14050127 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11792 TRINITY SPRING CT CONTRACTOR:SERVICE CHAMPIONS PERMIT NO: 14050127
OWNER'S NAME:
PLEASANTON,CA 94588 PHONE NO:(925)444-4444
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
/71 REPLACE(E)FURNACE,SAME LOCATION
License Class 2 ``Li..# 061-10`ID ,/
Contractor qP,",l 9 L&P/ C:ft�1\(pf(1iIS Date Z4 1
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 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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4545
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:36653043.00 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 180 LLED 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
granting of this permit. Additionally,the applicant understands and wi p y ue Date: r 2/
with all non-poi t source regulations per the Cupertino Municipal 4FUUe,Section
9 18.
RE-ROOFS:
Signatur Date �Jr� 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,
Section 3700 of the Labor Code,for the performance of the work for which this
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
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
n �
\ V
CONSTRUCTION PERMIT APPLICATION 0
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building
0-cupertino.org
❑NEW CONSTRUCTION ❑ ADDITION ❑ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROTECT ADDRESS 1'-7 q APN# S-
OWNER NAME
A�
n CA
CONTACT NAME f ` PHONE '` E-MAn,
W
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BURDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER V'70 L /C) LICENSE TYPE/ F/j� BUS.LIC#
COMP NAME ` E-MAII, b ld`� i�-lJ FAX
ST,6 ADDRES
ARCHITECT/ENGINEER NAME LICENSE NUMBER T BUS.LIC# 7
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
t)yl
EXISTING USE PROPOSED USE CONSTR.TYPE I #STORIES
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO I TOTAL
AREA AREA AREA NETAREA
BATHROOM KITCHEN - OTHER
REMODEL AREA REMODELAREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA DETACH
ATTACH
#DWELLING UNITS: ISA SECOND UNIT ❑YES SECOND STORY []YES
BETNGADDEDT ONO ADDITION! ❑NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES ALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER E 0mm HOME! 1:3NO '/���``l^l
By my signature below,I certify to each of the following: I am the property owner or authorized agent to qozO&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 b ' I nze representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL NFORMATION REQUIRED PLATT CRECK TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit forTHE cODNTER ❑ BUH.DING PLAN REVIEW
existing building(s). Demolition permit is requited prior to issuance of building
permit for new building. ❑ E"RESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DE
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
0 ENVIRONMENTAL HEALTH
B1dgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 11792 TRINITY SPRING CT DATE: 05/21/2014 REVIEWED BY: MELISSA
APN: 366 53 043 BP#: *VALUATION: 1$4,545
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: FURN/A
WORK REPLACE E FURNACE SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $139
TOTALS: $139.00
�F
Mech.Plan Check0.0 hrs $0.00 11hunh. Plan Che c/k �:z'�.�� Pan f`he>c§
Mech.Permit Fee: IMPERMIT P rmil 1,ee:
Other Mech.Insp. 0.0 hrs 1 $47.00 01,f,er Pillod)lnvi . Oihev
llc i?. Plumb, hisp. dee: !Jec. Ms,-, Nc'
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These ees are based on the prelhiniina information available and are only an estimate. Contact the De t or addn7 in o.
FEE ITEMS (&e Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check P_ee:
iPME Plan Check: $0.00
Vee
PME Unit Fee: $139.00
PME Permit Fee: $47.00
("o-sirtiction Tax:
Administrative Fee: (ADMIN $44.00
Work Without Permit? ® Yes 0 No $0.00
tcii' att`c'c 1'T tltzi,t s I` cjS:
Travel Documentation Fee: ITRAVDOC $47.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$278.50 $0.00 TOTAL FEE:: $278.50
Revised: 04/01/2014
Simplifie4-Prescriptive Certificate of Compliance:2005 Residential MVACAUeralions CF-IR-ALT-HVAC
Climate Zona 10 to 15
i n �jJ_ ,ge-': Bate_ Permit#:
r -z,-ly
Conditioned Floor
T ' List Jbfinimraa EfEci Duct insulation t Area Thermostat
r-nit
Furnace --- T�AF[JE p COP Over 40 ft of ducts added or
tepiaad is unconditioned space SeavedSGback
❑Indoor Cot? OSEER Q MPF O R 6 (CL 1013} bygst— Ot°r'�
❑•�oadassangUttit DEER O Resistaitee p A 8 (CZ 14-15} Pte+;must be
edJ
L Egagrmett Type:Choo-the egngrmew baling ntttalled f mare dear vee systcM tae mmther CF-IR-.41T-HY,1Cforeach spirem
2.Allen—Eq-iprruit E 13 SEED 78%AFV9 7.71WFfor typical rendemad systes m
HERS VERIFICATION SUMMARY listed below are fbm-HVAC alteration Options. The installer derides what work is being dux and
Picks one of the appropriate Options. Each Option lists the HERS measures that mast be conducted_A copy of the forma shall be left on site for final
inspection and s copy given to dee homeowner. At fatal,the inspector yr rtfies do the work listed on this from was m fact the work completed by dee
installer- The inspector also vmfres that each appropriate CF-6R Jmd registered CF-4R foams(no hand filled CF-4Rs allowed)art filled out and
signed. Goober 1,2010,a registered copy of the CF-1R Rod CF-6R shall also be on site for final hmpecdon.
jd I.HVAC Chan tet Requked Forms:.
! All HVAC Equipment replaced CF4R fmMs MECH-K ME(3I-21-HERS and(for split systans)h H-25-HERS
CF-4R fames MFCFI-21 and for Split s MECH-25
• Condenser Col!and/or CF-6R farm:: MECH-21-H ERS and ht
� Indoor Coil and/a (for split aysterns)MECH-25-HERS
• Furnatx CF-411 forma: MHCH-21 and(for split systems) MECH 25
For-Split Systems:Dud leakage<15 percent; RC,CCA>_300 CFMAom(Minimm¢i As Floor Req¢iretnent),TMAH
For-Packaged Units: Duct leakage<15 percent
Exempted flan duct leakage besting it
O 1.Dod systeaa was docorned:d tohave be apteviondy sealed and conrmncd
throag}rHERS vaificatitm,or
.. � Q 2 Dud apstema wig less than 40 Iarear feet In unoonditioaed apace,or - t -
❑3 . duct arc�octed.insulated orseded with asbestos
D 2.New HVAC System Required Forms:
Cut at mChangeout with new . CF-6R floors]1TECfF-04,MECH-ZO�iERS
ducts(at!new dadmg arg(all ,and(for split systems)MECH-22-IRM,and MFMH 25-Ht�
nesse
CF4R Rums MECFi 20-.and(for split gstems)M�;-22,and WCH 25
For Spi3t Systems:Duct Leakage<6 pe>cent;RC;CCA>_350 CFM/tams FWD,TMAK SI1bfS,and either HSPP or PSPP.
For Packaged Unks:Duct leaks <6 -
13 3.New Ducts with Replacement Required Forma:
• Includes replacing or i�IlWg all new ducting CF-6R kmnr MSCH-04,MEC1i-20-HERS,and(for split systems)MECii ZS-HERS
and/or outdoor cmrdetuhtg unit and/or indoor CF-4R fiffn=hWCH2O and(for split systems)PASM25
Coil and/or fiance. Not all equipment changed.
For Split Systems:Dad leakage<6 percent,RC,CCA_>300 CFM/ton,TMAH
For Packaged Units:Dad IeaTca e<6 percent
O 4.New Dn aver 40 feet uired Forms:
• Inckxks adding orreplacingmore than 40 CF-6R fbn= MECH-04,MECH 21 MMS CF 4R foams MEC7i-Zl
linear fiat of duct in uncaadrBoned ane.
F.or split system orpackaged units. Duct leakage<15 percerit
Q EXCEPTION: dud ooaeslru annotated or sealed with asbestos.
Contractor(Documentation Amber's/Responsible Designer's Declaration Statemebt)'
• 1 Beatify that this Certificate of,Conpianoe doemneata6eo is accurate and completes
•-.1 am e6grbk.onder Ilivisioa;3.ed theGiifomia Bormas and Pr cfessioot Code to accept rcV=ibirhy for the dcdp idooffsed on this Certificate of Complimm
• .1 certify tit the tWW fe M=and Pati=3UM tpecrfic 8ficm far the design identified on this CertW atc 0rC=%Mzn0e conbm to thn rezpareroents of-ride24,
Parts 1 sad 6 of the Clift"Corla-of Reg�ulat;oos.:.
• IUB drsSga
cea.sgtii-ov) eA 08 qqq - qkk-q
2008 Residential Compliance Forms March 2010
Address
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildinciecupertino.oro
D..,.. 4- AT..
PURPOSE
This affidavit is a self - certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314,2013 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 R314 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 sleeping room
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 8314 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 has/have been
installed in accordance vAth 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.
I have read and agree to comply with the terms and conditions of this statement
Owner (or Owner Agent's) Name:
....... ....... ..................................................... ............................... Date: .......3�( ..
Co tractor Name:
YV 40fdI"
Si natu Lic.* ...................................... Date9. /3fi
.
t q 1& V& dV7,W
Smoke and CO form.doc revised 03118114