B-2017-0638iI
CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS:
10619 FARALLONE DR CUPERTINO, CA 95014-4407 (369 39 03 8)
CONTRACTOR:
A R S AMERICAN
PERMIT NO: B-2017-0638 j
f
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS, TN 38120
OWNER'S NAME: MITCHELL RUBY B
DATE ISSUED: 04/24/2017
OWNER'S PHONE: 408-996-1425
PHONE NO: (916) 646-2222
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-20 Lic. #_7 59E4
Contractor A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIAIN
XBLDG —ELECT —PLUMB
X MECH X RESIDENTIAL — COMMERCIAL
Date 08/31/2018
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing -
with Section 7000) of Division 3 of the Business & Professions Code and that my
JOB DESCRIPTION:
license is in full force and effect.
REPLACE FURNACE (SAME LOCATION ATTIC ilk
I hereby affirm under penalty of perjury one of the following two declarations:
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.
J 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: $6470.00
APPLICANT CERTIFICATION
APN Number:
Occupancy Type:
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
369 39 038
and state laws relating to building construction, and hereby authorize
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We) agree to save indemnify and keep harmless the
PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities, judgments, costs, and expenses which
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
180 DAYS FROM LAST CALLED INSPECTION. '}
source regulations per the Cupertino Municipal Code, Section 9.18.
`
Issued by: Kim Dunbar
Signat Date 04/24/2017
Date: 04/24/2017
OWNER -BUILDER DECLARATION
RF ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
Signature of Applicant:
z. I, as owner of the property, am exclusively contracting with licensed
Date: 04/24/2017
contractors to construct the project (Sec.7044, Business & Professions Code).
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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. I will '!
Section 3700 of the Labor Code, for the performance of the work for which this
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the'
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous ';
3. I certify that in the performance of the work for which this permit 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 Quality Management District I'
i
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 ands
Worker's Compensation laws of California. If, after making this certificate of
the Health & SafetyCo , and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
�25505,
Owner or authorized agent'
be deemed revoked.
Date: 04/24/2017 U
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
CUPERTINO
G5E PRAL PERMIT APPLICATIONMm E
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE.AVENUE • CUPERTINO, CA 95014-3255 Amt.,
(408) 777-3228 • FAX (408) 777-3333 • buildina(a.cupertino.ong
m IsGi
l -v( 3 9
U numBiNG / �MECHAI\TICAL ❑ELECTRICAL / [:1 MISCELLANEOUS
PROJECT ADDRESS / / �j �� , 77—
APN # �/ „ �j 3 9 — 0 3 Y
OWNERNAME
STREET ADDRESS j
CONTACT NAME
STREET ADDRESS
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT
CONTRACTOR NAME
COMPANY NAME
STREET ADDRESS
E-MAIL
FAX
L.1vd � d
PRONE I E-MAIL
CITY, STATE, ZIP FAX
CONTRACTOR of CONTRACTOR AGENT ❑. ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑TENANT � }
LICE ) LIC g7Ef BUS Z/LQ ,1 `� y%`�
4- r
1:8501/
FAX
i
ARCHITECT/ENGDNTTEERN.AME i/
LICENSENUI\MER
BUS. Li
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF - '. V SFD orDUPLEX
BUILDING: ❑ COMMERCIAL
L.1 MULTI-F.AMH;Y
PROJECT IN WII.DLAND
URBAN INTERFACE AREA
L YES
❑ NO
PROJECT IN LI YES
FLOOD ZONE ❑ NO
IS THE BLDG A.N Li YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
MEPA1iscApp_2011.doc revised 06121111
CERTIFICATE OF COMPLIANCE CF1R-ALT-02-E
Alterations to Space Conditioning Systems (formerly CF -IR -ALT HVAC) (Page i of 3)
Project Name: Ruby Mitchell Date Prepared: 2017-04-19
A. General Information
CFIR-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
Ruby Mitchell
02
Date Prepared
2017-04-19
03
Project Location
10619 Farallone Dr,
04
Building Type
Single family
05
CA City
Cupertino
06
Dwelling Unit Name
Ruby Mitchell
07
Zip Code
95014
08
Dwelling Unit Conditioned
1500
Installing
Installing
Installing
Floor Area (ft2)
Location or Area
09
Climate Zone
4
system
Number of Space
entirely new
entirely new
Name
10
Conditioning (SC) Systems in
1
component?
components?
feet of ducts?
duct system?
this Dwelling Unit:
Alteration Type
B. Space Conditioning (SC) System Information
01
02
03
04
05
06
07
08
09
10
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
ducted
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
System 1
Location 1
1500
YesNo
Yes
No
No
No
Altered space
conditioning system
C. Extension of Existing Duct System, Greater Than 40 Feet (Section150.2(b)1Diib)
This section does not apply to this project.
Registration Number: 217-A020128080A-000-000-0000000-0000 Registration Date/Time: 2017-04-19 14:06:38
CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version: 2016.1.005
Schema Version: rev 10/16
HERS Provider: CaICERTS
Report Generated: 2017-04-19 14:06:54
CERTIFICATE OF COMPLIANCE CF1R-ALT 02-E
Alterations to Space Conditioning Systems (formerly CF -IR -ALT -HVAC) (Page 2 of 3)
D. Altered Space Conditioning System (Sections 1S0.2(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
Central gas
All new
No cooling
This field or
This field or
This field or
This field or
System 1
furnace
heating
AFUE
81
No cooling
component
section is not
section is not
Setback
section is not
section is not
components
altered
applicable
applicable
applicable
applicable
Reauired Documentation:
CF2R-MCH-01-E -Space Conditioning Systems
- Duct insulation requirement for the new portions of supply -air and return -air ducts or plenums: R6 (CZ 1-10, 12 and 13) and R8 (CZ 11 and 14-16)
CF211 and CF3R-MCH-20-H - Duct Leakage Test 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% or <=10% leakage to outside, or seal all accessible leaks.
CF211 and CF3R-MCH-25-H Refrigerant Charge verification required when refrigerant containing components are installed or altered (applicable in CZ 2, 8-15).
CF211 and CF3R-MCH-23 Airflow Rate >= 300 CFM per ton required when MCH -25 is required.
Exceptions:
Duct systems registered with HERS provider as previously sealed are exempt from MCH -20 Duct Leakage Testing requirements.
Heating -only systems and Air Handler Furnace changes do not require verification of Air Flow MCH -23, or Refrigerant Charge MCH -25.
Existing duct systems constructed, insulated or sealed with asbestos are exempt from MCH -20 Duct Leakage Testing requirements.
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)IC)
This section does not apply to this project.
Registration Number: 217-A020128080A-000-000-0000000-0000 Registration Date/Time: 2017-04-19 14:06:38 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version: 2016.1.005 Report Generated: 2017-04-19 14:06:54
Schema Version: rev 10/16
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:
Taitano-Scott, Jane
Documentation Author Signature: 09af�%2!�—t9T
9am
Company:
Signature Date:
A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC
2017-04-19 14:06:38
Address:
LEA/ HERS Certification Identification (if applicable):
965 RIDGE LAKE BLVD STE 201
742039
City/State/Zip:
Phone:
MEMPHIS TN 38120
408-286-8931 X123
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 building 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.
4. 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.
5. 1 will ensure that a registered copy of this Certificate of Compliance shall be made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable
inspections. l 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.
Responsible Designer Name:
Responsible Designer Signature: i?�,,c_,iLf9w—�C:fS&Taitano-Scott,
Jane
dan&L/ Gt,GG
Company;
Date Signed:
A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INC
2017-04-19 14:06:38
Address:
License:
965 RIDGE LAKE BLVD STE 201
742039
City/State/Zip:
Phone:
MEMPHIS TN 38120
408-286-8931 X123
2
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-A020128080A-000-000-0000000-0000 Registration Date/Time: 2017-04-19 14:06:38 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version: 2016. 1.005 Report Generated: 2017-04-19 14:06:54
Schema Version: rev 10/16