15010025 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10955 NORTHSEAL SQ CONTRACTOR:ONE HOUR HEATING PERMIT NO: 15010025
AND AIR
OWNER'S NAME: LYDIA BALANO TRUSTEE 1400 PETALUMA HILL RD DATE ISSUED:01/06/2015
OWNER'S PHONE: 4089731290 SANTA ROSA,CA 95404 PHONE NO:(707)545-1800
hd LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL El COMMERCIAL
q REPLACE(E)FURNACE,SAME LOCATION
License Class (_/'Q C �Lic.# 741'0 ��f /
Contractor Date L -1s—
I hereby affir 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:$4832
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:31640021 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 DAYS OF PERMIT 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 D LAST CALLED 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 the /
Date:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date ( � ` 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 25505 25533,and 25534. t^
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
GENERAL PERMIT APPLICATION �
MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 D misc
CUPERTINO (408)777-3228•FAX(408)777-3333•building(akupertino.org
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS /0��[� /� 0✓,/��SA4/ S� APN# 3 / O /\ �7 /
✓ V ! / G l L J (� r
OWNER NAME �/ ke//,m t �`' u • �� , r2� E-MAIL
STREET ADD No'V Sca I •J 7` ZT ITY,STATE,NO C� r S tro/L( FAX
CONTACT NAME (f, Sr PHONE �7 J 7E-MAII
STREET ADDRESS G l' CITY,STATE,ZIP FAX
❑OWNER ❑ OwNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER�!��y� LICENSE TYPE�U BUS.LIC#
CO WANE C/w h ee l-I m la fl-- kl Yif1 r ld_! e"f`f�J 00jt)%QVrQ l If.
•G O M FAX
S RE T ADD (� CITY,S ATE, PHONE
PUCE �vhva ti r« r� ASA c44 T5104 o7-yL4S•180 0
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
vin o-cQ CGS a.� v fi'
TOTAL VALUATION: Zf`j-3
iLLLJJ
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property oer' 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 comply with all applicable local
ordinances and state laws relating to build' ction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPKEMENTAL INFORMATION REQUIRED
/r ,;„ pFFICE USE ONLY
{]A EB-THE-CoLwun
a.
I D STANDAAR", g:
LARGE
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10955 NORTHSEAL SQ DATE: 01/06/2015 REVIEWED BY: MELISSA
APN: 316 40 021 BP#: "VALUATION: 1$4,832
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/A
USE: PERMIT TYPE: A
WORK REPLACE E FURNACE SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $143
TOTALS: $143.00
0 111.
Mech.Plan Check "00 $0.00 1'huu?s. ]'km Chcc% Aiec. Pian
Mech.Permit Fee: IMPERMIT t'errnif Fee,: Ue( ?'err,�it I'C",
Other Mech.Insp. 0.0 hrs $48.00 Other Plumb Ins,). Cather Liec.
Inv)- N"".. 1'hamb. Irasp. Fee: 1-1tic.It f
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the prelimina information available and are only an estimate. Contact the Dept/or addn 7 info,
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/131 FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
c'n Jd1
PME Unit Fee: $143.00
PME Permit Fee: $48.00
C;riJtstr action 7'6n_-
Administrative Fee: IADMIN $45.00
Work Without Permit? ® Yes (F) No $0.00
Travel Documentation Fee: ITRAVDOC $48.00
Strong Motion Fee: IBSEISMICR $0.63 Select an Administrative Item
Bldg,Stds Commission Fee: IBCBSC $1.00
$285.63 $0.00 TOTAL FEE: $285.63
Revised: 10/01/2014
STATE OF CALIFORNIA
ALTERATIONS - HVAC
CEC-CFIR-ALT-03-E Revised 06/14 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF1R-ALT-03-E
Alterations-HVAC CZ 1,3 to 7 and 16(formerly CF-IR-ALT-HVAC) (Page 1 of 1)
Site Address: orcement A ncf: Date Prepared: Permit#:
(70`55, lYar� cal SQ �Ll 1 -4 -15
Equipment Type Equipment Efficiency New:bucting,Plenums,Lineset Conditioned Thermostat
Required R-value Floor Area(sq ft)
❑ Packaged System ❑Evaporator Coil WAFUE COP ❑R-6 (CZ 1,3-7)Ducts Served by system Poetback
❑Split System ❑Condensing Unit SEER ❑ R-8' (CZ 16)Ducts (SG6 sq ft (if not already
HSPF ❑R-6(all CZ's)Plenums present,must
urnace ❑Lineset EER 1 ❑R-5 or R7.5 Lineset' 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.
;a.HVAC Changeout/Repair Required Compliance Documents to be left on site for Final:
Can include new ducting
All Equipment, CFIR-ALT-02-E
Condenser Unit,Evaporator Coil, CF2R:MECH-01,MECH-20-HERS
Air Handler/Furnace CF3R:MECH-20-HERS
Installer Requirement:Duct leakage(<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 112.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 z 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 CF111-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>_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
CF2R:MECH-20-HERS
space but less than All New Ducts'
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,dud material.
3 R-5(1"thick insulation)for linesets 1"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-2%",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 Desig igna r Date Signed: License:
esse Lie C . _ 1
5 7 Ufa??
Company: Address: City/State/Zip: Phone:
kuo- kea+1r% /q i r mo ialvwa hio Yd Samoa A c 4t5 /ocO
For assistance or q6istions regarding the Energy Standards,contact the Energy Hotline at:1-800-772-3300