14050129 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1125 STAFFORD DR CONTRACTOR:PELLE HEATING&AC PERMIT NO: 14050129
INC
OWNER'S NAME: RINDGE MARK F AND BARBARA A 3751 D CHARTER PARK DR DATE ISSUED:05/21/2014
OWNER'S PHONE: 4083139358 SAN JOSE,CA 95136 PHONE NO:(408)978-7060
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
c ADD NEW A/C UNIT IN SIDE YARD AREA
License Clasps C `�a //Lic.# �O / g�
Contractor '1��� h�C3,/v,.t 7(,�(/Date t
I hereby affirm that I am licensed under the provision of apter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I 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
ompensation,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:$4888
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 APN Number:36206012.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITEIIN 180 SSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 L ALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the g
granting of this permit. Additionally,the applicant understands and will comply Date:
with all non-point source regulations per the Cupertino Municipal Code,Se
9 18.
RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: l' ____.-Date: a
I certify that in the performance of the work for which this permit is issued,I shall L S
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9 18.
Signature Date
ti
GENERAL PERMIT APPLICATION a� MEP*
• ., COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
..
10300 TORRE AVENUE•CUPERTINO; CA 95014-3255 � misc
cup04
(408)777-3228•FAX(408)777-3333•building(ftupertino.org
PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS APN# Z I Q
.OWNER NAMEi.
PHONE 11� E-MAIL
STREET ADDRESS CITY,'STATE,ZIP -FAX
SO ILI
CONTACT NAME''(� PONE E-MAIL
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S'T'REET ADDRESS D C Y,STATE, ZIP FAX
❑ OWNER OWNER-BUILDER ❑,OWNE tAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME , A C E MAB � .n FAX
141
STREETADDRES$, °l Is� C ST TE,ZIP �� PONETWirLu
ARCHITECT/ENGINEERLAAME LICENSE NUMBER BUS.LIC#
COMPANY�IAMEI E-MAIL FAX
STREET ADDRESS j i CITY,STATE,ZIP PHONE
USE OF 1 $Fljo[.DUPLEX 13.MULTI-FAMB.Y PROJECT IN WB,DLAND ❑ YES 7PR0001ECT IN ❑YES IS THE BLDG AN ❑YES
BUILDINCr , ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO D ZONE ❑NO EICHLER HOME? ❑NO
DE$CRIP'I•ION OF WORK ,,/y� �1 � _
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By my slgnat}iio below I:certlfy to each.of the following: I am the property owner or authorized agent to act on the property owner alf. I have read this
appllcatloti and; le Infomarion.L hiv rovided is correct. I read the Description of Work and verify it is accurate. I agree to comply with all applicable Iota}
ordinances and''state laws relating tD b ildin onstruction I aut r' presentatives of Cupertino to enter the above-identified p perty for inspection purposes.
Stgifiture of Ap1ltcan�Agent t Date:
NTAL,IVORMATION REQUIRED
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j MEPMiscApp_2011.doc revised 06/21/11
I i
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 1125 STAFFORD DR I ]DATE: 05/21/2014 REVIEWED BY: MELISSA
APN: 362 06 012 BP#: `VALUATION: $4,888
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: p PERMIT TYPE:
WORK ADD NEW A/C UNIT IN SIDE YARD AREA
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=1 OK cfm) 1BREMAIR 1 # $70
TOTALS: $70.00
°Reny „� ^a -
srI �"Ki '
Mech.Plan Check 0.0 hrs $0.00 f'laar!h. lllalt E:'hcc, Alec, 1""w C'laects
Mech.Permit Fee: IMPERMIT I'lumb. Permit Fee: Tate(,. Permir 1°�x
Lther Mech.Insp. 0.0 hrs $47.00 Other I'lumb Irrs�p. o?her`�-1�'c'� Irrsl%-
l lvt1 ca: Phvirb, hr sp, Fee: Illec.Insp Fe".
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These _f n 7 info
-fees are based on the relimina information available and are onlyan estimate. Contact the Det .
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/13) FEE QTY/FEE MISC ITEMS
I'lan(7hcc
stvppl. PC FCC`
PME Plan Check: $0.00
-,'bell F"
PME Unit Fee: $70.00
PME Permit Fee: -FT $47.00
Consr7'i.iction Tail
Administrative Fee: IADMIN $44.00
Work Without Permit? 0 Yes (j) No $0.00
,I As unc cd Plttrming Fees:
Travel Documentation Fee: ITRA VDOC $47.00
Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
L ` $209.50 $0.00 TO'I'AI,FEE: $209.50
Revised: 04/01/2014
INSTALLATION CERTIFICATE CF-6R-MECH-04
Space Couditionn -S stems,Ducts and Fans (Page 2 of 2
Site Address: I Enforcement ency: Permit Nup�h i Z
l� .L YJ �� i ✓vc3 tqo
Ducts and Fans
§150(m):Duct and Fans
❑ 1.All air-distribution system ducts and plenums installed,sealed and insulated to meet the requirements of CMC
Sections 601,602,603,604,605 and Standard 6-5;supply-air and return-air ducts and plenums are insulated to a
minimum installed level.of R=4.2-.or enclosed entirely in conditioned space. Openings shall be sealed with mastic,tape
or other duct-closure system that meets the4pplicable requirements of UL 181,UL 181A,or UL 181B or aerosol
sealant that meets the requirements of UL 723. If mastic or tape is used to seal openings greater than 1/4 inch,the
combination of mastic and either mesh or tape shall be used;and
❑ 1.Building cavities,support platforms for air handlers,and plenums defined or constructed with materials other
than sealed sheet metal,duct board or flexible duct shall not be used for conveying conditioned air. Building cavities
and support platforms may contaiii'ducts. Ducts installed in cavities and support platforms shall not be compressed to
cause reductions in the cross-sectional area of the ducts.
❑ 2D.Joints and seams of duct systems and their components shall not be sealed with cloth back rubber adhesive
duct tapes unless such tape is used in combination with mastic and draw bands.
❑ 7.Exhaust fan systems have back draft or automatic dampers.
❑ 8.Gravity ventilating systems serving conditioned space have either automatic or readily accessible,manually
operated dampers.
❑ 9.Protection of Insulation.Insulation shall be protected from damage,including that due to sunlight,moisture,
equipment maintenance,and wind.Cellular foam insulation shall be protected as above or painted with a coating that is
water retardant and provides shielding from solar radiation that can cause degradation of the material.
❑ 10.Flexible ducts cannot have porous inner cores.
DECLARATION STATEMENT
• I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and correct.
• I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction,or an authorized
representative of the person responsible for construction(responsible person).
• I certify that the installed features,in components,or manufactured devices identified on this certificate(the installation)
conforms to all applicable codes and regulations,and the installation is consistent with the plans and specifications approved by the
enforcement agency..
• I reviewed a copy of the Certificate of Compliance(CF-1R)form approved by the enforcement agency that identifies the specific
requirements for the installation:=L certifythat the requirements detailed on the CF-1R that apply to the installation have been met.
• I will ensure that a completed,signed.copy of this Installation,Certificate shall be posted;or made available with the building
permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand
that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to
the building owner at occupancy.
Comp Name: (Install'Z.,
Subcontractor or General Contractor or Builder/Owner)
e ,
sponsible Person's Name:' Res' Bible Person's Si afore
\C/1y
CSLB Licen Date.Signed. Position ith ompany(Title):
aI mg_, i
2008 Residential Compliance Forms August 2009
INSTALLATION CERTIFICATE CF-6R-MECH-04
Space Conditioning Systems,Ducts and Fans (Page I of 2
Site Address: Enforcement gency: Permit Number:
S _ can 1�_ YJ 7—
Space
Space Conditioning Systems
Heating Equipment
Duct
Efficiency Location
Equip (AFUE, (attic,
Type ARI #of etc.)", crawl- Heating Heating
(package- CEC Certified Mfr.Name Reference Identical (zCF-1R space, Duct Load Capacity
heat um and Model Number Number 2 Systems value 4 etc.) R-value (Btu/hr) (Btu/hr
Cooling Equipment
Efficiency Duct
Equip (SEER Location
Type and EER) (attic,
(package #of 1.3 crawl- Cooling Cooling
heat CEC Certified Mfr.Name ARI Reference Identical (>_CF-1R space, Duct Load Capacity
um and Model Number Numbers -Systems value)4 etc. R-value (Btu/hr) (Btu/hr
YN,,t a v\
A,G tFoo -�a
1.If project is new construction, see Footnotes to Standards Table 151-B and Table 151-C for duct ceiling alternative
compliance.
2.ARI Reference Number can be found by entering the equipment model number at http://wlviv.aridirectory.org/ari/ac.php#
3.Listed efficiency on this page must be greater than or equal(>:)to the value shotivn on the CF-IR form.
4. When CF-IR is reference it is also applicable to the CF-IR, CF-IR-AA or CF-IR-ALT
ALL BOXES MUST BE CHECKED TO BE A VALID FORM
110-§113:HVAC equipment is certified by the California Energy Commission.
br§150(h):Heating and/or cooling loads calculated in accordance with ASHRAE,SMACNA,or ACCA.
Q'§150(1): Setback Thermostat on all applicable heating and/or cooling systems meet the requirements of§112(c).
§1500)2:Pipe insulation for cooling system refrigerant suction,chilled water and brine lines meets minimum
requirements of Table 150-B and includes a vapor retardant or is enclosed entirely in conditioned space.
2008 Residential Compliance Forms August 2009
Mq �� C) cP,1 YPr2rD
OD9PWr
OMM NfTY EVEL PME T DE RTM NT
BUILDINODIVISON-1,UPERFINO
PP OVA D CPE TI O
This-Set f pla s and speci icatio s MU3T be kept the iaild p p pa ent
ic b site durin cons ructio ri. It i unlav rful to make any
chz ages r alteations on sE me,o to dE viate °
t erefr m,wi hout ppro%al fror i the E luildin 3 Offi !al.
Thm starr.ping c f this Ian ai d sp ificat ons S /ALL RE IEW p R DE OT COMPLIAN CE
b t vioiati n Revi awed BY:
° isOr in nc or S ate L W.
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BY
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DATE_,_ MAY 21 Z014
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