14040201CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20552 SHADY OAK LN CONTRACTOR: PELLE HEATING & AC PERMIT NO: 14040201
INC
OWNER'S NAME: SLATEN LYNORE E 3751 D CHARTER PARK DR DATE ISSUED: 04/30/2014
OWNER'S PHONE: 4087381881 SAN JOSE, CA 95136 PHONE NO: (408)978-7060
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
REPLACE (E) FORCED AIR WALL FURNACE, SAME
License Class 20 Lic. 4 LOCATION
Contractor me ! 'L` A Date
r—
I hereby affirm that I am licensed under the provision 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: $2000
It Th -ave 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: 32344042.00 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 I DA*Sro 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 S FROM D INSPEC ION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments, --_
costs, and expenses which may accrue against said City in consequence of Issue Date: 3a
granting of this permit. Additionally, the applicant understands and wil p y
with all non -point source regulations per the Cupertino Municipal Code, Section
9 18.
RE -ROOFS:
Signatur Date ��'O 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 5, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent ate:
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
918.
Signature Date
f
GENERAL PERMIT APPLICATION oti MEP`..
.;' COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION v\
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 misc
(408) 777-3228 • FAX (408) 777-3333 • building(ftupertino.org U�
CUERTR 0
MPI.TIMRTW. 1AMECHATIICAL MELECTRICAL nMISCELLANEOUS
PROJECT ADDRESS -- --
APN II 0 2
OWNER NAME `
W.OM:132�
PHONE
191b
E-MAIL
STREET ADDRESS i
51
C STATE, ZIP
019014
FAX
CONTACT NAME
PH NEE-MAII
5 C. Ie bA 1
OVA-
STREETA6DRESi��":
C STA ZIP
FAX
13 3:9
l �4�
A006 2SA
❑ OWNER 0 OwNER•BUIIDER ❑ OWNER AGENT
*CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME�►�� eApc -
J I
LI SE BER LIC�S 'E
BUS: LIC#
FAX
COMPANY NAM
j
E-MAIL
STREET ADDRESS Y
ST TE ZIP
PHONEo�qq
ARCHITECTIENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANYN�II •
E-MAIL
FAX
STREET ADDRESS : j
CITY, STATE, ZIP
PHONE
USE OF: ; ' i 17 SFIZoi DUPLEX :. ❑ • MULTI-FAMQ.Y
PROTECT IN wEALAND [3YES
T—PRO00JE71N ❑ YES
IS THE BLDG AN ❑ YES
(]
BUILDING13COMMERCIAL
URBAN INTERFACE AREA [3NO
FLD ZONE ❑ NO
EICHLER HOME? NO
DESCRII�ION OF* k
til ! i'ii'
I'il
.
I �
I
I;'i Ali i -
T%T YAI�UA1701j1:1' �5
Bylmy S!patpr below I;certlfy to eac}iof the following: I am the property owner or authorized agent to act on the property owner's behalf. read this
apphcatlo>I and' fie n 6rfiiatlon.I have provided is correct.
I have read the Description of Work and verify It is accurate. I agree to com all applicable local'
ord nancgs and, id laws relating'to b, ding construction
au oa representatives of Cupertino to enter the above -identified grope or inspection purposes.
Sigdilture of ApJhcant/Agent
Date:
SUPPLEMENTAL IMRMATION
1
1
REQUIRED
CITY OF CUPERTINO
SUV Ucrr7n4Amnu—T2TTTT.nFNC nTVTRTnN
APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced -Air 1MFR=<100 1 # $139
TOTALS:$139.00
NOTE: This estimate does not include fees due to other ueparrments i.e. rcammng, r'uauc rr ulna, a c, �u.csaw.y �� . ..• . --
nat;rsrntn i nntnrt tho Dant for addn7 info.
ulstrict, et( eneae CCJ U/G OWJ 6fi V/s o..c • c w —.—
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13)
ADDRESS: 20552 SHANDY OAK LN
DATE: 04/30/2014
REVIEWED BY: MELISSA
Plan Check Fce:
APN: 323 44 042
BP#:
*VALUATION: 1$2,000
*PERMIT TYPE: Mechani=Permitj=PLAN
CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
PME Plan Check:
PENTAMATION FURN/AC
PERMIT TYPE:
USE:
Penr2it
WORKREPLACE
E FORCED AIR WALL FURNACE SAME LOCATION
SCOPE
PME Unit Fee:
APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced -Air 1MFR=<100 1 # $139
TOTALS:$139.00
NOTE: This estimate does not include fees due to other ueparrments i.e. rcammng, r'uauc rr ulna, a c, �u.csaw.y �� . ..• . --
nat;rsrntn i nntnrt tho Dant for addn7 info.
ulstrict, et( eneae CCJ U/G OWJ 6fi V/s o..c • c w —.—
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13)
FEE
_-
QTY/FEE
MISC ITEMS
Plan Check Fce:
Suppl. PC 1°`e��
PME Plan Check:
$0.00
Penr2it
suxop/. r isp Fee
PME Unit Fee:
$139.00
PME Permit Fee:
$47.00
C tt;wr•zrciion ,Tax:
Administrative Fee: ]ADMIN
$44.00
Work Without Permit? ® Yes Q) No
$0.00
�` £ib'Cdli"(J Pl armii-{r Fees:
i
Travel Documentation Fee: ITRAVDOC
$47.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
S
,.,
$278.50
$0.00 TOTAL FEE;
$278.50
Revised: 04/01/2014
STATE OF OALIFORNIA
MANDATORY MEASURES SUMMARY: RESIDENTIAL to
Site Address:
3
TION
M&M
NOTE: Low-rise residential buildings subject to the Standards must comply with all applicable mandatory measures listed,
regardless of the compliance approach used. More stringent energy measures listed on the Certificate of Compliance (CF -IR,
CF -JR -ADD, or CF -IR -ALT Form) shall supersede the items marked with an asterisk(*) below. This Mandatory Measures
Summary shall be incorporated into the permit documents and the applicable features shall be considered by all parties as minimum
component performance specifications whether they are shown elsewhere in the documents or in this summary. Submit all
a licable sections 9f the. MF -IR Form. with gLans.
DESCRIPTION
Building Envelope aasVres;,
§116(a)l: Doors and windows between conditioned and unconditioned spaces are manufactured to limit air leaks e.
§I 16(a)4: Fenestration products (except field -fabricated windows) have a label listing the certified U -Factor, certified Solar Heat Gain Coefficient
SHGC , and infiltration that meets the requirements of ' 10-111 (a).
§117: Exterior doors and windows are weather-stri ped; all joints and penetrations are caulked and sealed.
§118(a): Insulation specified or installed meets Standards for Insulating Material. Indicate type and include on CF -6R Form.
§ 118(i): The thermal emitiance and solar reflectance values of the cool roofing material meets the requirements of § 118(i) when the installation of
a Cool Roof is specified on the CF -1 R Form.
*§150(a): Minimum R-19 insulation in wood -frame ceiling or equivalent U -factor.
§150(b): Loose fill insulation shall conform with manufacturer's installed design labeled R -Value.
*§150(c): Minimum R-13 insulation in wood -frame wall or equivalent U -factor.
*§150(d): Minimum R-13 insulation in raised wood -frame floor or equivalent U -factor.
§150(0: Air retarding wrap is tested, labeled, and installed according to ASTM E1677-95(2000) when specified on the CF -1R Form.
§ 150(g): Mandatory Vapor barrier installed in Climate Zones 14 or 16.
§150(1): Water absorption rate for slab edge insulation material alone without facings is no greater than 0.31/o; water vapor permeance rate is no
greater than 2.0 g. rtn/i c anda. a 1 e_: rotected from. h sic 1 darn, e and UV li ht deterioration.
Fireplaces, Decorative Gas Appliances attd Gas Log Measures:
§ 150(e)IA: Masonry or factory -built fireplaces have a closable metal or glass door covering the entire opening of the firebox.
§ 150(e)1B: Masonryor factory -built fireplaces have a combustion outside air intake, which 'is at least six square inches in area and is equipped
with a with a readily accessible, operabte, and tight -fitting damper and or a combustion -air control device.
§ I50(e)2: Continuous burning pilot lights and the use of indoor air for cooling a firebox jacket, when that indoor air is vented to the outside of the
building, hlbit
Space Conditioning, Water_Heatii, and Plu. b to S stem Measures:
§ 110-§ 113: HVAC equipment,, water heaters showerheads faucets and all other regulated appliances are certified by the Energy Commission.
§I 13(c)5:' Water heating recirculation loops serving multiple dwelling units and High -Rise residential occupancies meet the air release valve,
backflow preventio$,pprap, isolation. valve and recirculation loop connection requirements of § 1 13 c 5.
§ 115: Continuously burning pilot lights are prohibited for natural gas: fan -type central furnaces, household cooking appliances (appliances with an
electrical sqp& voltage connection with pilot lights that consume less than 150 Btu/hr are exempt), and pool ands a heaters.
§ 150(h): Heating and/or cooling loads are calculated in accordance with ASHRAE, SMACNA or ACCA.
§150(i): Heating astems are equipped with, thermostats that meet the setback requirements of Section 112(c).
§1500)1A: Storage gas water heaters rated with an Energy Factor no greater than the federal minimal standard are externally wrapped with
insulation having an installed thermal resistance of R-12 or greater.
§ 1500)1B: Unfired storage tanks, such as storage tanks or backup tanks for solar water -heating system, or other indirect hot water tanks have R-12
external insulation or R-16 internal insulation where the internal insulation R -value is indicated on the exterior of the tank.
§1500)2: First 5 feet of hot and cold. water pipes closest to water heater tank, non -recirculating systems, and entire length of recirculating sections
of hot water pipes are,insulated r Standards. Table 150-B.
§ 1500)2: Cooling system piping (suction, chilled water, or brine lines),and piping insulated between heating source and indirect hot water tank
shall be insulated to. Table 150-8 and Equation 150-A.
§1506)2: Pipe insulation for steam hydropic heating systems or hot water systems >15 psi, meets the requirements of Standards Table 123-A.
wurr Resiaenttat c.ompuance Norms August 2009
Simplified Prescriptive Certificate of Compliance: 200$ Residential HVACAIterations CF -IR -ALT -HVAC
Climate Zones 1 and 3 - 7
Site Address:
nfercemen gency:
Dano1,4Permit
#:
Conditioned
Duct insu ation
Equipment T e�
List Minimum Efficiency,
Floor Area
requirement
Thermostat
0 Packaged Unit
Wumace
O AFUE
0 COP
Served by
Over 40 ft of ducts
Setback
O Indoor Coil
OSEER
13 HSPF
system
sf
added or replaced in
u
u
unconditioned space
(I not already present, must be
O Condensing Unit
O EER
0 Resistance
R b (CZ 1,
I.Waited)
❑ Other
1. Equipment Type: Choose the equipment being installed; if more than one system, use another CF -I R -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 l 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, pians and specifications submitted to a enforcement ag for approval with the permit
application.
Name:
Signature:
Company:
Dat ,
3
Address: ULicense
_:
City/Stale/Zip: s
Phone: /4b$ 60
2008 Residential Compliance Forms March 2010
INSTALLATION CERTIFICATE CF-611-MECH-04
Space Conditioning S stems, Ducts and Fans (Pagel of2)
Site Address: Enforcement Agency: Permit Number:
YAW
Space Conditioning Systems
Heating Equipment
Equip
Type
(package-
heat um
ARI
CEC Certified Mfr. Name Reference
and Model Number Number 2
#of
Identical
Systems
Efficiency
(AFUE,
etc.)'-'
(>_CF -1R
value ^
Duct
Location
(attic,
crawl-
space,
etc.)
Duct
R -value
Heating
Load
Btu/hr
Heating
Capacity
Btu/hr
Rx
r
Q0c76
a.vv.. ••s ..y. �•r•c••s
Equip
Type
(package
heat
um)
CEC Certified Mfr. Name
and Model Number
ARI Reference
Number 2
# of
Identical
Systems
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)
...r N. J.— w •.c rr vvnuor cr�swrq JGC. r uutnvrea ou oiurnuurca 3 ume r d i -v ana i ao[e i o i -u jor auct ceiling alternative
compliance.
2. ARI Reference Number can be found by entering the equipment model number at htip://lvtivw.aridirectory. org/ari/ac.php#
3. Listed efficiency on this page must be greater than or equal (>_) to the value shown on the CF -I R form.
4. When CF -IR is reference it is also applicable to the CF -JR, CF -1R -AA or CF -IR -ALT
ALL BOXES MUST BE CHECKED TO BE A VALID FORM
`U §I 10-§113: HVAC equipment is certified by the California Energy Commission.
*PQ 150(h): Heating and/or cooling loads calculated in accordance with ASHRAE, SMACNA, or ACCA.
IS § 150(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,S stems Ducts and Fans (Page 2 of 2
Site Address:Enforcement Agency: Permit Number:
o0 .
Ducts and Fans
§ 150(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 181 A, or UL 181 B 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
co bination 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.
It 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.
11 E I� 8. Gravity ventilating systems serving conditioned space have either automatic or readily accessible, manually
1 ` 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
• 1 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).
• 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.
• 1 reviewed a copy of the Certificate of Compliance (CF -1R) form approved by the enforcement agency that identities the specific
requirements for the installation. 1 certify that the requirements detailed on the CF -1 R that apply to the installation have been met.
• 1 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. 1 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.
Compan Name: (Installing Subcontractor, or General Contractor or Builder/Owner)
Vac NL
Responsible Person's Nam • Respo le erson's Si atu
10 AA4
CSLR License: Date Signed: ost ton it Comp (Title):
f%A Ma
13141 Iq Div n
2008 Residential Compliance Forms August 2009