13120046 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10777 ALDERBROOK LN CONTRACTOR:A&H HEATING PERMIT NO: 13120046
OWNER'S NAME: SLAMA BRUCE D TRUSTEE&ET AL 770 CHESTNUT ST DATE ISSUED:12/04/2013
OWNER'S PHONE: 4082558608 SAN JOSE,CA 95110 PHONE NO:(408)279-0722
❑ LICENS ED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL U COMMERCIALU
License Class C20 LLii...# 13L/7 q 7 Z- REMOVE AND REPLACE FURNACE IN SAME LOCATION
Contractor X `t (+IPI NOA" Date 7 y/y/13
I.hereby affirm that I am licensed under the provisions of Ch apter 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:$3167
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:36921043.00 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 F 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 Z
Date:
granting of this permit. Additionally,the applicant understands and will comply Issued by: _ 1
with all non-point source regulations per.the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature �� .��' ate � 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,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this �L 3
permit is issued. Owner or authorized agent Date: ,'
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 'V' r to
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O(�
is 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 ^`(L MISC
GUPERTINO (408)777-3228•FAX(408)777-3333•buildino(ftwertino.orq \
UPLUMBING MECHANICAL ELECTRICAL UMISCELLANEOUS
PROJECT ADDRESS WIT)7 ) A w&iz 5 wo14 01. I 3(oq- 2,!-01(.3
OWNE"10, my ✓1 �'/oum I PH OCJ/ _�J� CI�DVI MAIL —�
STREET ADDRESS/O1 T 7 .4L.r) 3Qv_, / _I/CTT&TA _[r D FAX r_
CONTACT NAME �,/� L(Ti LL?S '"" I ` {am 7Ttrf/Y w w C•l.aY!
STREET ADDRESS � v — C S TE, �. - F7 7D�, �,s 1 JIB u c 5T ..�e,Sr - �' !!D 2 7
❑OwNER ❑ OwNEt-BUIIAER ❑ OwNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTR/A�CTORNAIKF� r . I LICENSENUMBER� I LICN$ Y�E�� BUS.LTC#/2o7®
fff c E Ar1xf6,q4c[.. � F t [,4FW1—/�7
STR7TI&D E -r� tit 9,4-,*swo P oB)Z7g a7Z z.
ARCHITECT/ENGWEER NAME I LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF FD or DUPLEX ❑ MULTI-FAMQ.Y I PROJECT IN WILDLAND ❑ YES I PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: (� (�7 mQ I RECEIVED BY:
By my signature below certify to each of the following: I am the property owner or authorized agent to act on the property 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 accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I auth o tativeess of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: lZl�� I% '�% /f,4_Date: C 2 -3— /4
SUPPLEMENTAL INFORMATION REQUIRE) ' OFFICE USE ONLY
❑ OVER-THE-COUNTER
a
E" ❑ EXPRESS
❑ STANDARD
zU
a ❑ LARGE
a
❑ MAJOR
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10777 ALDERBROOK LN I DATE: 12/04/2013 REVIEWED BY:
APN: I BP#: *VALUATION: 1$3,167
*PERMIT TYPE: Mechanical Permit I PLAN CHECK TYPE: Alteration/Addition/Repair
PRIMARY I I SFD or Duplex PENTAMATION FURN/A
USE: PERMIT TYPE:
WORK REMOVE AND REPLACE FURNACE IN SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $139
TOTALS: I I $139.00
d
Tech.Plan Check . 0.0 hrs $0.00 Pltrnrb.flan 'heck �FI&�Pn(;heck
Mech.Permit Fee: IWERMIT I Plumh.Pe mrr Pee: I Elec Permit Fee
Other Mech.Insp. 0.01 hrs I $47.00 Other Plumb Insp. I Other Elec.Insp.
Heeh.Insp,Fee: Plumb. Irrsp.fee: Elec,Insp. Pee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). 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 711113) FEE QTY/FEE I MISC ITEMS
Plan Check Fee.
Suppl. PC Fee A
PME Plan Check: $0.00
Permit Fee
Suppl. Insp Fee
PME Unit Fee: I $139.00
PME Permit Fee: I $47.00
Conso-fiction Tar: n
Administrative Fee: 1ADMIN I $44.00
Work Without Permit? ® Yes (E) No I $0.00 I I
Advanced Planning Fees:
Travel Documentation Fee. 1TRAVDOC I $47.00 .
Strang Motion Fee: IBSEISMICR I $0.50 Select an Administrative Item
Bldu Stds Commission Fee: IBCBSC $1.00
up $278.50 $0.00 E $278.50
Revised: 10/01/2013
Simplified Prescriptive Certificate of Compliance:2008 Residential HVAC Alterations CF-lR-ALT-HVAC
Climate Zones 1 and 3-7
Site Address: Enforcement��-•t>�C 1�� Date.^3_�3 I Permit#
10?77 RLQaPU3=K LAWS Ia Ttl oIVeA
Conditioned Duct insulation
Equipment Type' List Minimum Efficiency2 Floor Area requirement Thermostat
Packaged Unit Over 40 ft of ducts
Furnace AFIJE /� COP CM Setback
Indoor Coil O SEER HSPF_ Served by system added it replaced in (If not already present,must be
Condensing Unit 13 EER Resistance Z dDsf unconditioned space installed)
Other R 6 (CZ I,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 submitted to the enforcement agency for approval with the permit
application.
Name: DA VLE- j>g5J..PS 040/} S Signature:
Com /i'1�l Date:
Address: 5� u, License: 3crgq 7lZ
City/State/Zip: Sa )C Lj �r�� Phone:K103)Z 71 —C-)7Z Z-
2008 Residential Compliance Forms March 2010