B-2016-3114CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
7562 KIRWIN LN CUPERTINO, CA 95014-4339 (359 22 028)
CONTRACTOR:
PERMIT NO: B-2016-3114
OWNER'S NAME: ARAVIND NAGARAJAN
DATE ISSUED: 11/14/2016
OWNER'S PHONE:
PHONE NO:
LICENSED ONT A TOR' DECLARATION ARATION
BUILDING PERMIT INFO:
License Class Lie. #
Contractor Date
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:
1 ST FLOOR MASTER BATHROOM REMODEL (48 SF); REPLACE
1. I have and will maintain a certificate of consent to self -insure for Worker's
PATIO DOOR; RELOCATE FURNACE (ATTIC)
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 NT ERTIFI ATION
certify that I have read this application and state that the above
"N Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
359 22 028
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 the granting this permit.
.Additionally,
the applicant understands and will comply with all non -point
l all
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date
Issued by: Abby Ayende
Date: 11/14/2016
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 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)
1F" 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:
I hereby affirm under penalty of perjury one of the following three declarations:
i. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
r r 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. 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
a. 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
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Air Quality Management District I
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:
I certify that I have read this application and state that the above information is
CONS TRUC FN IN A N Y
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
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
11�
Signature Date
Licensed
Professional
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CONSTRUCTION f ION PERNUT APPUGA t CQN
COMMNITY DEVELDPA4ENT DEPART10ENT • BUILDING DIVISION
10300 T ORRE AVENUE • CUPER T INO, CA 95014-3255
CUPERi INO- (408) 777-3228 , FA';X (408) 777-3333 • buildinaQcuoe ino.org
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ord,nancts and s a:e laws r_la::ng to b_;Id_a construction. I autbonze r p esen`atives of Cape; ilno to enter the above-identJiled prcpe ;y for inspection
proposes.
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4
CUPERTINO:
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • buildingp_cupertino.org
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:
ADDRESS �, ^ _ I APN
OWNER NAME _ I OWNER ADDRESS
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DESCRIPTION OF WORK: i`v L .[ y%wr
a� rad'►% a/a-ar l c�L c� u�{li c_ 9 n$ r � i
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. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
wilder 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.
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.
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3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
naamme� instead of my own.
Y,'4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
!�5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total 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.
%Ve—dera]
6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
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.
V,�7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential 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.
f, 1,• 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defect's in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
mow,
e 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the UnitedStates 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. I am aware of and consent to an Owner -Builder building permit applied for in m name, and understand
Y that I
am 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
b all applicable laws and requirements that govern Owner -Builders as well as employers.
agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information l 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 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: 114 b
--------------------------------------------------------------------------------------------------------------------------------------
(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, 1 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:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and l 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:
OwnefBuilderFonn 2010.doc revised 04114110
t
CERTIFICATE OF INSTALLATION
CF2R H-
Duct Leakage Diagnostic Tes
(Page f 3 )
Project Name: 7562 Kirwin Lane
Enforcement Agency:
City of
Permit Number: B-2016-3114
Building Type from CF -111
Cupertino
04
!
's,
Dwelling Address: i562 Kiri ane
City:
Cupertino
a
Zip Code: '---- ""95014
A. System Information
01
Space Conditioning System Identification or Name
System 1
02
Space Conditioning System Location or Area Served
Location 1
03
Building Type from CF -111
Single family
04
Verified Low Leakage Ducts in Conditioned Space
(VLLDCS) Credit from CF1R?
No, credit is not taken
05
Verified Low Leakage Air Handling Unit (VLLAHU) Credit
from CF1R?
No, credit is not taken
06
Duct System Compliance Category
New
MCH -2 ;
Oa -Completely New Duct•System ;
B. Duct, Leakage Diagnostic Test -
01
Condenser Nominal Cooling Capacity (ton)
0
02
Heating Capacity (kBtu/h)
68
03
Conditioned Floor Area served by this HVAC system (ft2)
1388
04
Duct Leakage Test Condition
Test final
05
Duct Leakage Test Method
Total leakage
06
Leakage Factor
0.06
07
Air Handling Unit Airflow (AHUAirflow) Determination
Method
Heating system method
08
Measured AHUAirflow
This field or section is not applicable
09
Calculated Target Allowable Duct Leakage (cfm)
89
10
Actual duct leakage rate from leakage test measurement
(cfm)
28
11
Compliance Statement: System passes leakage test
Registration Number: 217-A0025125A-M2000002A-0000
CA Building Energy Efficiency Standards
2013 Residential Compliance
Registration Date/Time: 2017-01-06 20:07:25 HERS Provider: CaICERTS
Report Version: 2013 Rev 1.008 Report Generated: 2017-01-06 20:05:15
Schema Version: 2013.1.007
r.
CERTIFICATE OF INSTALLATION CF211-MCH-20-11-1
Duct Leakage Diagnostic Test (Page 2 of 3 )
C. Additional Requirements for Compliance
t
01
i.
System was tested in its normal operation condition. No temporary taping allowed.
Outside air (OA) duct connections to the central forced air duct system shall not be sealed/taped off during duct leakage
02
testing. OA ducts used for Central Fan Integrated (CFI) Indoor Air Quality ventilation systems, or Central Fan Ventilation
Cooling Systems, that utilize dampers that open only when OA is required and automatically close when OA is not required,
may configure the OA damper to the closed position during duct leakage testing.
03
All supply and return register boots were sealed to the drywall.
04
Building cavities were not used as plenums or platform returns in lieu of ducts.
05
If,:cloth backed tape was used it was covered with Mastic and draw bands.
06
All connection points between the air handler and the supply and return plenums are completely sealed.
Visual Inspection at Final Construction Stage (applicable if system was tested at rough -in)
After installing the interior finishing wall and verifying that the above rough -in tests was completed, the following procedure must
be performed
07
For all supply and return registers, verify that:the spaces betWeenAhe_register boot and the -interior finishing wall are
properly sealed.
If the house rough -in duct, leakage test wa°s conducted vvitho,ut an: air handlerinstalled, inspect fhe connection points._:'
08
between the air handler and the supply and ;return -plenums to -verify that the -connection :points are_properly sealed,
09
1 Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used.
The responsible persons signature on this compliance document affirms that all applicable requirements in this table have
been met.
Registration Number: 217-A0025125A-M2000002A-0000
CA Building Energy Efficiency Standards
2013 Residential Compliance
Registration Date/Time: 2017-01-06 20:07:25 HERS Provider: CaICERTS
Report Version: 2013 Rev 1.008 Report Generated: 2017-01-06 20:05:15
Schema Version: 2013.1.007
CERTIFICATE OF INSTALLATION CF2R-MCH-20-H
Duct Leakage Diagnostic Test (Page 3 of 3 )
Documentation Author's Declaration Statement
l
1. 1 certify that this Certificate of Installation documentation is accurate and complete.
Documentation Author Name:
Kevin Harry
Documentation Author Signature:��7��� a
Company: i!:
Signature Date: 2017-01-06 20:05:03
Allied HERS Testing
Address: ',;
CEA/ HERS Certification Identification (if applicable):
853 West L Street
CC2006610
City/State/Zip:
Phone:
Benicia CA 94510
707-373-0196
Responsible Person's Declaration statement
I certify the following under penalty of perjury, under the laws of the State of California:
1. i, The information provided on this Certificate of Installation is true and correct.
2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the system design,
construction, or installation of features, materials, components, or manufactured devices for the scope of work identified on this Certificate of
Installation and attest to the declarations in this statement (responsible builder/installer), otherwise I am an authorized representative of the
responsible builder/installer.
3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this Certificate of Installation
conforms to all applicable codes and regulations, and,the installation conformsto.the requirementsgivenon the. plans and, specifications approved by
f
the enforcement agency.
4. 1 understand thata HERS rater will check the installation to verify compliance, and that if such checking identifies defects; Ham required to take
corrective action at my expense"J understand that Energy Commission and HERS Provider representatives will also perform quality assurance checking
of installations, including those approved as part:of a -sample group but not checked by a-HERSiater, and if-,those`iristallation's fai[to meet'tkp" =
requirements of such quality assurance checking, the required corrective action and addition al,checking/testing-of other installations in that HERS
sample group will be performed at my expense.'
5. 1 reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the scope of
construction or installation identified on this Certificate of Installation, and I have ensured that the requirements that apply to the construction or
installation have been met.
6. 1 will ensure that a registered copy of this Certificate of Installation shall be posted, or made available with the building permit(s) issued for the
p building, and made available to the enforcement agency for all applicable inspections. I understand that a registered copy of this Certificate of
Installation is required to be included with the documentation the builder provides to the building owner at occupancy.
Responsible Builder/Installer Name:
Responsible Builder/Installer Signature:
Aravind Nagarajan
Company Name: (Installing Subcontractor or General Contractor or
Position With Company (Title):
Builder/owner)
Homeowner
Home Owner - Installer
Address: 1°
CSLB License:
7562 Kirwin Ln
I N/A - Homeowner
City/State/Zip:
Phone:
Date Signed:
Cupertino CA 95014
408-828-5742
2017-01-06 20:07:25
Third Party Quality Control Program (TPQCP) Status:
Name of TPQCP (if applicable):
1'
,I
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: 217-A0025125A-M2000002A-0000 Registration Date/Time: 2017-01-06 20:07:25 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards Report Version: 2013 Rev 1.008 Report Generated: 2017-01-06 20:05:15
2013 Residential Compliance Schema Version: 2013.1.007