B-2017-1185CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1185
10555 DEODARA DR CUPERTINO, CA 95014-2430 (316 30 043)
ATKINSON
CLIMATROLLERS INC
SAN JOSE, CA 95112
OWNER'S NAME: ULLMAN RICHARD AAND ANNA L TRUSTEE
DATE ISSUED: 07/21/2017
OWNER'S PHONE: 408-828-6967
PHONE NO: (408) 294-6290
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO'
License Class C-20 Lic. #258540
Contractor ATKINSON CLIMATROLLERS INC Date 12/31/2018
X BLDG _ELECT —PLUMB
X MECH X RESIDENTIAL COMMERCIAL
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
license is in full force and effect.
JOB DESCRIPTION
REPLACE FURNACE (SAME LOCATION; (1) AC UNIT
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
Ferformance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
V2.V�Section
3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $12747.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
3
316
1630 043
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
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 LAST CALLED INSPECTION.
ure C� f(e�' Date 7/21/2017
Issued by Abby Ayende
Signa
RATION
Date: 07/21/2017
OWNER-BUILDFRDEC
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RF ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
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)
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: 7/2_1/2.017_
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.
2. 1 have and will maintain Worker's Compensation Insurance, as provided for by
HAZARDOUS MATERIALS DISCLOSURE
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
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
a. 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
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
C
be deemed revoked.
7/
Owner or authorized agent: _
APPTICAN3 CERTIFICATION
Date: 7121/2017
I certify that I have read this application and state that the above information is
CONSTRUCTION is a onsON LENDING AGENCY
I hereby affirm that there is construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
i
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
Signature Date 7/21/2017
Professional
® � -jj
GENERAL PERMIT APPLICATION
EP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408),777-3228 , FAX (408) 777-3333 • buildingCbeptinoorgCUPEKTINCMISIC
PLUMBING Fj M CHANICAL FJELECTRICAL Lj MISCELLANEOUS
PROJECT ADDRESS _ ^ _ NFA V(—
APN #
OWNER NAME U 0, � 1 ✓r 1�� tom: PHONE v o � _� t) �6.f
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STREET ADDRESS �/ `/�'�4 `'JdN DU .CITY, S'L' IP a 4 �"� iSA �j FAX
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CONTACT NAMED
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STREET AD� RESS � J CI STAT --v\JI
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❑ OWNER ❑ OWNER -BUILDER ❑OWNER AGENT CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME, LICENSE NUMBER LICENSE TY BUS. LIC #
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COMPANY NAME 6 Y E-MAILdj FAX � lLv V I �r h i444"
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STREET ADDRESS -7 1 / I /_ CITY, S QIP 1 , } v PHO �y
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ARCHITECT/BNGINEERNAME `-�((t, LICENSEN�UMBER 1 r BUS. LIC# ?�
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
USE OF SFD or DUPLEX ❑ MULTI-FAMILY7ROECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES
BUILDING: ❑ COMMERCJIjAL AN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK j/ J+� a q
TOTAL VALUATION: .r -h Z .`_
`TT 444 ,....
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By my signature below, I certi to each of the following: I am the property owner or authorized agent to act on the property 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 tq kullding construction.
�I'a�uttho i representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: y ' te r Date: -7/ z- 1 [
SUPPLEMENTAL INFORMATION REQUIRED
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MEPMiscApp_2011.doc revised 06121/11
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 1 of 3)
Project Name: 2017-0036' a d,Ullman ` Enforcement Agency: City of Permit Number: B-2017-11
Cupertino
Dwelling Address: 10555 Deodara City: Cupertino Zip Code: 95014
A.System Information
01 Space Conditioning System Identification or Name Replace Furnace and Air Conditioner
02 Space Conditioning System Location or Area Served Whole House
03 Building Type from CF-1R Single family
04 Verified Low Leakage Ducts in Conditioned Space(VLLDCS) No,credit is not taken
Credit from CF1R?
05 Verified Low Leakage Al4:Handling Unit Credit from CF1R? No,credit is not taken
06 Duct System_Compliance Category Alteration
,w z
MCH-20d-Complete Replacement or Altered DuctS stem 'z t F x, ,r i'
ti Ale
t . y,.3, L., 1 t i s n;'ra,.. § r fi ; ,e'ur.
... 4 ,fi '1 ST
r
fy a Y f t ;. ` `t % g.
Test. `
B. Duct Leakage Diagnostic Te
N.•.,�.: 4w, 'tom.._ 2.
01 Condenser Nominal Cooling Capacity(ton) 4
02 Heating Capacity(kBtu/h) 85
03 Conditioned Floor Area served by this HVAC system(ft2) 2200
04 Duct Leakage Test Conditions Test final
05 Duct Leakage Test Method Total leakage
06 Leakage Factor 0.15
07 :Air Handling Unit Airflow(AHUAirflow)Determination Cooling system method
Method
08 Measured AHUAirflow This field or section is not applicable
09 Calculated Target Allowable Duct Leakage Rate(cfm) 240
10 Actual Duct Leakage Rate from Leakage Test 201
Measurement(cfm)
11 Compliance Statement: System passes leakage test
12 Notes:
Registration Number: Registration Date/Time: 2017-08-10 12:36:17 HERS Provider:CaICERTS
217-A02023 6584A-000-001-M 20001A-M 20A
CA Building Energy Efficiency Standards Report Version:2016.1.006 Report Generated:2017-08-10 12:35:26
2016 Residential Compliance Schema Version:rev 03/16
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 2 of 3)
C.Additional Requirements for Compliance
01 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 usedforCentral 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 If a complete replacement,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;connectiion points between the air handler and the supply and return plenums are completely sealed.
If the system complies using the Smoke Test method,the smoke test was conducted in accordance with the requirements
07 of Reference;Residential Appendix RA3.1.4.3.6.Systems that comply using smoke test shall not be included in sample
groups for;HERS;uerification'compliance.
08 Verification Status; k� r. M f� Pass Nall applicabletrequirements are met:
14 1. r
09 Correction Notes * s P;J
..h i i sC sj it "144 . C' �.a
The responsible persons signature on this compliance document affirms that all applicable requirements inthis table,have
been met unless otherwise noted in the Verification Status and the.Corrections Notes in:this table.
D.Determination of HERS Verification Compliance
All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order
for this Certificate of Verification as a whole to be determined to be in compliance.
01 Complies:All specified verification protocol requirements on this document are met.
Registration Number: Registration Date/Time: 2017-08-10 12:36:17 HERS Provider:CaICERTS
217-A02023 6584A-000-001-M 20001A-M 20A
CA Building Energy Efficiency Standards Report Version:2016.1.006 Report Generated:2017-08-10 12:35:26
2016 Residential Compliance Schema Version:rev 03/16
S� ~
�., CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 3 of 3)
Documentation Author's Declaration Statement
1.I certify that this Certificate of Verification documentation is accurate and complete.
Documentation Author Name: Documentation Author Signature: � R/E><a
Gabe Wesley
Company: Date Signed:
Elements E3
2017-08-10 12:36:17
' Address: CEA/HERS Certification Identification(if applicable):
1718 Creek Drive
City/State/Zip: Phone:
San Jose CA 95125 408-634-6690
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 Verification is true and correct.
2. I am the certified HERS;Rater,who performed the verification identified and reported on this Certificate of Verification(responsible rater).
3. The installed features materials,components,manufactured devices,or system performance diagnostic results that require HERS verification
identified on this Certificate'of Verification comply with.the applicable requirements in Reference Appendices RA2,RA3,and the requirements
specified on the Certificate of Compliance forthe building approved by the enforcement agency.
4. The informat on reported on applicable sections'of the Certificates)of lnstallat'lon(CF2R)slgned•a td s ibmjt`ted by the persOn(s)responsible for the
construction or installation;conforrms to the equirementstspecified ofcthe Cer lficate(s):�f Cottipliance(CFIR)approved by the en{ofcementdgency.
5. I will ensure that a registered copy of this Certificate of Veriftcat on shall be postedyor made available with tCi°e"building perimt(s)`issued qr the
4 1 $ai` sz is f � ��` �'" + sy z d
building and madeavailabteto theenforceme t,ageencyz,forall applicable�nspectwn (tihderstand that ar cs erectcopy¢f thkertf icak
5 e; rn t 44 #�v3
Verification is re�q6uired to be'irjduded with the documentation the builder provides to tie building owner at occupancy.
J it i" I' k 4: 0 ^" 4s'," ar £ ,. Y.Y,4 .v-ez A 'I.uk"!s. X7°xr. R'Amft,,
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Builder Or Installer�lnformation As Shown On The"Certificate"Of Installation
Company Name(Installing Subcontractor,General Contractor,or Builder/Owner):
ATKINSON CLIMIATROLLERS INC dba VALLEY HEATING;COOLING&ELECTRICAL
Responsible Builder or Installer Name: ;I CSLB License:
Cindy Faulkner f 258540
HERS Provider Data;Registry Information
Sample Group Number(if'applicable)ii Dwelling Test Status in Sample Group(if applicable)
Tested
•
HERS Rater Information
HERS Rater Company Name: , .i
Elements-E3
Responsible Rater Name: , Responsible Rater Signature:
Gabe Wesley % edef f
Responsible Rater Certification Number w/this HERS Provider: Date Signed:
CC2016066 2017-08-10 12:36:17
•
Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document,and in no way implies
Registration Provider responsibility for the accuracy of the information.
Registration Number: • Registration Date/Time: 2017-08-10 12:36:17 HERS Provider:CaICERTS
217-A020236584A-000-001-M20001A-M 20A
CA Building Energy Efficiency Standards Report Version:2016.1.006 Report Generated:2017-08-10 12:35:26
2016 Residential Compliance Schema Version:rev 03/16
Abby Ayende
07/24/17
07/24/17
B-2017-1185
Abby Ayende