14010085CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21613 LA PLAYA CT
CONTRACTOR: SERVICE CHAMPIONS
PERMIT NO: 14010085
OWNER'S NAME:
PLEASANTON, CA 94588
PHONE NO: (925) 444-4444
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
REPLACE 10 (E) SUPPLY DUCTS & 2 (E) RETURNS
�I
License ClasssC 2y Lic.
SrS t&A Date
Contractor U iCA_, (.{ V,4A
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: $5118
I have and will maintain Worker's Compensation Insurance, as provided for by
1 Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 35623009.00
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 ordinarros and state laws relating
WITBIIN 180RMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (Rte}agree to save
180 D ROM L CALLED INSPECTION.
indemnify and keep harmless the City of -Cupertino against liabilities, judgments,
costs, and expenses which may accrue against sai .City in consequence of the
Date:
granting of this permit. Additionally, the applic t understands and will comply
with all non -point source regulations per the Cup rtino Municipal Code, Sectionzt
9.18.
" IS - Iq
RE -ROOFS:
being installed. If a roof is
Signature Date
All roofs shall be inspected prior to any roofing material
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DEC L
TION
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 wi
wages as their sole compensation,
will do the work, and the structure is not intende
or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively coritr
cting 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
f 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 if
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
Section 3700 of the Labor Code, for the performance
Insurance, as provided for by
of the work for which this
the Health & Safety Code, Sections 25505,, 2553839 a d25534.
Owner or authorized _) 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 p
ovisions 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 pe
unit 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 stat
that the above information is
correct. I agree to comply with all city and corm
ordinances and state laws relating
to building construction, and hereby authorize r
presentatives of this city to enter
upon the above mentioned property for inspecti
n purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupert
no.against liabilities, judgments,
costs, and expenses which may accrue against s
'd City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the'applici
at understands and will comply
with all non -point source regulations per the Cri
ertino Municipal Code, Section
Licensed Professional
918.
Signature
Date
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CITY OF CUPERTINO
FF.W FCTlMATOR — RITILDINO DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 21.613 LA PLAYA CT
DATE: 01/15/2014
REVIEWED BY: MELISSA
10,
APN: 3562$009
1 BP#:
"VALUATION:
1$5,118
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
$70
PENTAMATION
1 RMAP i
USE:
PME Plan Check:
PERMIT TYPE:
WORK
REPLACE 10 E SUPPLY'DUCTS & 2 E RETURNS
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
FEE ITEMS (Fee Resolution 11-053 E . 7/11132
QTY
UNITS
BP FEES
Other Appliance/Equip
113APPLOT
1
#
$70
PME Plan Check:
$0.00
Per mit .Fee.:
.suppi. Insp Fee
PME Unit Fee:
$70.00
PME Permit Fee:
$47.00
Construction :Tax:
TOTALS:
Administrative Fee: IADMIN
$44.00
$70 00�
Mr
1111
Mech. Plan Check 0.0 hrs $0.00 PhwiL Plan Check Elec...Plan Check
Mech. Permit Fee: IMPI RMIT Plumb..Permit Fee: Elec. Permit Fee
Other Mech. Insp. 0.0 . hrs $47.00 Other Plumb Insp.Lj Other Elec. Insp.
ilech: Insp. Fee: Plumb. Irrsp. Pee: Elec, Insp. Fee
NOTE: This estimate does not includefees due to other Departments (i.a Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). Theseees are based onaheprelimina information available and are only an estimate- contact the ue t or aaan't tno.
FEE ITEMS (Fee Resolution 11-053 E . 7/11132
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check:
$0.00
Per mit .Fee.:
.suppi. Insp Fee
PME Unit Fee:
$70.00
PME Permit Fee:
$47.00
Construction :Tax:
Administrative Fee: IADMIN
$44.00
Work Without Permit? ® Yes (E) No
$0.00
Advanced Planning Fees:
,
Travel Documentation Fee: 1TRAVDOC
$47.00
.
Strong Motion Fee: IBSEISMICR
$0.51
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
$209.51
$0.00
$209.51
Revised: 01/01/2014
Simplified Prescriptive Certificate of Compliance: 2008 Residential HVACAIteratiorrs CF -IR -ALT -HVAC
Climate Zona 10 to 15
S&e Adm
e� Age- Penni 11
=coilEISEER
List Ilfi*m n FSci =14,15)
ioa t Area lbemostatQ AF ucts added er ❑ Soxback
SEER Q HSJ'F ndi6oncd space Served by system�,� ��, EEP. p Reaistaisce 13) s€p.rse,t must be
15) inrtvit-7
I_ E9uip»+nt Tygc C7roase the egrripm-ew b -w -tailed if mae deme onesystm ore maoth r CF-IR-ALT-HV4Cfor each sysrenc
Z -Via+ Eqa4,-en t Ejid-zcim- 13 SFEk 78%AFVF, 7.7hWFfor typical --doomed syst=M
HERS VERIFICATION SUNfMARY Listed below ate fu=HVAC alk adon Opti=L The mstaller decides what work is being dome and
picks one of the appropriate Options. Foch Optica Juts the HERS measures that mast be conducted. A copy of the trams shall be Ieft ora site for final
inspection and a copy gives to the homeawae. At final, the iasprecxor verifies thffi the work listed on @ria form was m fact the work completed by fe
insulter. The inspector also vmfres that each appropriate CF -6R and registered CF -4R farms (no hand filled CF4Rs allowed) are filled o W and
signed. October 1, 2010, a registered copy of the CF -IR and CF -6R sbafl also be on site for final inspecdon.
El 1. HVAC Chan ut aired Forms-
! epadCF-All HVAC igaipment leoM foams: U'CFI-04, MECFb21-HERS and (for split aysteors) MECH- 25 -HERS
CF-4Rfarm, MECIi-Zlar� Soz lit s MECH-25
• Condenser Col[ and for or
foram MEM21-HERS and for
o Lidoor Coil and/or CF -4R forms. MEM- 2I and for ( sP1n systems)MECH- 25 -HERS
• Furnace ( split systems) N ECH-25
For.Split Systema: Duct leakage < IS percent; RC, CCA 230Q CFM/dm(Miuirnum As Flow Reijnirtment), TMAH
per
For Packaged Units: Duct leakage < 15 cent
Exmtpted firm dud leakage testing if!
O 1. Dactayrtoa was docmmtxhd to have beeupreviously sealed and confirmed
through HERS verification, or
Q 2- D wt systema wi& Joss tbaa 40linew feetin tmooaditioned space; or
Q 3. • duct arc crmsttucD4 insulated or sealed with asbestos {
O 2. New HVAC System Required Forms:
Cut in or Changeori with new . CF -6R Serene l�CFF 04,
dncbw (aii new ductmgwa all MECH 2O-HERS.and (forsplit systems) NEM 22 -HRS, and MEC- 25 -HERS
new est CF4R farms; 1 EC 20-, and (for split syacros)MEQI 21, and MECH 25 ,
For Split Systemr. Dud leakage <6 percent; RC. CCA 2_350 CF'M/tlon, FWD, TMAIL SrA� S, and either HSPP orPSPP.
For Packaged Units: Duct leaks <6 -
kE03 . New Ducts with Replacement iced Forms:
cludes replacing oriastalliagall Crewducting CF -6R items: MECH-04, M KII-20-FIMSand (for• split systems) MECH-25-HERSnd/oroutdoor condensing snit and/or indoor CF -4R forms MECFi-20 and (for split syst—) PASM25
t?amnd(orlinnet Notallequipme utehanV&
Spat Systema_ Dad leakage <6pencemF, RCy CCA 2_ 300 CFM/ton, TMAIi
4. New Dn over 40 feet aired Forms:
• Inchxks adding or replacing more fimr 40 CF -6R ft= MECH-04e MECH 21: HERS CF4R foams: MECH 21
linear feet of duct in utt�oaed spacm
For split system or packaged units: Duct leakage < 15 pement
Q EXCEPTION F.tosfin dud co-ft--t-4,inanlated: or sealed with asbestos
Contractor (Documentatfoo Auther's/Responable Designer's Dedarition Stateme6t)
I eaeify that ffris Cos Scam of Cotoplimee docmmeotatigt is atsvrate and compkce
• - - I am eSgrbk;ondc I?ivisiaa 3.adffie Catiftuai+u Bosi>ms sad profesdooa Code to accept respoasr'bifiry for the de dp ideatifiod an thio ces6fleaw of Compliaam
• ; I testify that fire tme v k4naw and.�ec&—wee apecificxtians for the design identified oa this Cewfiale afC..Pfl ace canfaah to the raore mmu of T dO 24,
Poria I sad 6 of the Ctiltfmrtia Cre of Regalatioas .
• The design &xtu es-ide_atified o m jbia Cadoere of Cemrpliaoa are corttictmtwith the mformatim doe®creed oa alba hcabk c Irene forms, worksheets,
ealati� ons P►+ms nfld rvexi5eatia>s anh>mtted m tree ceFe,..r:.,, ...a..- �__...a - --- -- 0nP
---� -•1 U i Le,. %/i ctK4
Liccrtsc
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2008 Residennvl Compliance Formes March 2010