12080249 CITY OF CUPERTINO BUILDING PERMIT
I UILDING ADDRESS: 20267 NOR'I'IiBROOK SQ CONTRACTOR:ATLAS-TRILLO IIVAC PERMITNO: 12080249
(DIAWER'S NAME: MI.CIRCLEI'I OPERTILS LLC 1965 KYLE PARK Cl' DA'Z'E ISSUED:08(23ROI2
O\VNI,R'S PDONIi: 4084580182 SAN JOSE.CA 95125 PHONE NO:(408)2868931
❑ LICENSED CON111ACI.OR'S DECLARATION IIUILDiNC PERMIT INFO: BLDC r ELECT r PLUNIB r,
'License Class Lie.N to Ql 93-1r r r
2 AIECII RESIDENTIAL COMMERCIAL
Contractor Date_
lie,chy affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE FURNACE IN SAME LOCATION
(co inienring with Section 701111)of Division 3 of the Business S Professions
Cudc:md that me license is in full force and effect.
hereby affirm under penalty of perjury one of the following oso 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 for which this permit is issued. Sq.FI Floor-Area: Valuation:$3000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perfam once of lac work for which this
permit is issued. AI.N Number:31639038.00 Occupancyl)PC:
APPLICANT CERTIFICATION
I certify that I have read this application mid state that the above information is
correct. lagree to comply with all city and county ordinances and state lairs relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property far inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 18O DAYS ROM LAST CALLED INSPECTION.
costs,and cxpenscs which tiny accrue against said City in consequence of Oat
granting of this permit. Additionally,the applicant understands mid will comply i
with all non- m u¢e 1•atioas per the Cupenino Municipal Cade,Section IssuEd V: � . L Date:
9.18. a CEJ
Signature _ Dam23ji�
RE-ROOFS:
❑ OWNISR-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material berg installed.If a roof is
installed withou first obtaining an inspection,I agree to remove all new materials for
hereby affirm Ilial I um exempt from the Contractor's License Llm for one of inspection.
the following two reasons:
I,as owner of the.property,or my employees with wages:6 their sole compensation. Signature of ApplicmC Date:
will do the work,mid the structure is not intended or offered for sale(Sec.7044,
Business h Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BUFFER
construct the project(Sec.7044,Business S Professions Code).
1 hereby affirm under penalty of perjury one of the following three I IA''/.ARDOl IS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health S Safely Code.Sections 25505,25533.and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupenino Municipal Code.Chapter 9.12 and the Ilealth J
performance of the work for which this permit is issued. Safety Code.Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices ohich emit hazardous air
Section 3700 of the Labor Code,for the perfamance of the work for which this contaminants its defined by the Req Area Air Quality Management District I will
permit is issued. maintain compliance ofth the Cupertino Municipal Code.Chapter 9.12 and the
llcal� `Safrq'Code,Sections 25505.25533,and 25534.
I certily that in the performance of die work for which Ibis permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's O cr or:i t ized agent: Q � (/�
Compensation hnvs of Culil'omia. If aRcr ranking this cenificate of cxenrption,I Date:
Yl
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked CONSfRI1C110N LENDING AGENCY
I hereby affirm that there is a conswction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state than the above information is Lender's Name
correct. I agree to comply with all city and county ordinances mad state laws relating
to building conswction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupenino against liabilities,judgments, ARCHITECT'S I'ITCf'S DECLARATIONcosts,and expenses which may.accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Sectiar
9.18. Licensed Professional
Signature Date
GENERAL PERMIT APPLICATION
` COMMUNITY DEVELOPMENT DEAR I MEN T- BUILDING DIVISION MEP
770300 TORRE AVENUE •CUPERTiNO, CA 95014-3255 m m i c
CUPERTINO (408)7777-3228 • FAX(408)7777-3333• buildincnc.Guoerino.ora m
❑KIIISUNG ❑G•l=CP_AlFiCAL ❑Er GC iZC?t
?ROTI ADDRESS `� I .4'V:
DwNPA NAhC ( V I avONG� � �u�
STRFTADDR:SS I GTY, STAT:,
FAX
7) qQ j
ODN7ACi NN%C I PHONE
ST?=ADDUSS I CITY.TATE, = FAX
❑ OWNER ❑ OwNER-BUIlDc'ti ❑ OWNEt AC.'NT CONTIACTOR ❑CON ACTORAO=NT ❑ AACv,t ❑T_VGBJ'c ❑ DEl^_.Opm ❑ Tye
C9,•iTaAC i OR A. I llC�JEc VLTf3cZ. gr TI LICE•ISE Et I 311 S._CI
COMPANY NAhC I EN.A.R .
I FAX
SiRL�ADDRESS
V5 /„ I y.STATS ZIP o
�G2PAONE
( Z �l ma , s,
A.TC:-I-�i�+GA't>NAG I L'CENSc NLMSER I BUS.L'C A
COMPANY NAbC I =N 1E.
FAX
STREET ADDRESS I C,1,STA i-- LT
PHONE
L'Sc OF SFD.DUPt--t ❑ Ml --FAMILY I FR=TN WyOL ❑ YS I FROlECTR1 ❑ YS I IS=BLDG AN ❑ y�
9tJILODtG: ❑j COMI✓J:itCIAL LRBAN NTcRFACE NLA C) NO FLOOD ZONE ❑NO MC-=nOM7 ❑NO
DESCRDMON OF WORK
TOTAL VALUATION: O I RECEIVED BY:
3y my signas-e below,i Tty to each of:he following; I am;he pmpe,y owner or zu:horized agent to ac:on thc;mp ., er's behalf. I have read;his
application and the iasorma,pm I have=Vdcd is comccL I have read the Desripdon o:Work and ve:iIy it is acr='te. I e to comply widI all applicable local
ordinanccs and save laws misting to buil .sTcc - I apdaor'ze;ep;eseaaves of Cenerrnc ^:er the zba iEcd5e3pmpe-•:cr inspection ou cses.
Sigaaa�e o`AmEcxnt/Agenn Date:
SUPPLEMENTAL IIvtOR.HAT?ON . QUIRED OFF F USE ONLY
y -THE-COUNTER
❑ EXPRESS
V
❑ STANDARD
U
a ❑ LARGE
❑ NL OR
MEPI�fLrc�pp_20J 1.dot revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20267 NORTHBROOK SO DATE: 08/23/2012 REVIEWED BY: SYLVIA
1-214 APN: BPP: 'VALUATION: 1$3,000
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRInLUiI SFD or Duplex ENTAIIIATION
USE: PPERMIT TYPE: FURN/AC
WoRK REPLACE FURNACE IN SAME LOCATION ,
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $133
TOTALS: $133.00
61ech. PlanEmIch
0.0 hrs $0.00 Plumb.Plan Check Due. Plan Cherk
Permit Fee: IMPER,WT Plamh. Permit Gee. Elec.Permit Fee:
Other Mech. I nsp. 0.0 hrS $45.00 Other Plumb lnap• Other F.lec. lay.
klech.hnP. Ere: Plmub. hhsp. Fee: Mee.hrcp.Fee:
NOTE: This estihnate does not include feet due to other Departments(i.e. Planning, Public Works, Fire.Sanitary Server District,School
District, etc.). These feev are hover/on the preflininarl information available and are onh'an eviinnne. Contact the Dept for at/dn'I info.
FEE ITEMS (Fee Resolution /1-053 Elf 7/1//1) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
SttppL PC F'ee
PME Plan Check: $0.00
Pe"nil Fee:
Supp/, htcp Fee
PML' Unit Fee: $133.00
PME Permit Fee: $45.00
Consnttction Ta.r:
Administrative Fee: (ADMIN $42.00
Work Without Permit? O Yes 0 No $0.00
Advanced Planning Fees•:
Travel Documentation Fee: ITRA FDOC $45.00
i
Strong Motion Fee: IBSEISA/1CR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $266.50 $0.00 TOTAL FEE: 1 $266.50
Revised: 07/01/2012
Simplified Prescriptive Certificate of Compliance: 2008 Residential HVA C Alterations CF-I R-ALT-KVAC
Climate Zoo"1 and 3-7
SiteA rens: Enforcement Agency: Date: Permit N:
Conditioned Duct insulation
E i mrnt T r List Minimum EfficicacyiFloor Area requirement Thermostat
Packaged Unit Over 40 ft of ducts
®Furnace EEE B COP — Served by system added or replaced in Setback
1®'I Loddon Coil SEER 2 HSPF i1 alle lrradypresenq mart 6r
Condensing Unit EER J ❑Resistanm sf unconditioned space i�alfrdJ
❑
other
❑R 6 (CZ f,3-5)
1. Equipment Type:Choose th6 equipment being installed;if more than onc,systcm,use another CF-I R-ALT-HVAC for each system.
2.Minimum Equipment Efficiencies: 13 SEER,78%AFUE,7.7HSPF for typical residential systems.
Contractor(Documentation Author's/Responsible Designer's Declaration Statement)
• 1 certify that this Certificate of Compliance documentation is accurate and complete.
• 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the design identified 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 Title 24,Pans 1 end 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 enforcement agency for approval with the permit
application. '
Name: u ' / Signature-
Company: C(S aIl� A\/AC ate: 3 U
Address: I tet, I nl n� - License:
City/State/Zip: IK l^ ` 2 Phone: �GYR_DSIT
2008 Residential Compliance Forms.doc revised 04//0112