13110121CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20173 APPLE TREE LN.
CONTRACTOR: SANDIUM
PERMIT NO: 13110121
OWNER'S NAME: SHEPHERD CHRISTOPHER J AND JAN
4223 VERDIGRIS CIR
DATE ISSUED: 11/19/2013
OWNER'S PHONE: 4082301231
SAN JOSE, CA 95134
PHONE NO: (408) 894 -9072
JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIALL]
LICENSED CONTRACTOR'S DECLARATION
Oog �%
RELOCATE FURNACE TO ATTIC, ADD A/C UNIT TO SIDE
License Class Lic. #
OF
������� L l
Contractor �i'" Date �.Q 3
SFDWL
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 perjuryone 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 Libor Code, for the
performance of the work for which this permit is issued.
Sq. Ft Floor Area:
Valuation: $14000
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 31633095.00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of the work for which this
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 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 DA F OM 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:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
RE- ROOFS:
9.18.
t
Signature Date 1 3
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, Sectio 25505, 25 and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
< < q /(3
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
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
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 \
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 \(�\
(408) 777 -3228 • FAX (408) 777 -3333 • building
(aDcupertino.org
MEP
misc
❑ PLUMBING ❑ MECHANICAL ❑ ELECTRICAL ❑ MISCELLA
"NEOOUS
PROJECT ADDRESS t APN # U /C qMAL OWNER NAME v PHONE ✓�fl / 23 �II C htrS. S nf0. C µ'HQ•
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STREET ADDRESS Y 'Q --t
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CITY, STATE, ZIP
FAX
CONTACT NAME 1� (�
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E -MAIL
STREET ADDRESS n` ( n ✓�`
CITY, STATE, ZIP SA - 14G �A C� 5�2
FAX
❑ OWNER ❑ OWNER - BUILDER ❑ OWNERAGENT 2 CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
; OIL
LICENSE NUI�
LICENSE TYPE
BUS. LIC #
COMPANY NAME , _
E-MAIL Wj:jU
FAX
STREET ADDRESS / , - / _ _
CITY, STATE, ZIP \
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V
PHONE
ARCHTTECT/ENGINEERNAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMILY
BUILDING-. El COMMERCIAL
PROJECT IN WI DLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
rE.CHLERHOME? THE BLDG AN ❑ YES
❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION:' O G MEN
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act o6 th operty owner's behalf. I have read this
application and the information I have provided is -correct. I have read the Description of Work and verify it is ac te. I agree to comply with all applicable local
ordinances and state laws relating to building4qtruction. I au representatives of Cupertino to enter the a ove- identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED � u o��ls;�..
MEPMiscApp_2011.doc revised 06121111
..����,,��, CITY OF CUPERTINO
��,,��.
1� 1 Llivr 1wQrrr1%4 s rrnu _ l21 Tll ,nINf nIVISION
Mech. Plan Check 1 0.0 1 hrs $0.00 P1 .... b. Plan Check Dec. Plan Check
Mech. Permit Fee: IMPERMIT Plumb. Permit Pee: Llc:c. Permit re:
Other Mech. Insp. 0.0 hrs $47.00 Other Plumb Insp. (they Elec. Insp. Li
_ilech. Insp. Fee: Plumb. Insp. Fee: Elec. Insp. Fee:
NOTE: This estimate does not include fees due to other vepartments (Le. rtanntng, ruauc rrorns, _,irc, ouriuury oervci
District, etc). These fees are based on the prefintina information available and are only an estimate. Contact the Dept-for addn7 info.
ADDRESS: 20173 apple tree In
DATE: 11/19/2013
REVIEWED BY: Mendez
MISC ITEMS
APN:
BP #:
"VALUATION: $14,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY D or Du lex
SF p
hrs
PENTAMATION *URN /AC
PERMIT TYPE:
USE:
IBREMAIR
A/C Units ( < =10K cfm)
PME Plan Check:
$0.00
WORK
relocate furnace to attic add a/c unit to side of sfdwl
Permit Fee:
$0.00
SCOPE
IMFR = <100
Mech. Plan Check 1 0.0 1 hrs $0.00 P1 .... b. Plan Check Dec. Plan Check
Mech. Permit Fee: IMPERMIT Plumb. Permit Pee: Llc:c. Permit re:
Other Mech. Insp. 0.0 hrs $47.00 Other Plumb Insp. (they Elec. Insp. Li
_ilech. Insp. Fee: Plumb. Insp. Fee: Elec. Insp. Fee:
NOTE: This estimate does not include fees due to other vepartments (Le. rtanntng, ruauc rrorns, _,irc, ouriuury oervci
District, etc). These fees are based on the prefintina information available and are only an estimate. Contact the Dept-for addn7 info.
FEE ITEMS (Fee Resolution 11 -053 E f 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
=
# Mechanical
Suppl. PC Fee: Q Reg. ® OT
0.0
hrs
$0.00
$70.00
IBREMAIR
A/C Units ( < =10K cfm)
PME Plan Check:
$0.00
F-T-1
# Mechanical
Permit Fee:
$0.00
$139.00
IMFR = <100
I Furnace, Forced -Air
Suppl. Insp. Fee-.0 Reg. _0 OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$47.00
ww U 1
Mech. Plan Check 1 0.0 1 hrs $0.00 P1 .... b. Plan Check Dec. Plan Check
Mech. Permit Fee: IMPERMIT Plumb. Permit Pee: Llc:c. Permit re:
Other Mech. Insp. 0.0 hrs $47.00 Other Plumb Insp. (they Elec. Insp. Li
_ilech. Insp. Fee: Plumb. Insp. Fee: Elec. Insp. Fee:
NOTE: This estimate does not include fees due to other vepartments (Le. rtanntng, ruauc rrorns, _,irc, ouriuury oervci
District, etc). These fees are based on the prefintina information available and are only an estimate. Contact the Dept-for addn7 info.
FEE ITEMS (Fee Resolution 11 -053 E f 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
=
# Mechanical
Suppl. PC Fee: Q Reg. ® OT
0.0
hrs
$0.00
$70.00
IBREMAIR
A/C Units ( < =10K cfm)
PME Plan Check:
$0.00
F-T-1
# Mechanical
Permit Fee:
$0.00
$139.00
IMFR = <100
I Furnace, Forced -Air
Suppl. Insp. Fee-.0 Reg. _0 OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$47.00
Construction Tax:
Administrative Fee:
Work Without Permit?
Advanced Planning Fee:
Travel Documentation Fee:
Strone Motion Fee:
Bldg Stds Commission Fee:
C
Select a Non - Residential U
-1 Building or Structure 0
Select an Administrative Item
$140.401 $209.00 $349.40
Revised: 10/01/2013
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY ;DEVELOPMENT DEPARTMENT • BUILDING DIVISION
C U P E RT I N O 10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255
(408) 777- 3228 FAX (408) 777 -3333 • buildinot(7i cunertino.oro
Permit No. -' 311012211
Address 2 �i 1�3 r�1 9°rCi' r= � �C�✓ # ofAlarms Smoke Carbon Monoxide: 2
PURPOSE
This affidavit is a self - certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section 8314; 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single - family and multi- family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section 8314 and CBC.Sections 907.2.11.5 and 420.6 require that Smoke Alarms and /or Carbon
Monoxide Alarms be installed in the following locations:
AREA
SMOKE ALARM
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On every level of a dwelling unit including basements
X
X
Within each sle2ping sleeping rdom
X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel - burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwelling units,alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above - referenced property, I hereby certify that the alarm(s) referenced above hasiliave been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
have read and agree to comply with the fewrs rnd txanditions of this statement
Owner (or Owner Ag''eJJnft) pName.
C.
Signature ....... ......... ......
/
......,........................... ............................... Date: �Z/: f.......
Contractor Name:
` �.
si na e........ ..(l1.rl .n............. Lic. ...... �? .. ........ Date t� (..�
Smoke and COform.doc revised 0311 S /14
INSTALLATION CERTIFICATE CF -6R- MECH -04
Space Conditioning Systems, Ducts and Fans (Page 1 of 2
Site Address: y Enforcement Agency: Permit Number:
�zv
Space Conditioning Systems
Heating Equipment
Equip
Type
(package-
heat um
CEC Certified Mfr. Name
and Modell
Number
ARI
Reference
Number 2
# of
Identical
Systems
Efficiency
(AFUE,
etc.) 1,3
(ZCF-1R
value °
Duct
Location
(attic,
crawl-
space,
Duct
-value
Heating
Load
(Btu/hr
Heating
Capacity
(Btu/hr
1�
1
J ` Nv
`
�(jG�
�ett�c..
��W�-
,R/
K�
7a k
3b' —Ac
5
Cooling Equipment
Equip
Type
(package
heat
um)
CEC Certified Mfr. Name
and Model Number
ARI Reference
Numbers
# of
Identical
S stems
Efficiency
(SEER
and EER)
1.3
(?CF -1R
value) 4
Duct
Location
(attic,
crawl-
space,
etc.
Duct
R -value
Cooling
Load
(Btu/hr )
Cooling
Capacity
(Btu/hr
�,
2N87
`
17 S
�c S`
36
36
1. If project is new 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:11ivww. aridirectory. org/ari/ac. php#
3. Listed efficiency on this page must be greater than or equal ( >_) to the value shown on the CF-]R form.
4. When CF -IR is reference it is also applicable to the CF -IR, CF -IR -AA or CF -IR ALT
ALj, BOXES MUST BE CHECKED TO BE A VALID FORM
•� § 110 -§ 113: HVAC equipment is certified by the California Energy Commission.
50(h): Heating and/or cooling loads calculated in accordance with ASHRAE, SMACNA, or ACCA.
YJ § 150(i): Setback Thermostat on all applicable heating and/or cooling systems meet the requirements of § 112(c).
500)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- MECII -04
Space Conditioning Systems, Ducts and Fans "(Pa e 2 of 2
Site Address: Enforcement Agency: Permit Number:
20k13
Ducts and Fans
§I50(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 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
,coombbination of mastic and either mesh or tape shall be used; and
-CI 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.
,Er2D. 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. P`
❑ 8. Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually
operated dampers. V%/d,
❑ 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
Z1retardant and provides shielding from solar radiation that can cause degradation of the material.
0. 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.
• L 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.
• I 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 Na (Installing Subcontractor or General Contractor or Builder /Owner)
Responsible Person's Name:
Respons' Person's Si re:
l
CSLB License:
igned
Position With ompanyw (Tiie):
1 �te,
'
�
2008 Residential Compliance Forms August 2009
7VV
r.LJPERTINO
ing DePartmen'
9 2013 ID
A
E COMPLIANCh
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