12070188CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1539 POPPY WAY
CON'IRACI'OR: SANDIUM
PERMIT NO: 12070188
OWNER'SNAME: DESAIRANJITANDPRIYA
4223 VERDIGRIS CIR
DATE ISSUED:07242012
OWNER'S PIIONE: 4086887464
SAN.IOSE. CA 95134
PUONE NO: (408) 894-9072
❑ LICENSED CON"FRACMIA'SpD ECLARATION
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BUILDING PERMIT INFO: BLDG ELECT
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License Class - .`�D- Lie. q'
MECIi I— RESIDENTIAL I— COMMERCIAL
Contractor
herehv affirm that l nunlicensed under the provisions of Chapter
JOB DESCRIPTION: REMOVE AND REPLACE FURNACE AND INSTALL AIR
(commencing with Section 7000) of Division 3 of the Business S Professions
CONDI'T'IONING
Code and that my license is in full force and effect.
hereby affirm under penalty' of perjury one of the following two declarations:
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 far which this permit is issued.
Sq. FI Floor Area:
Valuation: $13000
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of die work for which this
permit is issued.
,U'N Number: 36615030.00
Occupancy'I)Pe:
A1'I'LIGA\ I' CER"1'IPICA'1'IC)N
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 and state laws relating
to building construction, and hereby authorize representatives of this city to enter
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify -,aid keep harmless the City ol'Cupertino against liabilities,judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
180 DAYS FROM LAST CALLED INSPECTION.
granting of this pennnit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
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Issued by: A-14 Date: %•a
/
r��/y
Date 1/11
Signature
❑ OAVNER-BUILDFR' DECLARATION
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
hereby a1Tnn that 1 am exempt front the Contractor's License Law for one of
installed without first obtaining mm inspection, I agree to remove all new materials for
the following two reasons:
inspection.
1, as owner of the proper, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sce.7044,
Signature of Applicant: Date:
Business R Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
".\"
construct the project (Sec.7044, Business R Professions Code).
ALL ROOF COVERINGS'I'O BE CLASS OR BF; T'I'ER
IIA%ARDOUS MATERIALS DISCLOSURE
hereby affirm under penally of perjury one of the. following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health S Safety Code, Sections 25505, 25533, and 25534. I mill maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code, Chapter 9.12 and the I Iealth S
I have and will maintain Worker's Compensation Insurance, as provided for by
Safety Code, Section 25532(x) should I store or handle hazardous material.
Section 3700 of the Labor Code, for the perfomnance of the work I'or which this
Additionally, should 1 use equipment or devices which emit hazardous air
tby ty ent District I
permit is issued.
maintainmcomants pliance ened
w'iith the Cutmertinou MunAir icipaal Code Chapter 9.12 and the P I n n '
I cenily that in the performance of the work for which this permit is issued, I shall
Health S Safetv Code. Sections 25505. 25533, and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Cali forma. If. after making this cenilicate of exemption,)
Ovine r ulhorizeduy -7vy /I,L
I
become subject to the Worker's Compensation provisions of the Labor Code, I must
/0• C..b ` � Date 1/
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
,U'I'I.ICAN'I' CF.R"I'IFICA'I'ION
I hereby affirm that there is a construction lending agency for the perfomnance of work's
I cenifv [hit I have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree to complywith all city and county ordinances and stale laws relating:
Leader's Name
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accmc against said City in consequence of the
DECLARATION
granting of this permit. Additionally, the applicant understands and will comply
.\RCIII"1'ECI"S
with all non -point source regulations per the Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
Simplified Prescriptive Certificate of Compliance: 2008 Residential HVACAlterations CF -IR -ALT -HVAC
Climate Zones 1 aad 3 - 7
Site Address:
w
Enforcement Agency:
Dare:
� Iti
Prrnut 9:o
Conditioned
Duct insulation
E mcut Type'
List Minimum EBicicr'
Floor Arca
requirement
Thermostat
Pukaged Unit
amerce
ErAFUO
e COP_
Sm d by system
Over 40 ft of ducts
added or replaced in
etbxk
Indoor Coil
�Sf:ER
�2
HSPF_
unconditioned space
(1%nar alrmdvprrrmr, man be
ondensing Unit
❑ EER
❑ Resistance—sf
[3R 6 (CZ 1. 3-5)
iruratfedJ
Other
1. Equipment Type: Choose the equipment being installed; if more than one system, use another CF -IR -ALT -HVAC for each sysrem.
2. Minimum Equipment Efficiencies: 13 SEER 78% AFUE, 7.7HSPF for typical residential systems.
Contractor (Documentation Author's /Responsible Designer's Declaration Statement)
• I certify that this Certificate of Compliance documentation is accurate and complete.
• I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the design idendfied on this
Certificate of Compliance.
• 1 certify that the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the
requirements of Tide 24, Parts I and 6 of the California Code of Regulations.
• The design features identified on this Certificate of Compliance are consistent with the information documented on other applicable
compliance forms, worksheets, calculations, plans and specifications submitted to the rnCorcemrnt agency For approval with the permit
application.
Name: W� A&Lt Signature:
Company: Date: Z
Address: Lice
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+ZZS et/,.c,,Y'7 CA 2- O
City/Statelzip: S Phone:
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2008 Residential Compliance Forms.doc revised 04/10/12
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 7T7-3228 • FAX (408) 777-3333 • buildinc cuoertino-oro
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FRO= ADDRESS I.5 APNp
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OWNER NAME
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❑ OWNER ❑ 0WI-BUILDER 11OwNRAGENT 13 C`, T CMR ❑CON, CTDRA= ❑ ARmUTME� ❑ ENGENIDI ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME a�W ��LICENSE NUMBEij` 1LI LICENSENPE
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I BUS. LICA
CONGUNY NAME E-MAIL
FAX
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STREET ADDRESS 422,3 fvl Vl� �� I CTCY. SiA1E. Z� \ CR (5134
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I PHONE
ARC{ITEMENGLNER NAME LICENSE NUMBER
BUS. LIC
COMPANY NAME ' E-MAIL
FAX
STREET ADDRESS Or Y, STATE. ZIP
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USE OF ❑ SED m DUPI.FX ❑ MULTI -FAMILY PROJECT EN WILDCAND ❑ YES PROJECT' IN ❑ YES
BUIIDDJG. ❑cnM CIAL UJUTANENTERFACEAREA ❑ NO I FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ YES
mcl[LR HO.r4: ❑ NO
DESCRIPTION OF WORX
TOTAL VALUATION: 1P 13g�� I RECEIVED BY:
By my signature below. I certify m each of the following: I tun the propery owner or aurhoriud agent to act on dte props y awnerer'ss behalf. I have read VSs
application and the information I have provided is CO=CL I have read the Description of Work and verify it is accurate. I agree m comply with all applicable local
otdinancu and sate laws rtlatirg to buildi c ns=cdon. n- on= reprts uadves of Cuperaro to -rater the above -id en ifietd�pro e...y far inspecdoIt ptuposes.
Signature ofApplicanHAgenC �A�j Data: % IZ 7 �EZ
SUPPLEMENTAL INFORNEATION REQUIRED
OFFICE USE ONLY
OVER-THE-COUNTER _
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1
❑ LU'RESS
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U
❑ STANDARD
Z
❑ LARCE
❑ NIAJOR
X EP.MucApp_2011.doc revised 06/21/11