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B-2016-2261 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMI NO:B-2016-2261 10590 CULBERTSON DR CUPERTINO,CA 95014-3556(375 34 034) HOMEOWNER/BUILD ER OWNER'S NAME: BISWAS AMITAVA TRUSTEE&ET AL DATE I SUED:07/05/2016 OWNER'S PHONE:408-663-7323 PHON> O: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.# Contractor HOMEOWNER/BUILDER Date X BLDG _ELECT _PLUM COMMERCIAL I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: INSTALL HVAC SYSTEM-R101 OF 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. z. 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: Valuatio :$4500.00 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 APN Number: Occupain y Type: and state laws relating to building construction,and hereby authorize 375 34 034 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 F 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 L ST CALLED INSPECTION. Signature Date 7/512016 Issued by:AbbyAyende Date:07/05/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the - : following two reasons: All roofs shall be inspected prior to any roofing material bc ing installed.If a roof is t. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an ii spection,I agree to reir ove 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) z!. 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:7/5/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALLROOF COVERIN S 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 h iATERIALS D SCLO URE I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous matei ials 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 Cot e,Sections 25505,255 3,and 25534. 1 will y"permit is issued, maintain compliance with the Cull ertino 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 5532(a)should I store or handle hazardous /imaterial. Additionally,should I ui e equipment or devices which emit hazardous v shall not employ any person in any manner so as to become subject to the air contaminants as defined by thi 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 Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cod e,Sections 25505,255 3,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall e�p � be deemed revoked. 'F 0-�_ E Owner or authorized agent: APPLICANT CERTIFICATION 4`Date:715/2016 1 certify that I have read this application and state that the above information is CONSTRITC ON LENDING AGE�CY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a con truction lending ager cy for the.performance relating to building construction,and hereby authorize representatives of this city of work's for which this permit is i sued(Sec.3097,Ci 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 ARCHITITIS Code,Section 9.18. 1 understand my plans shall be u d as public records. c- Licensed Signature f Date 7/5/2016 Professional GENERAL PERMIT APPLICATION RIEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333 building(a)-cupertino.orgCUPERTINO y1sc 1 � Lu- [:1 u- 2 [:1PLUMBING /�MECHAI IICAL ❑ELECTRICAL ❑MISCE ANEOUS PROJECT ADDRESS I V ' 3( /p f� D / n Q� APN# J is ..��""° OWNERNAMEPHONE E-MAIL �°M t 7'A�VA. 1315 WAS �13Z3 STREETADDRESS Io��I d C4,tt� f&��� D� CITY, STATE,.ZIP G Upt&4-[0-0d g, I� FAX CONTACT NAME PHONE E-MAIL ( FaV Q b( W A� M t TA- V I, $1s w AS ®B 663 32.3 6 `(y STREET ADDRESS I b gC) �a CITY,STATE,ZIP _ � • ✓b,L(*,ff;-66 4 FAX El ,-•OWNER 11;.-BUILDER ElOWNERAGENT 13 CONTRACTOR 1:1 CONTRACTOR AGENT ❑ ARCHITECT ❑ FGiNEER ❑ DEvELOi 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 ❑ Multi-Family - PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes @NO FLOOD ZONE ❑ Yes 911"NO DESCRIPTION OF WORK, TOTAL VALUATION: 4-4-!5,D o 0 0 RECEIVED SYS By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property ov ner's 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 agree to comply with all applicable local ordinances and state laws relating to pbuilding construction. I authorize representatives of Cupertino to enter the above-i0entifiLed property for inspection purposes. Signature of Applicant/Agent: .J Date: i SUPPLEMENTAL INFORMATION REQUIRED " J oFr ICE[Isi i NLY +`*OVERTTiE- OUNTER; flv LARGE 1 ❑. MAJOR' , � AfEPA riscApp_2011.doc re vised 03116/11 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333 buildincip_cupertino.org CUPERTINC 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 JC) qC> C�,V_t jj eA,+56" P � �� BP#i� Lls�t'� OWNER NAME I' �� I OWNER ADDRESS (�C)C-9 0 6 �� T DESCRIPTION OF WORK: v`S9 �: We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make yc u aware of your responsibilities and,possible risk you may incur by having this permit issued in your n me 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 cann �t 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 lerify this information.) 1. 1 understand a frequent practice of unlicensed persons is to have the property d wner obtain an "Owner- Builder" wner-Builder":building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as an Owner-Builder, may be held liable and subject to serious financial III sk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My ho eowner'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 insurance coverage for injuries to workers on my property. P3 2. 1 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. 3. I understand as an"Owner-Builder" I am the responsible party of record on the permit. 1 understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having tl e permit filed in his or her name instead of my own. '74. I understand Contractors,are required by law to be licensed and bonded in Cali ornia and to list heir license numbers on permits and contracts. 5. 1 understand if I employ or otherwise engage any persons, other than CaliforniE licensed Contractors, and the total.value of my construction is at least five hundred dollars($500), including labor ani I materials, I may be considered an"employer"under state and federal law. 6. l understand if I am considered an "employer"under state and federal law, 11111.st register with the state and federal government,withhold payroll taxes, provide workers'compensation disability ir surance, and contribute to unemployment compensation for each"employee." I also understand my failure to abic e by these laws may subject me to serious financial risk. A17.n7. I understand under California Contractors'State License Law, an Owner-BuildE,r who builds sin le-family residential structures cannot legally build them with the intent to offer them for sale, un ess all work is performed by licensed subcontractors and the number of structures does not exceed four within any Dalendar year, or all of the work is performed under contract with a licensed general building Contractor. M. I understand as an Owner-Builder if I sell the property for which this permit is is ued, I may be h ald liable for any financial or personal injuries sustained by any subsequent owner(s)that result fror I any latent construction defects in the workmanship or materials. Owno-B ildef Form 2010.ddc revised 04114110 - 9. 1 understand l may obtain more information regarding my obligations as an"em loyer"from the Internal Revenue Service,the United States Small Business Administration, the California Dep rtment of Benefi Payments, and the California Division of Industrial Accidents. I also understand I may contact the alifornia Contractors' State License Board(CSLB)at 1-800-321-CSLB (2752)or www.cs[b.ca.gov for more inform :tion about licensed contractors. k >10. I am aware of and consent to an Owner-Builder building permit applied for in r y name, and understand that I am the party legally and financially responsible for proposed construction activity at thsite address listed above. 11. 1 agree that, as the party legally and financially responsible for this proposed Instruction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employ 11 rs. H'12. I 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 e to protect the public. If you contract with someone who does not have a license, the Contractors'State Licens 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 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 b a 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 iinsurance 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 wor 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 I he property ow er and returned to the agency responsible for issuing the permit. Note:A copy of the propert i owner's driver's license, form notarization, or other verification acceptable to the city may be required to be present6d when the permit is issued to verify the property owner's signature. Property Owner's Signature: - � 5 —� Date: i ----- ------ --------------- ------------------------------------------------------------------------ ---------------- --------------- (NOTE. The following Authorization Form is required to be completed by the property own r only when des'gnating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OW ER'S BEHALF Excluding the Notice to Property Owner,the execution of which I understand is my persone I responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the docu pents 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: 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 issu �d to verify the property owner's signature. Property Owner's Signature: Dater x Ownerl3 dderForm Z010.do revised 04/14/10 ->I A It=V t-I.HL11-UM V IH ALTERATIONS HVAC CEC-CFIR-ALT-03-E Revised 06/14 CAL( RNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE C 1R-ALT-03-E Alterations-HVAC CZ 1,3 to 7 and 16(formerly CF-1R-ALT-HVAC) (Page 1 of 1) Site Address: Enforcement Agency: ate Prepared: ermit#: l Equipment Type Equipment Efficiency New:Ducting,Plenums,Llneset onditioned !Required R-value loor Area(sq ft) hermostat 0 Packaged System ❑Evaporator Coil AFUE10 O;P l I R-6 (CZ 1,3-7)Ducts erved by system Setback 3`S BKSplit System ❑Condensing Unit ze"�2,SEER •� W&& ❑R-8' (CZ 16)Ducts sq ftIf not already S HSPF ❑R-6(all CZ's)Plenums present,must ❑Furnace ❑Lineset l3 13E R ❑R-5 or R7.5 Lineset3 be installed) HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options b low. At-permit--application-this, :form-•is'alloweil-tobe fined out-byYan-? For final inspection all forms are to be registered(no hand filled forms (lowed)and a copy left on site. 1.HVAC Ghangeout/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(<159/o or,: 10%to outside,or seal all accessible leaks) Exempted from duct leakage testing if: -P 6„S 7 O 1.Duct system registered with HERS provider as previously sealed,or 0 2.There is less than 40 linear feet q f duct in unconditioned space,or 0 3.Existing;duct systems are constructed,insulated or sealed with asbestos(list manufacture date oJ building 1 0 2.New HVAC System Required Compliance Documents to be left on site for Final: S All new equipment and All New Ducts2 CFIR-ALT-02-E CF2R-MECH-01,MECH-20-HERS,MECH-22-HERS,MECH-(23 or 4)-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 Tabl 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 CFIR-ALT-02-€ 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) 0 Exempted from duct leakage testing I existing duct systems are constructed,insulated or sealed wi 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 Ducts2 CF2R:MECH-20 HERS CF3R:MECH'-20-HERS Installer Required to:Duct leakage L15%or,<10%to outside,or seal all accessible leaks) Exempted from duct leakage testing I existing duct systems are constructed,insulated or sealed wi ih 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. I 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 1"and less. R-7.5(1.5"thick insulation)for linesets over.l inch. Most mfg will require Suction I ne Diameter with insulation as the following 1.5=2T-2%",2.5-3T-2%",3.5 to 4T-2y.",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 th a information on this document. 3. That the energy features and performance specifications for the design identified on this Certificate of Cor ipliance conform to I he 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 devic as for the building dE sign or system design identified on this Certificate of Compliance conform to the requirements of Title 24,Part 1 E nd Part 6 of the CCR 5. The building design features or system design features identifiedon this Certificate of Compliance are coni istent with the information provided on other applicable compliance documents,worksheets,calculations,plans and specifications su mitted to the enforcement agency for approval with this building permit application. Responsible Designer Name: Responsible Designer Signature: DateSigned: License: ft C t P'V r S W IS Company:. Address ow Pho e: [VS-9c) r_ 095-�s Cnl State/Zip: n S� �..1��� For assistance or questions regarding the Energy Standards,contact the Energy Hotline at:1-800-77 -3300'