14120009 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1585 JAMESTOWN DR CONTRACTOR:TBD-TO BE PERMIT NO: 14120009
DETERMINED
OWNER'S NAME: ALEX TANG DATE ISSUED: 12/02/2014
OWNER'S PHONE: 4083183855 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
REPLACE(E)FURNACE,A/C UNIT AND WATER HEATER
License Class Lic.# (SAME LOCATIONS)
Contractor Date
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$13000
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:36610096 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 DA IT 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 DA OM t1c3 ALLED 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 2
granting of this permit. Additionally,the applicant understands and will comply sued b Date:
with all non-point source regulations per the Cupertino Municipal Code,Se
9 18.
RE-ROOFS:
Signature Date All roofs shall be inspecte 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)
jI,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 t /y/r
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
918. t
Signature Date �'�
APPLICATION GENERAL PERMIT APP ^ b MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �O
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 � MISC
CUPERTINO (408)777-3228• FAX(408)777-3333•building
a.cupertino.org
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS (T b S T'�y
APN# / ) _I I0ICIF S7
6
OWNERNAME PHONTaV-3�Or -MAIL
r 0®
u7h �J
STREET ADDRESS CITY, STATE,ZIP / -n &/_ FAX
1SdJ :awa0' vwn Py
CONTACT NAME PHONE _&r �(J'�-ld�tGt i •!�(/yj�
E-MAIL
STREET ADDRESSAX
l;K SaMa&AV W h CITY,STATE,ZIP c7 ,I F
OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGE NT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE MB ER LICENSE TYPE BUS.LIC#
-,(, e I
COMPANY NAME E-MAIL F X
7zvl4- . 6sn- uti,-D s
STREET;4YS�S` N O[� CITY,STATE,ZIP e PHONE _ -
'-C GrV �J V V o 2
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMILY PROJECT IN77tAND ❑ YESPROJECT IN ❑YES IS THE BLDG AN ElYES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
F!1_464 elc_i5+ n -GYr)A A-L w--ler 12otfe
TOTAL VALUATION:
t'
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on theprope ow s e have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. �to comply with II applicable local
ordinances and state laws relating to building con structio . I authoriz;representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: �?'( Z/(' "c
SUPPLEMENTAL INFORMATION REQUIRED ,OFFICE usE:oNLY
fiiiOVER-TIIE COUNTER
W1,_,'-EXPRESS
STANDARD
U
LARGE
MAJOR
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 1585 JAMESTOWN DR DATE: 12/02/2014 REVIEWED BY: MELISSA
APN: 366 10 096 BP#: *VALUATION: 1$13,000
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: FURN/A
WORK REPLACE E FURNACE A/C UNIT AND WATER HEATER SAME LOCATIONS
SCOPE
Mech.Plan Check 0.0 hrs $0.00 Plumb.Plan Check 0.0 hrs $0.00 P/e".
Mech.Permit Fee: IMPERMIT Plumb.Permit Fee: IPPERMIT t;lcc- Pe t„i;
Other Mech.Insp. 0.0 hrs $48.00 Other Plumb Insp. 0.0 hrs $48.00 offer'l;C{,'c fnsla.
Ili"r,h, Ir_sp. Fi'c: I'hanb. hisp. Fee: 1'tc:c.h?sp.
NOTE:This estimate does not include fees due to other Departments(Le.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/or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E f 711/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Mechanical
Suppl.PC Fee: Q Reg. O OT Fo.0 hrs $0.00 $143.00 IMFR=<100 Furnace,Forced-Air
PME Plan Check: $0.00 1 # Mechanical
Permit Fee: $0.00 $72.00 1 IBREMAIR A/C Units(<=10K cfm)
Suppl. Insp. Feer Reg. O.OT 0.0 1 hrs $0.00 0 # Plumbing
PME Unit Fee: $0.00 $29.00 IPRWHEATR Water Heater
PME Permit Fee: $96.00
Administrative Fee: (ADMIN $45.00 O
Work Without Permit? ® Yes (E) No $0.00 1 E)
Advanced Planning Fee. $0.00 Select a Non-Residential E)
Travel Documentation Fee: ITRAVDOC $48.00 Building or Structure O
i
Strom Motion Fee: IBSEISMICR $1.69 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
r M ,
$191.69 1 $244.00 TOf'AL FEE: $435.69
Revised: 10/01/2014
1
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333•buildingacupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS i s.8s� 3^A0s (T�VwV1 Da/ /U / BP /1-0009
OWNER NAME _ OWNER ADDRESS O N �(� �A C4S
LA 1
DESCRIPTION OF WORK:
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed,and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
�k 2. I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
k�— 3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
�L 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" understate and federal law.
14,,X(�6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
Federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
I understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service,the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
110. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
y all applicable laws and requirements that govern Owner-Builders as well as employers.
�12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: Date: _1�1
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following.Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OwneYBuildeYForm 2010.doc revised 04/14/10
STATE OF CALIFORNIA
ALTERATIONS - HVAC
CEC-CFIR-ALT-03-E Revised 06114 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CFIR-ALT-03-E
Alterations-HVAC CZ 1,3 to 7 and 16(formerly CF-IR-ALT-HVAC) (Page 1 of 1)
Site Address: E,Worcement A enry: Date Prep ed: Permit#:
158 Saw c4own Pr Gv %�-r� / % /y/2,600�,
New:Ducting,Plenums,Lineset Conditioned
Equipment Type Equipment Efficiency Required R-value Floor Area(sq ft) Thermostat
❑Packaged System ❑Evaporator Coil AFUE COP ❑R-6 (CZ 1,3-7)Ducts Served by system 13 Setback
❑Split System ❑Condensing Unit SEER ❑R-8' (CZ 16)Ducts sq ft (If not already
HSPF ❑R-6(all CZ's)Plenums present,must
❑ Furnace ❑Lineset EER ❑R-5 or R7.5 Lineset3 be installed)
HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this
form is allowed to be filled out by hand. For final inspection all forms are to be registered(no hand filled forms allowed)and a copy left on site.
P 1.HVAC Changeout/Repair Required Compliance Documents to be left on site for Final:
Can-include new ducting
All Equipment, CF1R-ALT-02-E
Condenser Unit,Evaporator Coil, CF2R:MECH-01,MECH-20-HERS
Air Handler/Furnace CF3R:MECH-20-HERS
Installer Requirement:Duct leakage(:5_15%or,: .10%to outside,or seal all accessible leaks)
Exempted from duct leakage testing if:
❑1.Duct system registered with HERS provider as previously sealed,or❑2.There is less than 40 linear feet of duct in unconditioned
space,or ❑3.Existing duct systems are constructed,insulated or sealed with asbestos(list manufacture date of building
❑2.New HVAC System Required Compliance Documents to be left on site for Final:
All new equipment and All New Ducts' CF1R-ALT-02-E
CF2R-MECH-01,MECH-20-HERS,MECH-22-HERS,MECH-(23 or 24)-HERS
CF3R-MECH-20-HERS,MECH-22-HERS,MECH-(23 or 24)-HERS'
Installer Requirement:Duct leakage<6%,Fan Efficacy(.58W/CFM),Air Flow>_350 CFM/ton(or Standards Table 150.0-C/D alternative)
❑3.All New Ducts with Replacement Required Compliance Documents to be left on site for Final:
Includes replacing or installing All New C1`1111-ALT 02-E
Ducts'and one or more of the following: CF2R-MECH-01,MECH-20-HERS,MECH-(23 or 24)-HERS
Condenser Unit,Evaporator Coil,Furnace CF3R-MECH-20-HERS,MECH-(23 or 24)-HERS
Installer Requirement:Duct leakage<6%,Air Flow;z 350 CFM/ton(or Standards Table 150.0-C/D alternative)
❑Exempted from duct leakage testing I existing duct systems are constructed,insulated or sealed with asbestos.
❑4.New Ducting over 40 feet Required Compliance Documents to be left on site for Final:
Adding or replacing ducts in unconditioned CFIR-ALT-02-E
space but less than All New Ducts' CF2R:MECH-20-HERS
CF3R:MECH-20-HERS
Installer Required to:Duct leakage(<15%or,<10%to outside,or seal all accessible leaks)
❑ Exempted from duct leakage testing I existing duct systems are constructed,insulated or sealed with asbestos.
'All new ducting R-8 required when more than 40 ft installed and R-6 when less than 40 ft installed. This includes in walls,between floors etc.
'A New Duct system is when the duct system is constructed of at least 75 percent new duct material,and up to 25 percent may consist of reused
parts from the dwelling unit's existing duct system(e.g.,registers,grilles,boots,air handler,plenums,duct material.
3 R-5(1"thick insulation)for linesets I"and less. R-7.5(1.5"thick insulation)for linesets over 1 inch. Most mfg will require Suction line Diameter
with insulation as the following 1.5-2T-2%",2.5-3T-2Y4",3.5 to 4T-2'/.",5T-4%"
Contractor(Documentation Author's/Responsible Designer's Declaration Statement)
I certify the following under penalty of perjury,under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the information on this document.
3. 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(CCR).
4. That the energy features and performance specifications,materials,components,and manufactured devices for the building design or
system design identified on this Certificate of Compliance conform to the requirements of Title 24,Part 1 and Part 6 of the CCR.
5. The building design features or system design features identified on this Certificate of Compliance are consistent with the information
provided on other applicable compliance documents,worksheets,calculations,plans and specifications submitted to the enforcement
agency for approval with this building permit application.
Responsible Designer Name: Responsible Des gner Signature: Date Signed: License:
3iA HsFh I -o 1 z�z�( q
Company: Address: City/State/Zip: Phone:
For assistance or questions regarding the Energy Standards,contact the Energy Hotline at:1-800-772-3300