15090151 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21092 WHITE FIR CT CONTRACTOR:VIDYA SINHA&AAT PERMIT NO: 15090151
KUMAR
OWNER'S NAME: VIDYA SINHA&AAT KUMAR 21092 WHITE FIR CT DATE ISSUED:09/22/2015
OWNER'S PHONE: 4088351375 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
RECONFIGURE/RMODEL(E)KITCHEN,INCLUDING REMOVAL
OF(E)CHIMNEY/FIREPLACE(100 S.F.).INSTALL(N)
License Class Lic.# A/C UNIT IN REAR YARD AREA
Contractor Date
I hereby affirm that 1 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: Sq.Ft Floor Area: Valuation:$15000
t 1 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. APN Number:35905092.00 Occupancy Type:
2 1 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
permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF_PKR�M�SUANCE OR
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 180 DAYS F �AL D INSPEC ION.
to building construction,and hereby authorize representatives of this city to enter _
upon the above mentioned property for inspection purposes. (We)agree to save ! Z
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Date: /
costs,and expenses which may accrue against said City in consequence of the
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
t. 1,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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code)
&1,as owner of the property,am exclusively contracting with licensed contractors to I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project(Sec.7044,Business&Professions Code). California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
1 hereby affirm under penalty of perjury one of the following three declarations: Safety Code,Section 25532(x)should I store or handle hazardous material.
t 1 have and will maintain a Certificate of Consent to self-insure for Worker's Additionally,should 1 use equipment or devices which emit hazardous air
Compensation,as provided for by Section 3700 of the Labor Code,for the contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued. Ilealth&Safety Code,Sections 25505,25533,and 25534.
2 1 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 Owner orauthorized agent: ^-
1 �e `
ermit is issued. Date: Y y\
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,1 I hereby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.)
must forthwith comply with such provisions or this permit shall be deemed Lender's Name
revoked.
Lender's Address
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is ARCHITECT'S DECLARATION
correct.I agree to comply with all city and county ordinances and state laws relating l understand my plans shall be used as public records.
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Licensed Professional
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 will comply with
all non-points urce regulations per the Cupertino Municipal Code,Section 9.18,.1
Signature Date v'
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•buildingC@cupertino.org
L
❑NEW CONSTRUCTTON ADDITION ❑ ALTERATION/Tl ❑ REVISION/DEFERRED -ORIGINAPERMIT#
PROTECT ADDRESS �) C)9
'_\W)� f n , /�4 APN 1 �AO�- 0
9 1OWNER NAME /�j-I 7 Ku r-1
v (� PII(1\I 140
9
'835'1
371� E-MAIL ki f,TI AJ) r MAIL' M
STREET ADDRESS 2.1 I�,/� �� CITY, STATE,ZIP ey+iM0 CA 7DA FAX
CONTACT NAMEn T I w aY PHONE H Iola, RY7� � E-MAIL 1/) L
STREET ADDRESS rT I O n,I . CITY,STATE,ZIP I� f A` TF.AX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME Q }� LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME 177 Y E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK � I ,
I IbA 4
PJ4 rA r)e- rn evw Gr.1. *' mock- d 1
EXISTING USEROPOSED USE CONSTR.Tl-I'L 4 STORIES
1 LSI I)N u 1 M I TT. VA UATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
I
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECKAREA TOTAL DECKIPORCH AREA GARAGE AREA. DETACH
ATTACH
a DWELLING UNITS. ISA SECOND UNIT ❑YES SECOND STORY ❑YES
BEING ADDED' []NO ADDITION' ❑NO
rk F-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN RECEIVED B TOTAL VALUATION:
r L ANNING APPL# []NO PLANNING APPROVAL LETTER EICIILER HO ❑NO 1 A , o-0/0
By my signature below,I certify to each of the following: I am the property owner razed agent to act o s be 1 have read this C7V
application and the information 1 have provided is correct. I have read the Description of Work and v curate. I agree to comply with a cable local
ordinances and state laws relating to buildi onstruction 1 authorize representatives of Cupertino to enter the above-identified ertty four inspection purposes
Signature of Applicant/Agent: Date: C!� I2 /�� l_y/5—
SUPPLEMENTAL INFORMATION REQUIRED PLAN('HECK TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW
c\isting building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 1:1 STANDARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
B1dgApp_1011.doc revised 06/11/11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
[APN:
DDRESS: 21092 WHITE FIR CT DATE: 09/22/2015 REVIEWED BY: MELISSA
359 05 092 BP#: "VALUATION: 1$15,000
OPERMT TY
PE:: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM
USE: T PERMIT TYPE:
WORK RECONFIGURE/RMODEL E KITCHEN INCLUDING REMOVAL OF E CHIMNEY/FIREPLACE 100
SCOPE S.F.). INSTALL (N) A/C UNIT IN REAR YARD AREA
Mech. Plan Check 0.0 1 hrs $0.00
Mech. Permit Fee: IMPERMIT
Other Mech. Insp. 0.0 hrs n
Li
i
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the preliminan information available and are only an estimate. Contact the De t or addn7 info.
FEE ITEMS (Fee Resolution 11-053 Efl: 7'/'13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 100 s.f. Remodel,Kitchen(<=300 sf)
Suppl. PC Fee: � Reg. 0 OT 0.0 hrs $0.00 $645.00 IREMRESKITI 'A
PME Plan Check: $0.00 17 # Mechanical
Permit Fee: $0.00 $72.00 IBREMAIR A/C Units(<=10K cfm)
Supp/. Insp. Fee-(E) Reg. Q OT 0 0 111-S $0.00
PME Unit Fee: $0.00
PME Permit Fee: $48.00
Cons'tr,-
Administrative Fee: 1ADMIN $45.00 O
Work Without Permit? O Yes (E) No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRA VDOC $48.00 Building or Structure O
i
Strong, Motion Fee: IBSEISMICR $1.95 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $143.95 $717.00 TOTAL FEE: $860.95
Revised: 07/02/2015
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•building at)cupertino.or4 —
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 Z 0(a , _1 t_ , r 1�Y �'t , JAPN �� _Ql_DQ
BP#
OWNER NAME Q�I�✓ I/Nu1 r�v` n,p OWNER ADDRESS 2 10/a)71_1 W l�
DESCRIPTION OF WORK: Rgf1\ n/'TSR Q m J ✓V �Vet/nG
2r MOVOJ OL :ByCRtA,4 av chime rttw W coneu4inn.4,
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. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
ilder" 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.
k2.
I understand building permits are not required to be signed by property owners unless they are responsible for
construction and are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
rotect 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��4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
tubers on permits and contracts.
I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
I value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
I understand if I am considered an"employer" under state and federal law, I must register with the state and
eral 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.
kq. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
riidential 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.
I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
y 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
Rev nue 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.
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
Val
a the party legally and financially responsible for proposed construction activity at the site address listed above.
1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
applicable laws and requirements that govern Owner-Builders as well as employers.
x'12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
i formation 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 acc table 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: 0 �s
------------------------------------7--------------------------------------------------------------------------------------------------------
(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:
OwnerBuilderForm 2010.doc revised 04/14/10
STATE OF CALIFORNIA 06
ALTERATIONS - HVAC
CEC-CFIR-ALT-03-E Revised 06/14 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: Z) i�9 W �'�• �— r E*rcement A ye cy: De Prepare Permit#:
(.cam Z Z /s-qov-I
Equipment TypeEfficient ment E ui New:Ducting,Plenums,Lineset Conditioned
G q p Y Required R-value Floor Area(sq ft) Thermostat
❑Packaged System ❑Evaporator Coil AFUE COP ❑R-6 (CZ 1,3-7)Ducts Served by system Setback
❑Split System ❑Condensing Unit SEER ❑R-8' (CZ 16)Ducts sq ft (//not already
HSPF ❑R-6(all CZ's)Plenums present,must
❑Furnace ❑Lineset EER ❑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.
❑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:Dud leakage L15%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 dud in unconditioned
space,or 113.Existing duct systems are constructed,insulated or sealed with asbestos(list manufacture date of building
New HVAC System Required Compliance Documents to be left on site for Final:
All new equipment and All New Ducts' CF111-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)-HERS2
Installer Requirement:Duct leakage<6%,Fan Efficacy(.58W/CFM),Air Flow 2 350 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 CF1R-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 CF1R-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.
I 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.S-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.
Re onsible Designer Name: Responsible Designer Signature: Date Signed: License:
J f �- ow 912�120 1
Company: Address: 1 ;,� ,, City/State/Zip: Phone:
ZID9L wkiIvvv-nL.LL eyfir,o,G' 96W uvae-, g,�5- ►37S
For assistance or questions regarding the Energy Standards,contact the Energy Hotline at:1-800-772-3300
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