1499 BAYSHORE HWY STE 238 DATE ISSUED:05/07/2013
OWNER'S PHONE: 6073424543 BURLINGAME,CA 94010 PHONE NO:(650)758-4901
r LICENSED CONTRACTOR'S.DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALS
License Class Lie.# REPLACE(E)FURNACE&A/C UNITS,LIKE FOR LIKE,
SAME LOCATION
Contractor Jok
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$11200
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:34214119.00 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 WIT�IIN 18 O ERMIT 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 D FR T 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 S
granting of this permit. Additionally,the applicant understands and will comply Issued b Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. ,7*'�+' __..
RE-ROOFS:
Signature Date 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.
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
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 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 by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the 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: =4 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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING 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 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 Licensed Professional
9.18.
Signature Date
GENERAL PERMIT APPLICATION O MER
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 O
(408)777-3228•FAX(408)777-3333•building cDcupertino.org misc
CUP1LR7l�+tt3
❑PLUMBING' : " MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS APN#
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❑OwNER D QwNER-BUn.DER:. ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
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USE':;OF ,0 SFD pi DUPLEX�! ❑.MULTI-FAMILY PROJECT IN WB.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN - ❑.YES -
BUILDING. ❑COMMERCIAL 5' URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
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By imy slgnatua below; certrfy tv;each of the following: I am the property owner or authorized agent to act on the perry o e alf. I have read thrs
apglrcatron and the uifoemation I have pio'ide6 is correct. I have read the Description of Work and verify it is accurate. I agree to comply:with all applicable locaF
ordinances and s<atIelaws relating to b lding construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature ofApplibant/Agent Date: ;
SUPPLEMENTAL INFORMATION REQUIRED
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I MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10169 S FOOTHILL BLVD DATE: 05/07/2013 REVIEWED BY: MELISSA
APN: 342 14 119 BP#: '`VALUATION: 1$11,200
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
pglMAgy PENTAMATION
USE: SFD or Duplex PERMIT TYPE: FURN/A
WORK REPLACE E FURNACE&A/C UNITS LIKE FOR LIKE SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE H) QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $67
Furnace, Forced-Air 1MFR=<100 1 # $133
TOTALS:
$200.00 .s
� ��
0X91
Mech.Plan Check 0.0 hrs $0.00 Ph n&Plan Check Elec.Plan Cheek
Mech.Permit Fee: IMPERMIT Plrrmb.Permit Fee: Zilec. Permit fee:
Other Mech.Insp. 0.0 hrs $45.00 Other Plumb Insp. Other flee.Insp,
t ech.Insp.Fee: Plumb.hap.Fee: Elec.Insp.Fee
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These ees are based on the prelimina information available and are only an estimate Contact the Dept for addn'1 info.
FEE ITEMS(Fee Resolution 11-453 E . 7ff 11112) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
4Suppl. PC'Fee
PME Plan Check: $0.00
Permit Fee:
.Suppl—hasp Fee.
PME Unit Fee: $200.00
PME Permit Fee: $45.00
Construction Tax:
Administrative Fee: (ADMIN $42.00
Work Without Permit? 0 Yes (E) No $0.00
,advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00
Strong Motion Fee: IBSEISMICR $1.12 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC 1 $1.00
$334.12 $0.00 Oft—, $334.12
f -
�• Revised: 04/29/2013
Simplified Prescriptive Certificate of Compliance: 2008 Residential HVACAlterations CF-IR-ALT-HVAC
Climate Zones 8
iteAddress: Enforcement Agency: Date: Permit#:
b � , 1 -
E m ent T e Li inimum Efficienc Conditioned Floor Area Thermostat
Packaged Unit aa
rnace UE 6(J COP Served by system etback
ndoor Coil FER
R HSPF �d sf (If not already present,must be installed)
ondensing Unit k.O ®Resistance
El Other T�
1.Equipment Type:`Choose the equipment being installed if more than one system use another CF-IR-ALT-HVAC for each system.
2.Minimum EquipmentEfficiencies: 13 SEER,78%AFUE,7.7HSPF for typical residential systems.
HERS.VERIFICATION SUMMARY Listed below are three HVAC alteration Options. The installer decides what work is being
done andpicks 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 CF-4R 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 EquipmentCF-6R forms: MECH-04,MECH-25-HERS
replaced CF-4R forms: MECH-25
Condenser Coil and/or
CF-6R forms: MECH-25-HERS
• Indoor Coil and/or CF-4R forms: MECH-25
• Furnace
For Split Systems: RC,CCA?t 300 CFMIton,TMAH
For Packaged Units: No testing required
2.New HVAC System Required Forms:
• Cut in or Changeout with CF-6R forms: MECH-04,MECH-25-HERS
new ducts:(all new ducting CF-4R forms: MECH-25
and all new equipment)
For Split Systems:kC,CCA>_300 CFM/ton,TMAH.
For Packaged Units:No testing required
[3 3..New Ducts with Replacement Required Forms:
• Includes replacing or installing all new CF-6R forms: MECH-25-HERS
ducting and/or outdoor condensing unit CF-4R forms: MECH-25
and/or indoor coil and/or'furnace. Not all
e ui ment changed.
For Split Systems: RC,CCA>_300 CFM/ton,TMAH
For Packa ed.Units.:No testing required
Contractor(Documentation Author's/Responsible Designer's Declaration Statement)
• :I certify that this Certificate of Compliance documentation is accurate and complete.
• I am eligible underpivision 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 submitted to the enforcement agency for approval with the
permit applicaton.
Name: Signature:
Comp y.. Date
t l� ILA6 i 1OL'o-L
ess; Licens O, /
City/State/Zip: l v w Phone:
2008 Residential Compliance Forms March 2010