B-2016-2812 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2812
21076 GRENOLA DR CUPERTINO,CA 95014-1624(326 28 066) ATKINSON ,
CLEVATROLLERS INC
SAN JOSE,CA 95112
OWNER'S NAME: BORNER WILLYAND VRENI TRUSTEE DATE ISSUED:09/27/2016
OWNER'S PHONE:203-241-3501 PHONE NO:(408)294-6290
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#258540
Contractor ATl<INSON CLIMATROLLERS INC Date 12/31/2016 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 hereby affirm under penalty of perjury one of the following two declarations: REPLACE FURNACE,SAME LOCATION(ATTIC)
i. 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: Valuation:$3700.00
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 326 28 066
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 18Q 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 LAST CALLED INSPECTION.
Signature , ' CVS Date 09/27/2016 Issued by:MELISSAa IE
Date:09/27/2016
OWNER-BUILDER DARATION
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 being installed.If a roof is
1. 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:09/27/2016
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
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. 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
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
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 Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:09/27/2016
1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is 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 ARCHIT'ECT'S DECLARATION
Code,Section 9.18. f understand my plans shall be used as public records.
Licensed
Signature Date 09/27/2016 Professional
GENERAL PERMIT APPLICATION MEP
its COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•building aacupertino.org
CUP l�TI O
MISC
PLUMBING ZMECHANICAL ELECTRICAL MISCELLANEOUS
PROJECT ADDRESS (� �i APN# 6
�V
OWNER NAME C@'� PHONE 0 � �t I e 35-01E-MAIL
STREET ADDRESS t Coa 0 e V" 54 CITY, STATE,ZIP / at FAX
CONTACT NAME PHONE q 0 7® E-MAIL
STREET ADDRESS } y CITY,STATE, ZIP -� 1 O�n Q 1 11 FAX
VIV
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT II ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME1 n 1 / LICENSE NUMBER(j /1 LICENSE TYPE C-W BUS.LIC#
COMPANY NAME 'V1 ey V�j�✓ V E-MAIL O J FAX
/
STREET ADDRESS 14 1-71 (� 5 Y CITY,STATE,ZIP �� } � PHONE (L� rJ lz
ARCHITECT/ENGINEER NAME LICENSE NUMBER v ` t BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF g 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
L) loll aG tee, G t'j V\
TOTAL VALUATION: ( B
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on tha prop owner'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 toQ ing o \cction. I authorize representatives of Cupertino to enter the above-identified prope for inspeerion purposes.
Signature of Applicant/Agent: ``� 1�/u� Date:
SUPPLEMENTAL INFORMATION REQUIRED
..."XPT SB R
MEPMiscApp_2011.doc revised 06121111
CERTIFICATE OF COMPLIANCE CF111-ALT-02-E
Alterations to Space Conditioning Systems(formerly CF-1R-ALT HVAC) (Page 1 of 3
Project Name: 2016-0172 Taft Coleman Date Prepared: 2016-09.09
A.General Information
CF1R-ALT-02 is applicable to multiple space conditioning systems contained within a single dwelling unit.When multiple dwelling units must be documented,
use one CFIR-ALT--02 document for each dwelling unit.
01 Project Name 2016-0172 Taft Coleman 02 Date Prepared2016-09-09
03 Project Location 21076 Grenola Drive 04 Building Type Single family
05 CA City Cupertino 06 Dwelling.Unit Name 2016-0172 Taft Coleman
07 Zip Code 95014, 08 Dwelling Unit Conditioned 2000
Floor Area(ft2)
Number of space conditioning'
09 Climate Zone 4 10 (SC)systems in this dwelling 1
unit.
B.Space Conditioning(SC)System Information
01 02 .03 04 05 06' 07 09 10
,.
'ls the SC"''k In"stalling
SC System SC System CFA served system r frige a tt Installi4g'he SC Instal,i g los Ili g nstalling
Identification or Location or Area by this SC ducted containing system more than 4l entirely new entirely new
Name Served System(ft2) system? component? components? feet of ducts? duct system? SC system? Alteration Type
Furnace Altered space
replacement whole house 2000 Yes No Yes No No No 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-A0334637A-000000000-0000 Registration Date/Time: 2016-09-09 14:11:48 HERS Provider:CaICERTS
CA Building'Energy Efficiency Standards-2013 Residential Compliance Report Version:2013 Rev 1.008 Report Generated:2016"-09-09 14:12:18
Schema Version:0.555SDD
CERTIFICATE OF COMPLIANCE CFI11-ALT-02-E
Alterations to Space Conditioning Systems(formerly CF-1R-ALT-HVAC) (Page 2 of 3)
D.Altered Space Conditioning System(Sections 150.2(b)1E and F)
01 02 03 04 05 06 07 08 09 10 11 12
Heating Cooling
System Heating Altered Heating Minimum Altered Cooling Minimum Required New or
Identification System Heating Efficiency Efficiency Cooling Cooling Efficiency Efficiency Thermostat Replaced New Duct
or Name Type Components Type Value System Type Components Type Value Type Duct Length R-Value
Furnace Central gas All new No cooling This field or This field or This field or This field or
replacement furnace heating AFUE 80 No cooling component section is not section is not Setback section is not section is not
components altered applicable applicable applicable applicable
RequiredDocumentation:
CF2R-MCH-01-E-Space Conditioning Systems Ducts and Fans
-Duct insulation requirement for new plenums:R6.
CF2R-MCH-20-H&CF3R-MCH-20-H—Duct Leakage testing,required when heating or cooling components are installed in ducted systems,or when more than 40 ft of duct length is replaced.
Leakage rate compliance:<_15%,ora 10%leakage to outside,or seal all accessible leaks.
CF2R-MCH-25-H&CF311-MCH=25-H Refrigerant Charge Verification required when refrigerant containing components are installed or altered(applicable in CZ 2,8-15).
CF2RCF3R-MCH-23&CF311-MCH-23 Air Flow i'300 CFM/ton required when MCH-25 is required.
Exceptions:
-Duct systems registered with HERS provider as previously sealed are exempt from,MCH 20 Duct Lepkage T r c�uiremgnts
Heating-only systems and Air Handler/Furnace changes do not require verification cf Air Flow MC 23 r 6frig nt Charge mit
-Existing duct systems constructed,insulated or seated with asbestoslare exempt,from MCH 20 DucLpakage Test^ r,quifW 7"7777-
ements.
y p p c 11 stem,wi her thou#Egyi{ament Ch ngeir�ut(Sections 1 0 2 )�Dila andJ50.2(b)1E, F)
E. Entire) New or Complete Replacement Duc
W
This section does not apply to this project.
F. Entirely New or Complete Replacement Space Conditioning System(Section 150.2(b)1C)
This section does not apply to this project.
Registration Number:216-A0334637A-000000000-0000 Registration Date/Time: 2016-09-09 14:11:48 HERS Provider:CaICERTS
CA Building Energy Efficiency Standards-2013 Residential Compliance Report Version:2013 Rev 1.008' Report Generated:2016-09-09 14:12:18
Schema Version:0.555SDD
CERTIFICATE OF COMPLIANCE CFIR-ALT-02-E
Alterations to Space Conditioning Systems(formerly CF-1R-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:
Faulkner,Cindy
Company: Signature Date:
ATKINSON CLIMATROLLERS INC dba VALLEY HEATING,000LING&ELECTRICAL 2016-09-09 14:11:48
Address: CEA/HERS Certification Identification(if applicable):
1171 NORTH 4TH STREET
City/State/Zip: Phone:
SAN JOSE CA 95112 408-294-6290
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 ofthe 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,co orients,and anufactured devices for the building design or system des' n identified on this Certificate of Compliance conform to the
.requirements of Title 24,Part 1 and Part 5 of the California Code of afi+ins.
'^
4. The building design features or system design features i ntified o ;his Certifica of Compliance are;pansEste 3with>the i ormation rovided on gth,iQ` [ca a compliance documents,worksheets,
calculations,plans and specifications submitted to the eZorcementiagency fo roval with,this building per t a icatiE3 %'
5. I will ensure that registered copy of this Certificat C pliance shail �n tleauail ble wttlr he b"wilding pgrmit .:issued for--the b ud g,and rnac au :fib tg,,th0 nforcement agency for all applicable
inspections.I understand that a registered copy of this ertificate of Compliance„is�eq"d to be,,lncluded v-%, ml
the documentatiort,the builder provides to the building owner at occupancy.
;:
Responsible Designer Name: Responsible Deigri'erSnatures ?- _ L
Faulkner,Cindy C�G�e;G
Company Date Signed
ATKINSON CLIMATROLLERS INC dba VALLEY HEATING,000LING&ELECTRICAL 2016-09-09 14:11:48
Address: License:
1171 NORTH 4TH STREET 258540
City/State/Zip; Phone:
SAN JOSE CA 95112 408-294-6290
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-A0334637A-000000000-0000 Registration Date/Time: 2016-09-09 14:11:48 HERS Provider:CaICERTS
CA Building Energy Efficiency Standards-2013 Residential Compliance Report Version:2013 Rev 1,008 Report Generated:2016-09-09 14:12:18
Schema Version:0.555SDD