11020006 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22141 LINDY LN CONTRACTOR:SUPREME AIR SYSTEMS PERMIT NO: 11020006
OWNER'S NAME: ANDONIAN ROBERT W AND MARIA I 80 GILMAN AVE STE 1 DATE ISSUED:02/01/2011
OWNER'S PHONE: 4084469149 CAMPBELL,CA 95008 PHONE NO:(408)376-0406
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class
C'-'20_ Lic.# �...7 t 1 C)G�/-7 INSTALL(2)FURNACES IN SAME LOCATION IN ATTIC
AND
Contractor V p(`SIM<, Date Lt ON IST FLOOR.
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.
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
Compensation,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:$9000
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 wh this APN Number:35627017.00 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 WITHIN 180 DAYS OF PERMIT ISSUANCE 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 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,anxpenses whic ma accrue against said City in consequence of the C
grantin of is permit. A di ally,the applicant understands and will comply Issued by:
with all on oint sou e r g a ions per the Cupertino Municipal Code,Section
9.18. `
} I RE-ROOFS:
Signature Date 1 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(x)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 definedthe Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance th a Cup tin, unicipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S ti s 25 ,2 33,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this `
permit is issued. Owner or authorized agent: Dater
I certify that in the performance of the work for which this permit is issued,I shall
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,
-sts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
sting of this permit.Additionally,the applicant understands and will comply
..,,I all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
f
SUPREME AIR SYSTEMS
WWW_SIJPR E 1 tE.AIR_NET Ray@SUPREMEAIR.NET
80 Gilman Avenue, Suite 1 CCL#740667
Campbell, CA 95008
(408)376-0406 Fax 408-376-0506
Cell 866-346-6467
December 23,2010
Robert&Marybell Andonian
22141 Lindy Lane
Cupertino, CA
408-446-9149
Subject: Heating project(E2RS010511A)
Per your request and our conversation,I have provided the following scope of work.
The scope of work consists of.
1. Removal of existing equipment
2. Installation of an American Standard 2-stage 95%Efficient variable speed
downflow furnace. (80,000 BTU's/downstairs in garage location)
3. Installation of a complete new PVC flue venting system
4. Installation of(2)New title 24 digital programmable thermostats
5. Installation of a Coleman 80%Efficient single stage horizontal furnace
(80,000 BTU's/upstairs in attic location)
6. Installation of transitional flu pipe
7. Installation of condensate trap and vent material
8. Installation of transitional 24v control wire
9. Installation of transitional sheet-metal
10. Installation of transitional gas pipe
11. Installation•of earthquake gas flex connector
12. Installation of plenum insulation
13. Seal plenums to CPBCA standards
14. Permit&Fees
15. Haul away and disposal of old material and equipment
16. Customer orientation
Special conditions
1. Any changes that may be requested will be written on a change order and will be pre-approved by
Robert or Marybell Andonian(Home Owners)
2. Change orders are written at cost+30%and$85.00 per man hour
3. Due to the volatility in the price of material and equipment this quote is subject to change without notice
and can only be guaranteed for 30 days. The flue venting of the new furnace will side wall terminate
Building Department
City Of Cupertino
ELI] 10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT#
OWNER'S NAME:( p�p�;._ moi` �l 1 �C+-►f (J PHONE# � — 040 G
GENERAL CONTRACTOR: &(L M S BUSINESS LICENSE#
ADDRESS: YC LI-<< " ,u ()+ -e— CV) b- 1 CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINALUPAN 1 ECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND AL Sr
ORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. Z l^ I
1 am not using any subcontractors:
gnature Date
Please check applicable subcontractors and complete the following information:
j/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting /Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35627017 . 00
DATE ISSUED. . . . . . . : 02/01/2011
RECEIPT #. . . . . . . . . BS000012627
REFERENCE ID # • . . : 11020006
SITE ADDRESS . . . . . : 22141 LINDY LN
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : ANDONIAN ROBERT W AND MARIA I
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4836
RECEIVED FROM . . . . : SUPREME AIR SYSTEMS
CONTRACTOR . . . . . . . : ALLEN SENNERT LIC # 21614
COMPANY . . . . . . . . . . : SUPREME AIR SYSTEMS
ADDRESS . . . . . . . . . . : 80 GILMAN AVE STE 1
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) 376-0406
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 9, 000 . 00 1. 00 0 . 00 1 . 00 0. 00
1BSEISMICR VALUATION 9, 000 . 00 0. 90 0 . 00 0 . 90 0 . 00
1MFR=<100 UNITS 2 .00 252 . 00 0 . 00 252 . 00 0 . 00
1MPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 337. 90 0 .00 337 . 90 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 337 . 90 13651
---------------
TOTAL RECEIPT 337 . 90
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 22141 lindy ave. DATE: 02/01/2011 REVIEWED BY: bobs.
APN:3!5(p -XI O I i BP#: I V�rD( *VALUATION: 1$9,000
;';PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: I PERMIT TYPE:
WORK replace 2 furnaces at existing first floor and attic locations.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 2 # $252
TOTALS: $252.00
Mech.Plan Check 0.0 hrs $0.00 /'!;w P/(;", y.l
Fmech.Permit Fee: IMPERMIT >;z. ,rt��,. Lf'( 1" tr i[Vl"'
Other Mech.Insp. 0.0 hrsLL42.00
Li
NOTE: Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Eff 711,%10) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $252.00
PME Permit Fee: $42.00
0Ms0W('fi017 7'O
>ICOUSiiC01 1i('vicl'; FCC.'
Work Without Permit? 0 Yes E) No $0.00
Travel Documentation Fee: ITRA VDOC $42.00
Strona Motion Fee: IBSEISMICR $0.90 Select an Administrative Item
Bldg;Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $337.90 $0.00 TOTAL FEE: $337.90
Revised: 01/15/2011
AC RIP' DA
os/
CERTIzs/2a10
FICATE OF LIABILITY INSURANCE ` "°° '
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poltcy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME-
Doug Jones c/o AJG Risk Management Services, Inc. PHONE
8800 E.Chaparral Rd, Suite 230 ILEW- we Nu:
Scottsdale,AZ 85250 A ss:
INSURED INSU S AFFORDING COVERAGE MAIC A
INSURERA: American Zurich Insurance Corn n 40142
Better Business Systems, Inc.;Avitus,Inc.dba:Avitus Group Labor INSURER 8:
Contractor,for leased workers to:Supreme Air Systems
550 S.24th St.,W.,Ste.201 P.O.Box 81590 INSURER c
Billings,MT 59102 INSURER D.
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:1OMT1901754340 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. N07WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
IiLTR! TYPE OF INSURANCE POLICY NUMBER POLICY ADDL Y EXP LMN173
GENERAL LIABILITY
1 EACH OCCURRENCE ;
h'COMMERCIAL GENERAL LIABILITY { S
IEe ncc w�LAW-MADE �OCCUR � � � i MED EXP( one Person) s
PERSONAL 8 ADV INJURY S
GENERAL AGGREGATE $
I�GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-CCNNP OP AGG =
POLICY PRO' —�LOC
S
AUTOMOBILE LIABILITY j I COMBINED SINGLE LIMIT $
ANYAUTO ' ; (Ea accident)
i ALL OWNED AUTOS BODILY INJURY(Par person) s
— 1 I
_I SCHEDULED AUTOS j BODILY INJURY(Per acddent)I$
1 HIRED AUTOS PROPERTY DAMAGE
! i(Par accident) $
NON-OWNED AUTOS j S
� f
!s
UMSRELLA LAB OCCUR j
i EXCESS LIAB �C ( I j { EACH OCCURRENCE $
tAtMS_N1ApE7', f
J 1 iAGGREGATE $
DEDUCTIBLE
RETENTION $ I 3
WORKERS COMPENSATKIN ;S
j AND EMPLOYERS'LIABILITYY I N i I X WC STATU- DTH-I
ANY PROPRIETORIPARTNEPJEXECUTI'dE I i
A OFFICER/MEMBER EXCLUDED ❑1 NIA! f WC 38-8&743-05 i 04/01/2010 04/01/2011 E.L.EACH ACCIDENT S 1,000,000
(Mandatory in NH) iI
H es,describe under i i E.L.DISEASE-EA EMPLOYE $ 1,000,000
DESCRIPTION OF OPERATIONS below ! E.L.DISEASE-POLICY UMtT I S 1,000,000
i � 1
Location Coverage Period. 04/01/2010 04/01/2011 Client#:326
i
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N mare space is required)
m
Coverage is provided for ) Endorseents:Waiver a}SubropeGon
only those employees Supreme Air Systems Waiver issued in favor of Eastridge Shopping Center,LLC,Eastridge Shopping Inc.,GGP
leased to but root 80 Gilman#1 Ivanhoe IV,Inc..GFP Limited Partnership,General Groth Properties.Inc and its direct and
subcontractors of: Campbell, CA 95008 Indirect parents and subsidiaries,any of thir afilated entities,successors and assigns and nay
Current or future director.officer,employee,partner,member or agent of any of them.For leased
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Eastridge ACCORDANCE WITH THE POLICY PROVISIONS.
Re:Eastridge Management Office
2200 Eastridge Loop,Ste.2062 AUTHORIZED REPRESENTATIVE
San Jose,CA 95122
®+1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
-'7 - --?-)�2
CITY OF CUPERTINO a 7c- T3 v ��
FURNACE/AC D 6�
CUPEITINO PERMIT APPLICATION FORM
APN # Date: ` t
Building Address:
Owner's Name: Phone#: j iC�
�L 17 c%,-. /11. ✓�r l `�' I ;]rel(i �' "c 1� `-1(, �- c�`i(C'
Contractor: Phone#: g i� � -3-7 -U
Fax#:
Contractor License#: Cupertino Business License#:
D, � � �
Contact: Phone#: 3 7 to
N tIaeA Fax#: `t U�r �71�
Building Permit Info:
Elect C'- Plumb ❑ Mech [�J
Residential Commercial
Job Description:
For Rer
ent' 1 Installations:
Attic 1 sc floor [�'— 2"d floor ❑
Adhere to minimum setback re uirement ❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation
New installation Planning Approval Required ❑
Cost of Project: aU Type of Construction (Usage Class):
bob , L"/-(3
Strapped On Platform Bonded New Location Replacement
Project Size: Express Standard ❑ Large ❑ Major❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable,include in plan set& the sheet index.
Revised 01/07/09