14010003 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11500 CHARSAN LN CONTRACTOR:AAA FURNACE&AIR PERMIT NO: 14010003
CONDITIONING
OWNER'S NAME: MARISSA KOBYLENSKI 1712 STONE AVE DATE ISSUED:01/02/2014
OWNER'S PHONE: 4082530237 SAN JOSE,CA 95125 PHONE NO:(408)293-4717
{ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL E]
REMOVE&REPLACE(E)WATER HEATER,SAME
License Class�l�/2n2 Lic.# l g-9 LOCATION
Contractor AAA FO r N A CQ Date . z Z01
I hereby affirm that I am licensed under the provisions f C at 9
(commencing with Section 7000)of Division 3 of the Bu iness&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:$1750
have and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this APN Number:36210043 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 RMIT 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 1.80 D ROM 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 2
granting of this permit. Additionally,the applicant understands and will compl ss
with all gsn- source regulatio s per the Cupertino Municipal Code,Section
9. RE-ROOFS:
Signature Date a 1 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 h the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain coir a with Cupertino Mu icipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Saf Code,Sections 5505 .5 and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this - Date:
Owner or authorized agent:
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
918.
Signature Date
0-- MEp
GeN:ERAL PERMIT APPLICATION
�:.. .
COMMUNITY DEVELOPMENT DEPARTMENT-"' 'U.ILDING DIVISION, \O
�. 10300 TORRE AVENUE -CUPERTINO; CA 95014-3255S- C
(408)777-3228 FAX(408)777-3333 •buildinOoCUpertinO.Orq M1
supe 11 o
y
. IVIG 11 MECHANICAL ELECTRICAL ❑MISCELLA'noUS.
PROJECT'ADDRESS 1� wd`/Sa �.� APNS I a t�/
1/1
OWNER NANDr /�/►�►%�JSJ,CG V)I ny If I', '- PHONE / � ,�f 2`(n�� E MAlL
9rmv ADDRESS,/1(/11 I v KJ I(A ,r F
CONTACT'NAME PHONE E-MAIL
STREET ADDRESS CrrY,STATE, ZIP FAX
z.
' ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT --a�UONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHTTBCT ❑ ENoWEER ❑ DEVELOPER ❑ TPNANT
p n ,^�^ LICENSE NUMEER-1( �Q.� i f Lt S G HUS.u 1
CONTRACTOR NAME I u� � J��,/`�/►�J b�j/(J l
CDhO'ANY NAME 1 V�Y V l G�e e7l F Li
STREET ADDRESS 1 07M 1 J V C ' ")'--li 6:/yl ✓IV 11
ARCHrrECT/ENOII•fEEANRME
LICENSE NUNMER aUS.LIC I
COMPANY NAME E-MAJL FAX
•
STREET ADDRESS Crl Y,STATE,ZIP PHONE
USE OF or Duplex p• Multi-Family .PROJECT IN WTLDLAND
PROTECT PI
STRUCTURE: O Commercial
URBAN zNr�ACE AREA p yes No FLOOD ZONE �C3Y=�No.
DE9CRIP1TOTa of wDRIC re/owe ow I Sfi -l5 C-I IC LVI
TOTAL VALUATION: \� /,IJ✓
By my signature below,I certify to c f the folio 'ng. I am the property owner or authorized agent to act on the property owner's behalf. ley
read this
application and the infartnation I ave pr vided is o cct, .I hake read the Description of Work and verify it is accurate I agree to comply with all applicable local
ordinances and cute laws relati g to bui g cc ction. I authorize representatives of Cupertino w enter the abovei-id nttifi(ed�p opeity for inspection purposes.
Date:
Signaturc of Applicant/Agcnt: ,,..
SUPPLEMENTAL INFORMATION REQUIRED
A-ffFAfucApp_201I.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 11500 CHAKSAN LN DATE: 01/02/2014 REVIEWED BY: MELISSA
APN: 362 10 043 1 BP#: *VALUATION: 1$1,750
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: PERMIT TYPE: i
WORK REMOVE &.REPLACE E WATER HEATER SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE '. FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $28
TOTALS: FF r: $28.00 _
° y' � _ ak is a
% onff _ e
§rvY� P - ilyq'gr ,. 0 jh.r".9 ,Jr<I"..i
Xlech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Cheek
Llech.Perwii Fee: Plumb.Permit Fee: IPPERMIT Elec. Permit fee:
Clthcte Heck(resp. CT—t— —j I
Other Plumb Insp. 0.0 hrs $47.00 Other Etc,(,-.Insp.
1lech. Insp.Pee: 111unib. hisl�.Tee: Elec.Insp. fee.
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7f� /1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Stipp/.PC:T ee
PME Plan Check: $0.00
Perin it:Fee:
Suppl. Insp Fee
PME Unit Fee: $28.00
PME Permit Fee: $47.00
Construction Tax: FA
Administrative Fee: 1ADMIN $44.00
Work Without Permit? ® Yes .0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VDOC $47.00
Strong;Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
ISOtI.FEE� 167.50
$167.50 $0.00 . „ $
Revised: 10/01/2013
ALT
Prescri tive Certificate of C.om liance: Residential Pa e 4 of 5)
Residenflai Alterations O)mate Zone tE #of Stories
ProjectNs�me:
HVACDuCr prg
Paocnkfsgua roartioH
n
SY 'vlS HEATING C
Minimum Insulation Thermostat (Central,Split,
Heating'Equip Efficiency Distribution + RValue
. SPF Type and Location T e
T eandCaact � Vor
dronic)
1.indicate Healing Type(Central Furnace, ,Wall Furnace. Hear pump, Boiler. Electric once. etc.)
Resist
2:Electric resistance heating is allowed only in Component Package C. or except where electric heating is supplemental(i.e.,if total capacity
,• < 2 KWor 7,000 Btu/hr electric heating is controlled by a lime-limiting device not exceeding 30 minutes). See 315I(b)3 exception.
3.Refer to the HERS Verification section on Page 4 of the CF-1 R-.ILT Form for additional requirements and check applicable boxes.
4. Indicate Type or Location(pu(,•ts. Hvdr•onic in Floor, Radiators.etc.)
HVAC SYSTEMS-COOLING
MinimumConfiguration
Efficiency Duct or Piping
Thermostat
Central,Split,
(SEERJEER or Distribution Insulation
dronic
Cooling Equipment 3 R-Value Type S aPksH
1'' COP) Type and Location
Type!aCaa
nLd
1. Indicate Cooling Type(A/C. Hear pump;Evap. Cooling, etc)
2. Refer to the HERS Verification section on Page 4 of the CF-IR-ALT Form for additional and check applicable boxes.
requirements
J. Indicate Type or Location (Ducts, H dronic iii Floor, Radiators, etc.)
WATE I R HEATING
List water hearers and boilers for borh•dome.r.tic ho[water(DH►'l)h aters sit on frndhydom the DHW heat ra the k he )larnd a underground b
gas or propane tired, and may not exceed SO gallons. Kot ware pipe
hot water Pipes is require I in al!eom.anent packages in all climate sones. External Tank
Number in Tank Energy Factor or insulation
Water Heater Type/Fuel Distribution Type Ca acity( al) Thermal Efficient R-Value3
T Del (Standard, Recirculating)' S s[em
1. Indicate Tvpe(Storage Gas, Heat Primetc
Primp, Instantaneous. .) do
2. Recirculating systemsserving multiple dwelling units shall meet the recirculation requirements of§I50(n). The Prescriptive requljea�s
not allow the installation of a recirculating water heating system for single dwelling units.
3. The external wafer heating rank and
Les shall be insulated to meet the re uirements o 150
e special Features specified in this checklist below.
SPEA
SPECIAL FEATURES The enforcement agenev should pav special
attention
to
trbn
These ilems.ma re afire written 'usti ication and documentation and s e iale
NEl'1 lYOOF ASSIa11"I�L,Y R'adia'nt Barrier
The radiant barrier requirement of 151( Z does not "y to roof alterations.
Slab Edge(Perimeter) insulation EJ YES 0 NO
YES: in Climate Zone 16 in Component Packages D,R 7 insulation is required.
Heated Slab Insulation O YES Q NO
YES:Slab ed a insulation re uire,d for all.heated.slabs in all Climate Zones. See details in Table 118-A of the standards.
Raised Slab Insulation Q YES Q NO
uired'undercomponentP
Climate Zones l
YES: In Climate Zones I>2; 1 I, 13, IG& 16,R=8 insulation is re:uired; in 2;& 15,R441 re
Thermal Mass
To obtain Compliance Credit.for the installation of thermal mass;tiae the.Performatoaeh.
_ncel'e".
Registration Number: Registration Dare/Time:
HERS Provider: August 20
2008 Residentlal Compliance Forms
�a
is
S'i�piif�ed Prescri.p'tive Cert%ficate of Compliance:304.9 Resi4-,t�.FYACAlterations CF �1R-ALT-AY1 C :4
Cruitate Zones;i and 3-7
Site Address: Ettforcemetrf Agency: Dal,I
11� G➢'�ti'�t✓I 1p'r� ��(r
Co4#9ned Duct wsuMon
EquiornentType' TitTiim>EfCcieti 'r Tlieimosfat' i
Packege�Unit S g Y i t CNcr 40 8 of 166
Q Pomace t1FUE COR rServ�'Fry'system ` ,aided ariiegla�xd m Setbaclt
Indoor Cot? 01 Wt: SPH__ sf unconditioned space
irfrrady presort miui be
Condensing Unit ®EER E Raststance ®R 6 (CZ 1,
Other
1.Equipmeut Type:Choose the egtupment being installed,if mom than one_systein,use another CF-IR-ALT;HVAC for each'systesn
2.Minimum Eguipmmnt Efacieacies:13 SEER,78%AFI7E,VHSPF for typical residential:syseems.
Conumctor(Documentatioa Author's/Responsible Designer's Declaration Statement)
• I eatify that this Certificate of Compliance documentation is accurate and'c=-,IP,lete:
• I am eligible under Division 3 ofthe California Business and Professions Code to acceptrespQnsibility for.,the design identified.on this
Certificate of Compliance.
• I certify that the energy features and perfomzancc•specificadons for the design identified on this Certificate of Compliance conform to the
requirements of Title 24,Parts I and 6 of the California Code of Regulations.
• The desigt.ftahwas identified on this Certificate of Compliance are-consistent with the informalion documented on other applicable
compliance forms,worksbeets,calculations,plans and specifications.submtited to far ., , t agency for approyal.,with the permit.
,., .
tion. r p
Name: �/ `3 (. Si> :
Company: Dam
* YW c AX2,C2.
Address.I (Z ,S. 1 1 wH
City/State/Zip:
1
2008 Residential Compliance Forms.doc revised 04/10/1