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13050138 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10367 SAN FERNANDO AVE CONTRACTOR:SERVICE CHAMPIONS PERMIT NO:13050138 OWNER'S NAME: G,LAYDS CAMPIDONICA 7020 COMMERCE DR DATE ISSUED:05/20/2013 OWNER'S PHONE: 4082553564 PLEASANTON,CA 94588 PHONE NO:(925)4444444 I LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALS I?70q o - REMOVE AND REPLACE FURNACE IN SAME LOCATION License Class Contractor F C)tc.P, (�6t la t�an s Date ' _) 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:$5755 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:35712004.00 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 WITIIIlv I D YS 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 DAY LAST CALLED 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 Issued by: Date: granting of this permit. Additionally,the applicant understands and will comply �� 3 with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 0 1L 0- I ROOFS: r Signature � Date J All roofs shall be inspected prior to anyy 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 Date: Signature of Applicant: I.hereby affirm that Iam 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 notintended.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 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and performance of the work for which this permit is issued. the Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or authorized agent. Date:, -20- permit is issued. 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,I 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 GENERAL PERW APPL.ICATI N q M EP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION! /i I 10300 TORRE AVENUE-CUPERTINO,CA 95014.3255 CilPERTFNO (4 38)TTT=B-FAX(40)777-3333-bui-d"muQcuperdnc-= misc QPLL'IMING IAMEMAMCAL QELECMCAL QMLSCMLANEOUS PRCL0=ADM13S �b3t�'I S(Xn fern olgn d AM# 3S-7 Z OD "7110,4A CO CW 6V\L&0., P4009 tS5-3"--G 1.B44AM ,mm - R5o FAX CONTACT NAME - SMAM STREErADDRM CUT SCATF-W FAX Q OWNM ❑ owNMZEMMM Q oWNMAGWr Ok ommAcroa IZ cmir ACrmmaiT E3 ARCM= G a mmm Q nEymnpm ❑TENANT CONTRACTORNAMS LXMNWNU1fH 8 i*�' TYPE Bmucf COMPANY NAME ` E-MALE. FAX S �+�+FFr ADDMD mAyaL2, , Or - �STAT(, , ` B.uc# COMPANY NAM'•' E-MAM FAX S'TREErADDRESS iXw SCATf.m PSOIIM um cW �.s,a[=� 13 J&Mn-FAMMY Pi =1K W=AM Q Yr3 ret:m==i Q Y3 ]STL3X=" Q YTS VMM Ri7 WMXARFA 13 NO FLOOD [3 m MOMMLHOM0 Q No aFsc�rtaxr of woRx - �� TOTAL VALUAT Cn't* � tr �V RECEMM Y• By mp sigoatara below,I= fy to eaek of**Mowi V I=th WTedy owu�ori ag=m act ttwnds bel]aIf I have red t3sss angficatiaa and(Iseikon Z to-provided is coazct jhwc read the Desspdam of Work��i{p it is I qFW to Cpl-/with all applicable local mifmm=aa.dao laws reladaVzp2p�� ewer the y fur�on P Sigpat—ofApgc-dAg=L- Dam 5-ZO�t� M��AL INFORMATION REQ[JIIUD OFHCE USE ONLY d 0ri z�cow 'a D STANDARD j' -c LARGE I) L� asAaari 1. PtLFscffpn 2011.doc reuised 06/21/11 $133.58 $133.00 % _ $266.58 Revised: 04/29/2013 Prwm*Wve Cerdflca#e of Nwlcr.2M RedArmW HY.4CAftnWiow CF-lR-ALT-HVAC Mate zMw 18 to 13 Sited �'tSe 7 Pes Caofidaad Flock List Mini== Deft Area TbemurtA 0 Fmeaged Leis AFUE €I CX?P Gww 40 ft of dws added or L3 IOPF_, m space Served by� 0fam 0 CCd 138F� 13 R 6 (CX7f1-73} if proazir."IIS be acondwsingunit 13 EHL 13 R ORS (CZ I4I5J 13 Usher I-E Zryp c amaw the egrngmr:mbeft fintauffit If M_tGswesys�are ani t�II��LT-gY•4C�eErh s z rEj, aa.t r 13AML MAFW 7 MPFfir tpid r=daUa[slesl+M VERMCAJIM SUBMARY listed below am AwHVAC Uptoa L The instafflierdeeicks whatwa*is being daoc and picim sat of Hre appsagriaw Coo& Fsch Optkst NM do$ERS unassses dumas-be eanducto&A copy ofd=ft=shat[be left on sse ibr MW and a ccgy gives to drebumemvn= At fid dx iia vermes 9M the wa&1sled as Ibis form spas in fed Hie work cozopleted by Bre ilmder_The ias x=w abovcdf'res that each off owe€F4R and negidezed CFAR flims Cao haad Sgod CF-Ws 89awed)are Med an and [kosher 1,24IIL ae of&a CF-JR and CF_�sho alae be sim sne for Esal t 1.HVAC Re�shseat Firms • Alt HVAC laced CF-6R '*MW hMCH- NECH-21-HERS and(ft� )its 25-ITERS CFAR fix= hfECH—21 and WZH-25 CandmscrGoofs sad lar C2<-GR farrar bMN-21-1m aa1(fur spot )MECH-25-BEES • bdoor•C off and/or CFAR 6 MSCH-21 and(far RAit sysftm)NECK-25 .Fwnam For Dszd <15 pati RC,CCA 2:300 CF44(ltan{#irlinimun Air Flow iie�asrrsnent},TMAH FerPaekaged Dud kakage<15 ge va t Mmmpted ftan dart I IlIZIF U5629 iia Q 1.DuctMulem was dorsmeaad tobave beenpteriawly sealed and c onfrrmcd ff gl HERS vedficafim or 132_D asysOMwidtksstbsa401 wwfeatie or 133_ _ ' docs me insidwedorswWwAasbcatof D 2.New HVAC System Requkvd Fay . Cutis arl: Z,,geed wilt w. - Cr-6R foams~D Md&r a;p&Waeu s} 22-H M.acrd U 25-MB S d (al ww 1d alt C.F4R iitssrG 211-,and(fcrspfit syskWECEI-22,incl 25 - Fot-SPM Systems:Duct leakage<6 p RC,CCA>_350t ltuo,F FD; .ahtil either 13SPP orPSFF. 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