B-2016-2249 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2249
10902 CANYON VISTA DR CUPERTINO,CA 95014-3909(356 28 028) OWNER-BUILDER
OWNER'S NAME: REICHARDT SHARON A TRUSTEE&ET AL DATE ISSUED:06/30/2016
OWNER'S PHONE:408-529-0879 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER-BUILDER Date XBLDG _ELECT XPLUMB
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:
INSTALL(N)GAS LINE-SIDEYARD;INSTALL A/C UNIT-ROOF
I hereby affirm under penalty of perjury one of the following two declarations:
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.
2. 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
permit is issued. Sq.Ft Floor Area: Valuation:$8000.00
APPLICANT CERTIFICATION
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 356 28 028
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 consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAS ID PECTION.
Signature Date 6/30/2016 Issued by:Alex Vallelunsa f`
Date:06/30/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material be g installed.If a roof is
1. I,as owner of the propert};or my employees with wages as their sole installed without first obtaining an inspection,I agree to rem ve all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(See.7044,Business&Professions Code)
�a. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:6/30/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A".011 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 DISCLO URE
2. 1 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. 1 will
permit is issued. maintain compliance with the Cupertino Municipal Cod ,Chapter 9.12 and the
I certify that in the performance of the work for which this permHealth&Safety Code,Section 25532(a)should I store or handle hazardous
it is issued,I 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 QualityManagement District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Gode,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,2553 3,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Qwner_d authorized-ages :_
APPLICANT CERTIFICATION Date:6/30/2016
certify that I have read this application and state that the above information is ON T TI L E Y
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that ther ' a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is 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'Sli _I understand my plans shall be used as public records.
Code,Secti 9.18.
J Licensed
Signature "`� Date 613012016 Professional
GENERAL PERMIT APPLICATION
IEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildingC�cupertino.org 1SC
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL []MISCELLANEOUS
PROJECT ADDRESS V'1 9 1-• APN# �-,�S — 2 27- p��
OWNERNAME r PHONE � E-MAIL lJ
STREET RESS CITY, STATE,ZIP FAX
CONTACT NAME PHONE EMAIL
407 151n�
STREET DRESS CITY,STATE,ZIP FAX
❑OWNER uY OWNER-BUII.DER ❑ OwNER.AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELO ER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME 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
USE OF ❑ SFD or Duplex ulti-Family PROJECT IN WILDLAND PROJECT IN
C.cvn�,� URBAN INTERFACE AREA ❑ Yes I] No FLOOD ZONE El Yes ❑ No
STRUCTURE: ❑ Commercial �y
DESCRIPTION OF WORK
C.�
119A //7//
Vii
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TOTAL VALUATION: BY
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By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I haver d this
application and the infonnati have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all app icable local
ordinances and state laws lating b ding construMth6ere ie ntatives of Cupertino to enter the a�e-i fled p r inspectio purposes.
Signature ofApplicant/Age Date:
u1su
PLEMENTAL INFORMATION REQUIRED " oFFzci�'uSE; NLS
ovER:T gTWTER
Y
H )] Iar �ss
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LD LARGE,
MAJOR,
MEPMiscApp_2011.doc r vised 03116111
S 1 A It Ul•GALWUMIA
ALTERATIONS - HVAC
CEC-CFIR-ALT-03-E Revised 06/14 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF LR-ALT-03-E
Alterations-HVAC CZ 1,3 to 7 and 16(formerly CF-IR-ALT-HVAC) Page 1 of 1)
Site Address: Enforcement Agency: Date Prepared: ermit#:
�; t 'D 4:,
Equipment TypejC tl: E ui ment Efficient New: ucting,Plenums,Lineset Conditioned
DY e q P y Required R-value Floor Area(sq ft) herrnostat
El Packaged System 0 Evaporator Coil AFUE CCP ❑R-6 (CZ 1,3-7)Ducts Served by system Setback
0 R-8''CZ 16 Ducts `L 'Q � ( not already
?LSAlit System Condensing'Unit SEER HSPF ❑R-6(all CZ')Plenums t sq ft resent,must
❑Furnace ❑Lineset EER ElR-5 or R7.5 Lineset3 a installed)
HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At-permit-apple atiorr-this,
form_is-allowed to be led-odt-byNa'nd For final inspection all forms are to be registered(no hand filled forms allowed)and a copy left on site.
1.HVAC Ctiangeout/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(:S.15%or,<10%to outside,or seal all accessible leaks)
Exempted from duct leakage testing if:
O 1.Duct system registered with HERS provider as previously sealed,or 0 2.There is less than 40 linear feet of duct in uncondition d
space,or ❑3.Existing duct systems are constructed,insulated or sealed with asbestos(list manufacture date of building 1
2.New HVAC System Required Compliance Documents to be left on site for Final:
All new equipment and All New Ducts' CFIR-ALT-02=E
CF2R-MECH-01,MECH-20-HERS,MECH-22-HERS,MECH-(23or 24)-HERS
CF3R-MECH-20-HERS,MECH-22-HERS,MECH-(23 or 24)-HERS'
Installer Requirement:Duct leakage<69/.,Fan Efficacy(.58W/CFM),Air Flow 2 350 CFM/ton(or Standards Table 150.0-C/D alternative)
113.All New Ducts with Replacement Required Compliance Documents to be left on site for Final:
Includes replacing or installing All New CFIR-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:Ductleakage<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.
0 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 fl oors etc.
'A New Duct system-is.when the ductsystem is constructed of at least 75 percent new ductmaterial,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 Ii ie Diameter
with insulation as the following 1.5-2T-2%",2.5-3T-2%",3.5 to 4T-2%",5T-4W, -
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 tot ie
requirements of Title 24,Parts 1 and 6 of the California Code of Regulations(CCR).
4. That the energyfeatures and performance specifications,materials,components,and manufactured devices for the building de ign 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: Resp Bible Desi ner ignature: Date Si ned: License:
Company: dress: City/State Zip: e Phone: r
For assistance or questions regarding the Energy Standards,contact the Energy Hotline at:1-800-772-3300
OWNER-BUILDER DISCLOSURE IFORtilIl
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
:10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAx(408)777-3333•building(a.cupertino.org
CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the prc perty
improvements specified at:
-7 SITE ADDRESS .IO�flZ Cep O►'9 V�Sk ��< APN BP#
OWNER NAME OWN&MIESWn
"AV k4
DESCRIPTION OF WORK: ` �1i -Z C� 7t ,en
9eptage, AC. lP M 1 C
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 no ice 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.)
frso
1. ! understand a frequent practice of unlicensed persons is to have the property owner obtain an" wner-
er'building permit that erroneously implies that the property owner is providing his or her own labo and material
nally. 1, 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 insura ice may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
in rance coverage for injuries to workers on my property.
y2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
heonstruction 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
Ytenme
ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in is or her
instead of my own.
4. I understand Contractors are required by law to be licensed and bonded in California and to list i heir license
ftal
bers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contra tors, and the
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.
6. I'understand if 1 am considered an"employer'under state and federal law, I must register with the state and
decal government,withhold payroll taxes,provide workers'compensation disability insurance, and co tribute to
unemployment compensation for each"employee." I also understand my failure to abide by these laws ay subject
me 4o serious financial risk.
7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds sin ie-family
Yicseinsed
ential structures cannot legally build them with the intent to offer them for sale, unless all lwork is performed by
subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is p ormed under contract with a licensed general building Contractor.
8. 1 understand as an Owner-Builder if t sell the property for which this permit is issued, I may be held liable for
ny financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OW7Ze7Bziilde7FO7774 2010.do revised 04/14/10 -
9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal
0 V
nue Service, the United States Small Business Administration,the California Department of Benefi Payments,
he 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
m the party legally and financially responsible for proposed construction activity at the site address listed above.
11. 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. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
ormation I have provided on this form. Licensed contractors are regulated by laws designed to protectthe public. If
ou contract with someone who does not have a license, the Contractors'State License Board may be ynable 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 Contraci or 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: t'o v-44 Lender Address: K lA
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 drivers license,
form notarization, or other v 'fication accep le to the city may be required to be presented when the per it is issued
to verify the pro erty owneftsiNgtqre. 12
Property Owner's Signature: Date: ��t)*eO
---------------------------------U------------------------------------------------------------------------------------------ -----------
(NOTE: The following Authorization Form is required to be completed by the property owner only when de fgnating 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 BEHA F
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 o 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:
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 notari ation, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the pr perty owner's
signature.
Property Owner's Signature: Date:
OwnerBuilderFonn 2010.do revised 04114110