13090023 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20172 NORTHCOVE SQ CONTRACTOR:ONE HOUR HEATING PERMIT NO:13090023
AND AIR
OWNER'S NAME: CHANDRA VANAMALA 1400 PETALUMA HILL RD DATE ISSUED:09/05/2013
OWNER'S PHONE: 4088355058 SANTA ROSA,CA 95404 PHONE NO:(707)545-1800
al/ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class �//7 C�� Lic.# 0; �� REPLACE(E)A/C UNIT IN REAR YARD,(E)FURNACE IN
q GARAGE AREA&ALL(E)DUCTWORK
Contractor Date /< t`
I hereby affirm that I ad r 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:$8800
ft 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:31641032.00 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 Iss Date:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
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
Signature of Applicant: Date:
I hereby 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
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 2 25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent. Date• 9 (3
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 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 � MEP
I
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION (\O
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �"\ misc
GUPERTINO (408)777-3228•FAX(408)777-3333•buildingna.cupertino.org \�
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS` --017 AQ ?b APN# �f
Q
OWNER NAM- �(OOOC(/ 01/vl % -1 0058 E-MAIL
STREET ADDRESSo f72 JVDr� OVeJ4T 'fhO ^A '7S6/
CONTACT NAME PHONE
FAX
E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAM[EJ _ /�ifS� �/ /'/� LICENSE NUM ER�� LICENSE TYPE0 C BUS.LIC#
61 COMPANY &ME(I (�1/YI 1 vIVC7 Aq f EMAIL FAX
STWDRPS ICTE,ZI PHONE
KOSA- CA �C,/� 707. 5q5
ARCHITECT/ENGINEER NAME LIC ENSE NUMBER V L� BUS.LIC# `-[
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES 7PROOCT IN ❑YES IS THE BLDG AN ❑YES
BUIIAING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO D ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK C /o� �C Z &JQ1 Y'e
TOTAL VALUATION: W.
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the ate. I o s behalf. I have r
application and the information I have provided is correct. I have read the Description of Work and verify it' cure to with all applicable loca
ordinances and state laws relating to build' traction. I authorize representatives of Cupertino to enter the above' pr for inspection purposes.
Signature of Applicant/Agent: Date: -/
!jPPCMZMKTAL INFORMATION REQUIRED `
RRs � CFl
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 20172 NORTHCOVE DATE: 09/05/2013 REVIEWED BY: melissa
APN: 316 41 032 BP#: *VALUATION: 1$8,800
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: p PERMIT TYPE:
WORK REPLACE E A/C UNIT IN REAR YARD E FURNACE IN GARAGE AREA&ALL E DUCTWORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $70
Furnace, Forced-Air 1MFR=<100 1 # $139
TOTALS: a
$209.00
,.`
Mech.Plan Check 0.0 hrs $0.00 Plumb.Plan Cheek F_lec,Plan Check
Mech.Permit Fee: IMPERMIT Plumb. Permit Fee. I:krc. Permit Fce:
[Other Mech.Insp. 0.0 hrs $47.00 Other Plumb Insp, Other t'lec.Insp. Lj L-
ech.Insp. Fee: Plurnh.Insp.Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These fees are based on the prelimin information available and are only an estimate. Contact the Dept for addn'l info,
FEE ITEMS(Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
;SuppI. PC F'ee
PME Plan Check: $0.00
Permit.Fee,:
Suppl. Insp Fee
PME Unit Fee: $209.00
PME Permit Fee: $47.00
Construction Tiles:
Administrative Fee: IADMIN $44.00
Work Without Permit? 0 Yes 0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $47.00
Strong M.otion Fee: 1BSEISMICR $0.88 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
Y -
„ ; ws $348.88 $0.00 3 k A A 'EE $348.88
.`" :.
Revised: 07/01/2013
INSTALLATION CERTIFICATE CF-6R-MECH-04
Space Conditioning Systems,Ducts and Fans (Page 1 of 2
Site Address: Enforcement Agency: Permit Number:
20 f-72 NoV-1 cove s�sk t 3 0 o 2
Space Conditioning Systems
Heating Equipment
Duct
Efficiency Location
Equip (AFUE, (attic,
Type ARI #of etc.)1,3 crawl- Heating Heating
(package- CEC Certified Mfr.Name Reference Identical (SCF-1R space, Duct Load Capacity
heat um and Model Number Number 2 Systems value a etc.) R-value (Btu/hr) (Btu/hr
Cooling Equipment
Efficiency Duct
Equip (SEER Location
Type and EER) (attic,
(package #of 1'3 crawl- Cooling Cooling
heat CEC Certified Mfr.Name ARI Reference Identical (>_CF-1R space, Duct Load Capacity
um and Model Number Number 2 Systems value)4 etc. R value (Btu/hr) (Btu/hr
14 (C
1.If project is neiv construction, see Footnotes to Standards Table 151-B and Table 151-C for duct ceiling alternative
compliance.
2.ARI Reference Number can be found by entering the equipment model number at http://lvwiv.aridirectory.org/ari/ac.php#
3.Listed efficiency on this page must be.greater than or equal(>_)to the value shoivn on the CF-IR form.
4. When CF-IR is reference it is also applicable to the CF-IR,CF-IR AA or CF-IR-ALT
ALL BOXES MUST BE CHECKED TO BE A VALID FORM
E§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 RCCA.
§15 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-6R-MECH-04
Space Conditioning Systems,Ducts and Fans (]?age 2 of 2
Site Address: Enforcement Agency: Permit Number:
w i 2 6►� cvJ� ( 3 oria U 1-3
Ducts and Fans
§150(0):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 181A,or UL 181B 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
• I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and correct.
• I 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).
• 1 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-1R)form approved by the enforcement agency that identifies the specific
requirements for the installation, I certify that the requirements detailed on the CF-1R that apply to the installation have been met.
• I 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. I 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)
0122 P �Ow h-eq, hyrp
Responsible Person's Name: Responsible Pe n's Signature:
es 2 L-0-<
CSLB License: Date Signed: Position-With Company(Title):
S_ /3
2008 Residential Compliance Forms August 2009