B-2017-0081 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0081
1158 ELMSFORD DR CUPERTINO,CA 95014-4950(362 09 013) A R S AMERICAN
RESIDENTIAL
SERVICES OF
CALIFORNIA INC
MEMPHIS,TN 38120
OWNER'S NAME: GHISELLI DAVID AND RUTH A DATE ISSUED:01/17/2017
OWNER'S PHONE:408-655-8182 PHONE NO:(408)286-8931
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C220 Lic.#742039
Contractor R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA INCX BLDG —ELECT _PLUMB
Date 10/31/2017 X MECH X RESIDENTIAL_COMMERCIAL
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 JOB DESCRIPTION:
license is in full force and effect. REPLACE FURNACE(SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
2. 1 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 Sq.Ft Floor Area: Valuation:$10380.00
permit is issued.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above APN Number: Occupancy Type:
information is correct.I agree to comply with all city and county ordinances 362 09 013
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 indemnify and keep harmless the PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgments,costs,and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION.
source regulation p�upertino Municipal Code,Section 9.18.
Issued by:Kim Dunbar
,- Signature Date 1/17/2017 Date:01/17/2017
OWNER-BUILDER DECLARATION RF-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1. I,as owner of the property,or my employees with wages as their sole inspection.
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professions Code) Signature of Applicant:
2. I,as owner of the property,am exclusively contracting with licensed Date:1/17/2017
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to 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
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 255 5,25533,and 25534.
exemption,I become subject to the Worker's Compensation provisions of the -
Labor Code,I must forthwith comply with such provisions or this permit shall.'owner or authorized agent:
be deemed revoked. Date:1/17/2017
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon,the above mentioned property for inspection purposes. (We)agree Lender's Address
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
= = Er%
GENERAL PERMIT APPLICATION ja
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CtlF'>vRTINO (408)777-3228• FAX(408)777-3333•building(a)-cupertino.org misc
❑PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS
N#
OWNER NAME : / ` PHONE GCj1 / / E-MAIL
STREET ADDRESS ITY,STATE, IZIPP [b� J�j FAX
_ CONTACT NAME � /r'W'/�✓ 4CITY,,STATE,
H MAII.STREET ADDRESS p// ZIP - FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT. ❑ CONTRACTOR - CONTRACTOR AGENT ❑�ARr=FCT F1 ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NTJNIBER LICENSE TYPt BUS.
COMPANY NAME E-MAIL FAX
STREET ADDRESS // �! C J jl�j E,ZIP C 312 PHOT p
ARCHITECT/ENGINEER NAME `` (/ LIC EA'SE NUMBER J ` G/ BUS.LIC$Q S Jl
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ MULTI-FAMII,Y PROJECT IN WILDLAND ❑ YES PROSECT IN ❑YES IS THE BLDG AN ❑YES
BUILD 0: COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: yo
RECEIVED
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information 1 have provided is correct. I have read the Description of RTork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building nstruction. authorize representatives of Cupertino to enter the above-identified for inspection purposes.
Signature of Applicant/Agent � Date: ( { l < /!
SUPPLEMENTAL INFORMATION REQUIRED OFFICE US ONLY
❑ OVER THE-COUNTER
❑ EXPRESS
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MEPMAcApp 2011.doc revised 06/21/11
STATE OF CALIFORNIA
ALTERATIONS - HVAC
CEGCF1R-ALT-03-E Revised 06/14) CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF111-ALT-03-E
Alterations-HVAC CZ 1,3 to 7 and 16(formerly CF-IR-ALT-HVAC) (Page 1 of 1)
Site Address: E 6174 4r Enforcement Agency: Date Prepared: Permit#:
Equipment Type (wrro�CC, Equipment Efficiency New:Ducting,Plenums,�ineset Conditioned
Required R-value Floor Area(sq ft) Thermostat
❑Packaged System ❑ Evaporator Coil UAFLIE COP ❑ R-6 (CZ1,3-7)Ducts Sery d by system Setback
❑ R-8' (CZ 16)Ducts (If not already
)Split System ❑Condensing Unit SEER sq ft
HSPF 13R-6(all CZ's)Plenums', present,must
Rf Furnace Lineset EER ❑ R-5 or R7.5 Uneset3 be installed)
HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this
forsp is allowed to be filled out by hand. For final inspection all forms are to be registered(no hand'filled forms allowed)and a copy left on site.
1.HVAC Changeout/Repair. Required Compliance Documents to be left on site for Final:
Can-include new ducting
All Equipment, CF111-ALT-02-E
Condenser Unit,Evaporator Coil, CF2R:MECH-01,MECH-20-HERS
Air Handler/Furnace CF3R:MECH-20-HERS
Installer Requirement:Duct leakage(: 15%or,: 10%to outside,or seal all accessible leaks)
Exempted from duct leakage testing if:
❑1.Duct system registered with HERS provider as previously sealed,or❑2.There is less than 40 linear feet of duct in unconditioned
space,or 113.Existing duct systems are constructed,insulated or sealed with asbestos(list manufacture date of building
❑2.New HVAC System Required Compliance Documents to be left on site for Final:
All new equipment and All New Ducts' CF1R-ALT-02-E
CF2R-MECH-01,MECH-20-HERS,MECH-22-HERS,MECH-(23 or 24)-HERS
CF3R-MECH-20-HERS,MECH-22-HERS,MECH-(23 or 24)-HERS'
Installer Requirement:Duct leakage<6%,Fan Efficacy(.58W/CFM),Air Flow>_350 CFM/ton(or Standards Table 150.0-C/D alternative)
❑3.All New Ducts with Replacement Required Compliance Documents to be left on site for Final: .
Includes replacing or installing All New CF1R-ALT-02-E
Ducts'and one or more of the following: CF2R-MECH-01,MECH-20-HERS,MECH-(23 or 24)-HERS
Condenser Unit,Evaporator Coil,Furnace CF3R-MECH-20-HERS,MECH-(23 or 24)-HERS
Installer Requirement:Duct leakage<6%,Air Flow>_350 CFM/ton(or Standards Table 150.0-C/D alternative)
❑Exempted from duct leakage testing I existing duct systems are constructed,insulated or sealed with asbestos.
❑4.New Ducting over 40 feet Required Compliance Documents to be left on site for Final:
CFIR-ALT-02-E
Adding or replacing ducts in unconditioned CF2R:MECH-20-HERS
space but less than All New Ducts' CF3R:MECH-20-HERS
Installer Required to:Duct leakage(:S_15%or,<10%to outside,or seal all accessible leaks)
❑ Exempted from duct leakage testing I existing duct systems are constructed,insulated or sealed with asbestos.
'All new ducting R-8 required when more than 40 ft installed and R-6 when less than 40 ft installed; This includes in walls,between floors etc.
'A New Duct system is when the duct system is constructed of at least 75 percent new duct material,and up to 25 percent may consist of reused
parts from the dwelling unit's existing duct system(e.g.,registers,grilles,boots,air handler,plenums,duct material.
3 R-5(1"thick insulation)for linesets 1"and less. R-7.5(1:5"thick insulation)for linesets over 1 inch. Most mfg will require Suction line Diameter
with insulation as the following 1.5-2T-2%",2.5-3T-2%",3.5 to 4T-2%",5T-4%"
Contractor(Documentation Author's/Responsible Designer's Declaration Statement)
I certify the following under penalty of perjury,under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the information on this document.
3. Thatthe energy features and performance specifications for the design identified on this Certificate of Compliance conform to the
requirements of Title 24, Parts 1 and 6 of the California Code of Regulations(CCR).
4. That the energy features and performance specifications,materials,components,and manufactured devices for the building design or
system design identified on this Certificate of Compliance conform to the requirements of Title 24,Part 1 and Part 6 of the CCR.
5. The building design features or system design features identified on this Certificate of Compliance are consistent with the information
provided on other applicable compliance documents,worksheets,calculations,plans and specifications submitted to the enforcement
agency for approval with this building permit application.
Responsible DeWerm Responsible D g er Signat re: Date igned- Li4ense:
/7 /2 i W-03
Company: �ddre,,* City/State ip: hone:
For assistance or questions regarding the Energ Standards,contact the Energy Hotline at:1-800-772-3300