B-2016-2189 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2189
19112 TILSON AVE CUPERTINO,CA 95014-3553(375 09 001) RELIABLE
APPLIANCE SERVICE
INC
EL CAJON,CA 92020
OWNER'S NAME: DECILLIS PAUL AND PAULA J TRUSTEE DATE ISSUED:06/22/2016
OWNER'S PHONE:408-257-8120 PHONE NO:(800)767-4040
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-20 Lic.#932632
Contractor RELIABLE APPLIANCE SERVICE INC Date 06/30/2017 X BLDG - ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(I)AC AND HEATER DUCTS-OUTSIDE
I hereby affirm under penalty of perjury one of the following two declarations:
r. 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.
2. I have and will maintain Worker's Compensation Insurance,as provided for by
SMSection 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$9200.00
APPLICANT CERTIFICATION
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 75 Number: Occupancy Type:
3
and state laws relating to building construction,and hereby authorize 375 09 001
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in congLequencAeof the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant unders ¢ an ill comply with all non-point
source regulations per the Cupe 6 Mu ipal Code,Section 9.18. 180 DAYS FROM LAST A LE PECTION.
i
Signature Date 6/22/2016 Issued by:Alex Vallclunga
Date:06/22/2016
O ER ER DE TI
I herebyffrr tha am exempt from the Contractor's License Law for one of the RE-ROOFS:
following sons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
r. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:6/22/201
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Mun' 1 Code Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25 5 d 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized ag
APPLICANT CERTIFICATION Date:6/22/20
I certify that I have read this application and state that the above information is O TR CTI D AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm tha there is con ction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said.City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 6L2212016 Professional
i
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE'AVENUE•OUPERTINO,CA 95014-3255
GUFERTttVO (408)777-3228• FAX(408)777-3333•building(cDcupertino.ora misc
❑PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS
OWNER NAME � wW PH JD,CI / r�® E-MAIL _- --
STREET ADDRESS nom/�/V /I. / CITY,STATE,ZIP �c� ! !✓ A7fn 9�/0//
CONTACT NAME i1 I S` PHONE -MAIL Ep d e V�fL.�iZ-'Itt
STREET ADDRESS/S
/J ��` r+� CITY,STATE,ZIP
❑OWNER ❑ OwNER-BuiLDER ❑ OwNERAGENT ❑ CONTRACTOR WONTRACTORAGENT ❑ ARCHITECT [:]ENGINEER ❑ DEVELOPER ❑TENANT
CONT C�R t*I - A� 1 ( tA �, hn P ICENSE NUMBER/�J/'rl LICENSE T BUS.LIC# /Q/�z C \^
C ANY NAM (��/�(/�J 1� lX�i v E-MAIL G J FAX '(t/ J J
ARCHITECT/ENGINEER NAME EICENSE NUMBER BUS.LIC#
4
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF • SFD or Duplex (Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ElCOmmerClal URBAN INTERFACE AREA E] Yes E] No FLOOD ZONE ElYes ElNo
DESCRIPTION OF WORK
TOTAL VALUATION: /)J�`� 00 *RECEIVED BX �� " 4
B m signature below,I certify to each of the following: I am the' roe o ner or authorized agent to act on the roe owner's behalf. I have read this
Y Y � � fY g property rtY g property rtY
application and the information I have provided is correct. I have read the s iption Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize en ti &,Cupertino to enter the above-ide ' ed prope for inspection purposes.
Signature of Applicant/Agent: Date:
S. I REtIRED ,wOFFICE`IJSEONliY_? „
r= PLE NTAL INF
w _ R-THE-COUNTER� 5
\ � ❑ EXPRE§S � 3
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MEPMiscApp 201I.doc revised 03/16/11
CERTIFICATE OF COMPLIANCE CF1R-ALT 02-E
Alterations to Space Conditioning Systems(formerly CF-IR-ALT HVAC) (Page 1 of 3)
Project Name: Paul De Cillis Date Prepared: 2016-06-22
II 1t•� � n ��11�� •
A.General Information
MR-ALT-02 is applicable to multiple space conditioning systems contained within a single dwelling unit.When multiple dwelling units must be documented,
use one MR-ALT-02 document for each dwelling unit.
01 Project Name Paul De Cillis 02 Date Prepared 2016-06-22
03 Project Location 19112 Tilson Av 04 ' Building Type Single°family
05 CA City Cupertino 06" Dwelling Unit Name Paul.Re..Cill)s
07 Zip Code 95014 08. Dwelling Unit Conditioned 1544,•'"
e� Floor Area(ft2)
Number of space conditioning
09 Climate Zone 4 10 (SC)systems in this dwelling 1
unit.
B.Space Conditioning(SC)System InformationA, xy
01 02 03 04 07 08 09 10
F'2 Is the SC Installing a
SC System SC System CFA served 'system a refrigerant { •Installing new•SC Installing Installing 'installing
Identification or Location or Area by this SC uducted containing system more than 40 entirely new entirely new
Name Served System(ft2) system? component? components? feet of ducts? duct system? SC system? Alteration Type
Entirely new or
System 1 Location 1 1 Yes Yes Yes Yes Yes Yes complete
replacement space
conditioning system
C. Extension of Existing Duct System,Greater Than 40 Feet(Section 150.2(b)1Diib)
This section does not apply to this project.
Registration Number:216-A0231393A-000000000-0000 Registration Date/Time: 2016-06-221' : 9:40 . HERS Provider:CaICERTS
CA Building Energy Efficiency Standards-2013 Residential Compliance Report Version:2013 Rev 1.007 Report Generated:2016-06-22 11:22:36
rncamn Warci.,n•n GI;scnn
CERTIFICATE OF COMPLIANCE CF111-ALT 02-E
Alterations to Space Conditioning Systems(formerly CF-IR-ALT HVAC) (Page 2 of 3)
D.Altered Space Conditioning System (Sections 150.2(b)1E and F)
This section does not apply to this project.
E. Entirely New or Complete Replacement Duct System,with or without Equipment Changeout(Sections 150.2(b)1Diia and 150.2(b)1E, F)
This section does not apply to this project.
F. Entirely New or Complete Replacement Space Conditioning System (Section 150.2(b)1C)
.01 02 03 04 05 06 07 08 09 10 11
Heating Cooling
System Heating Minimum Cooling Minimum Required
Identification or Heating System Altered Heating Efficiency Efficiency Cooling Altered Cooling Efficiency Efficiency Thermostat New Duct
Name Type Component Type Value System Type Component Type Value Type R-Value
Central gas All new heating ;Central spilt All.new cooling SetbackTher
System 1 AFUE" 78; SEER 13 R-6
furnace components _ AC components mostat
Required Documentation: _
CF2R-MCH-01-E-Space Conditioning Systems Ducts and Fans0, `
_Duct insulation requirement for new plenums:R6. L
CF2R&CF3R-MCH-20-H Duct Leakage Verification required.
-Leakage rate compliance:5 6%.
CF211&CF3R-MCH-22 Fan Efficacy Verification
CF2R&CF3R-MCH-23 System Air Flow Rate Verification
-Compliance:Fan Efficacy<_0.58 W/cfm and System Airflow>_350 cfm/ton.
-Alternative Compliance:CF2R&CF3R-MCH-28 Return Duct Design Verification is an alternative to MCH-22 and MCH-23 verification.
CF2R&CF3R-MCH-25-H Refrigerant Charge Verification required when refrigerant containing components are installed or altered(applicable in CZ 2,8-15).
Exceptions:
Heating-only systems are exempt from the 0.58 W/cfm and 350 cfm/ton requirements.
Note:
An"entirely new or replacement duct system"means at least 75 percent of the duct system is 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,coil,plenums,duct material)if the reused parts are accessible and can be sealed to prevent leakage
Registration Number:216-A0231393A-000000000-0000 Registration Date/Time: 2016-06-22 11:19:40 HERS Provider:CaICERTS
CA Building Energy Efficiency Standards-2013 Residential Compliance Report Version:2013 Rev 1.007 Report Generated:2016-06-22 11:22:36
Cncomn\/crcinn•n GCCCnn
CERTIFICATE OF COMPLIANCE CF1R-ALT-02-E
Alterations to Space Conditioning Systems(formerly CF-IR-ALT HVAC) (Page 3 of 3)
Documentation Author's Declaration Statement
1. 1 certify that this Certificate of Compliance documentation is accurate and complete.
Documentation Author Name: Documentation Author Signature:
Mirolyants,Sergey OOO
Company: Signature Date:
Reliable Appliance Service Inc 2016-06-22 11:19:40
Address: CEA/HERS Certification Identification(if applicable):
324 Coogan Way
City/State/Zip: Phone:
El Cajon CA 92020 800-767-4040
Responsible Person'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 Business and Professions Code to accept responsibility for the building design or system design identified on this Certificate of Compliance(responsible designer).
3. That the energy features and performance specifications,materials,components,and manufactured devices for the budding design or system design identified on this Certificate of Compliance conform to the
requirements of Title 24,Part 1 and Part 6 of the California Code of Regulations.Mt
4. The building design features or system design features identified on this Certificate of Compliance are consistent with the information`provided onAother applicable compliance documents,worksheets,
calculations,plans and specifications submitted to the enforcement agency forapprovaFwth this budtling permit application. _
h
5. I will ensure that a registered copy of this Certificateyof Compliance shall be mi&4 ailable with the building prmit(s)issued for the,�biaildmg,and:mad'e availableao;the-enforcement agency for all applicable
inspections.I understand that a registered copy of this Certificate of Compliance_is required to be included with the documentation the,builder provides to the building owner at occupancy.
_ ... -„ is �. . .�. _
Responsible Designer Name: Responsible Designer Signature. _<
Mirolyants,Sergey �'P�P�j/(Gl%�ti�y�'
Company: Date Signed: O O
Reliable Appliance Service Inc 2016-06-22 11:19:40
Address: License:
324 Coogan Way 962632
City/State/Zip: Phone:
EI Cajon CA 92020 800-767-4040
Digitally signed by CaiCERTS. This digital signature is provided in order to secure the content of this registered document,and in noway implies Registration Provider responsibility for the accuracy of the information.
Registration Number:216-A0231393A-000000000-0000 Registration Date/Time: 2016-06-22 11:19:40 HERS Provider:CaICERTS
CA Building Energy Efficiency Standards-2013 Residential Compliance Report Version:2013 Rev 1.007 Report Generated:2016-06-22 11:22:36
Crhomn Vorcinn•n rrE;cnn
--------------
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RECEIVED BUILDING DiVi.,.'31ON-CUPI-ERTINO
AN
L io This, spr;c.�jica,,;
�j u 1�i 2 '0, ions MUST b&kept at the
an same, or to de'Viate
praval-
V -O-tbe Eau Wing,
The stamping of this plan and z4:-iciflications SHAI-L NOT
16140-penm--ft--ot1u-b-,--arr-u�Yrovdl of dI-,-#&a—11.'ITT---
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of any provisions of any City C rdinance or ate Law.
BY
DA HE-
PERMIT i4 0.
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SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300 TORRE AVENUE<CUPERTINO,CA 95014-3255
CUPERTINO
(408)777-3228«FAX(408)777-3333®building(a.cupertino.org
Permit No. bl 4, •4a
Address R r.. ra #of Alarms Smoke: Carbon Mon xide:
����cAoT���z�vA>J��A�I���mPi�cT�t1r�tTZL Tis GERTIP��AT
a �✓ _ f�+i 1'f��ti ��'j`�+v�St.� yrs y 1/� sa" TuTTr. Y (� �;
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 , COALARM
Outside of each separate sleeping area in the immediate vicinity of the X X
bedroom(s) _
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 R314 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 ave been
installed in accordance with 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 a rea to comply with the terms and conditions of this statement
wner(or\Owner Agent's)Name: �
Li(((S Signature ,.... .... ate:
/Contractor Name:
Signature ... .:..:............ . Lic.#...... ... . .. :.. ... ate: ....................
Smoke and CO form.doc revised 01118/14
WATER-CONSERVING 'PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
CUIE' RT;NO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
,(408)777-3228-,FAX(408)777-3333•building(a)-cupertino.org
Owner Name P[ {. be Permit No. " 2-01 ' Z/- A
AddressC4 f570
1. Is your real property a registered historical site?
El Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
X No Go to Question 2.
2. Does your real property have a licensed plumber certifying that,due to the age or configuration of the property oi its
plumbing;installation of water-conserving plumbing fixtures is not technically feasible?
ElYes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form..
❑ No Go to Question 3.
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
l No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
Yes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign
bottom of form..
5, Please check ONE of the following:
My property is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1,2014,building alterations or improvements shall require all non-compliant plumb*n fixtures
to be replaced with water-conserving plumbing fixtures throughout the building.On or before January 1,201-7,all non-
compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
❑ My property is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1,2019,all non-compliant plumbing fixtures shall be replaced with water-
conserving plumbing fixtures throughout the building(regardless of whether property undergoes alterations o
improvements).
El My property is a commercial real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building(regardless of whether property undergoes alterations or improvements).
I,as the owner or owner's agent of this property,certify under penalty of perjury that non-compliant plumbing fixtures will be
replaced prior to date specified above with water-conserving plumbing fixtures in accordance with Civil Code Sections 1101.1
through 1101.8,the current California Plumbing Code and California Green Building Standards Code,and mann acturer's
installation requirements,and that the water-conserving plumbing fixtures comply with the requirements as indicated in the
table on the following page.
Owner or Owner Agent's Signature: —`# j C Date: orf o
Upon completing and signing this Certificate,please return it to the Building Division in order to final your buildi g permit.
SB4072015.doc revised 08126115