12070035 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 74661'117ATHERWOOD DR CONTRACTOR:PAUL FALCIONI PERMIT NO: 12070035
OWNER'S NAME: PAUL FALCIONI 428 STANFORD AVE DATE ISSUED:07/06/2012
OWNER'S PHONE: 8314263234 SANTA CRUZ,CA 95062 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIALO CONIMF,RCIAI.
License Class Lic.N REPLACE FURNACE IN SAME LOCATION
Contractor 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 sclf-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for whichthis permit is issued. Sq.FI Floor Area: Valuation:$2052
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ofthe Labor Code,for the performance of the work for which(his
APN Number:35928051.00 Occupancy Type:
peril 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 stale 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 properly for inspection purposes. (We)agree to save 180 DAY F . OM LAST CALLED INSPECTION.
indemnify and keep harmless the City ofCuperlino against liabilities,judgments,
costs,and expenses which may acerae against said City inconsequence of the ,,f
granting of this permit. Additionally,the applicant understands and will comply Issued by: / / Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. /
RE-R( FS:
Signature Dale 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 ApplicnnL Date:
I hereby affirm That I am exemptfrom the Contractor's License Lew for ane 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. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cuperlino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should 1 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,u provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Buy Area Air Quality Management District l
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Alunicipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safely Code,Sections 25505 25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
pemnit is issued Owner or authorized agent: �if�lf GAN Dale: ZJ�
1 certify'Ihm in the performance of the work for which this permit is issued,1 shall Cl
not employ any person many manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONS'TRUCT'ION LENDING.AGF-NG.V
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 1 have read this application and slate that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARflll'1'F.f.'T'S DECLARATION
and keep harmless the City of Cupertino against liabilities.judgments.
costs,and expenses which may accrue against said City inconsequence of die 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.
Signmurc�Ly7/L`/ Dale �_" ,_ZJf z
Simplified Prescriptive Certificate of Cowolianec2008 Residential HVACAllerations CF-IR-ALT-HVAC
Climate Zones t and 3 4-
'EnforcemeGvN gency:
Date: Permit k:
G(a �(Qse'I"VIes4�v0o��- . �Rz- o 'b •
'Conditioned Duct insulation
Equipment Type' ' List Minimum EfficicoW, Floor Area regutrement Thermostat
Packaged Unit Over 40 ft of ducts
Furnace AFUEV I• COP S by system added or replaced in Setback
Indoor Coil SEER BHSPF nes alreadyprrsau•must be
Condensing Unit • [3 EER' Resistance D sf unconditioned space aatalled)
_ ❑
011ier R 6 (CZ 1.3-5)
"
1.Equipment Type:Choose the equipment being installed;if more than one system,use another CF-1 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 Desiguer.'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 perfoimaaa specifications for the design identified on this Certificate of Compliance conform to the
requirements of Tide 24.Parts 1 and 6 of the California Code of Regulations.
• The design features identified on this Certificate of Complionce am consistent with the information documented on other applicable
compliance forms,worksheetR calculaGms,plans and specifications submitted to the enforcement agency for approval with the permit
appfiw• . .
Names RJ `- N IC-)01)4; 'Signature: ar T
Company: - Date:
Address: License:
City/State/Zip: - - Phone:
i
2008 Residential Compliance Forms.doc.revised 04110/12
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BV:
APN: BP#: 'VALUATION: $2,052
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD Or Duplex PENTAMATION FURN/A
USE: pPERMIT TYPE: Al
WORK
SCOPE
Mech. Plan Check 0.0 hrs $0.00 Phwd._ P(ou Chard Co. !'Gm Ch:06
Mech. Permit Fee: IMPERMIT I'll... /1:rmir Fr.::
Other Meeh. Insp. 0.0 hrs $45.00 Orhrr 1'om11)hire, herr
.Ilrrh. Imp. /Yr: 1'hm,h. hr.yt Frd: lila_bnp,
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District.etc. . Thesefees are based on the relimina information available and are only an estimate. Contact lite De t or arldn7 info.
FEE ITEMS (Fee Resolution 11-053 Q. 7111112 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Mechanical
Suppl. PC Fee: Q Reg. O OT FO.0hrs $0.00 $133.00 /MrR=1100 Furnace,Forced-Air
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. Q OT F0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
G qw?iwow! T n.
Administrative Fee: (ADMIN $42.00 0
Work Without Permit? O Yes Q No $0.00 0
Advanced Plannine Fee: $0.00 Select Non-Residential (7
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure
A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $133.50 $133.00 TOTAL FEE: $266.50
Revised: 07101/2012
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION lS�
10300 TORRE AVENUE•CUPERTINO. CA 95014-3255 10 M I
sc
CUPERTINO (408)777-3228 • FAX(408)777-3333• buildina(a) rti
cuoeno.ora ^
❑PLUNMING CHAMCAL ❑ELECTRICAL ❑MISCELLA.NEOUS
PRoaEcrADDREss AFNi Cl :�<\ 0051
OWNER NAME PQV1 I g1C(OVI % PHONE b3I - 4Zb' 3Z3'( E �1 -�CVI. 7,Ct U+ll�t)a*.nj
STREET ADDRESS y2g SC—t�,�� .A� - G�, STA�.�SCa�1+�. CSUy.� Cl-I (a . F•ycG_-
CONTACT NAME 5 ZS G W YYQt" PHONE E-MAIL E'
STREETADDRESS =,STATE Z1P FAX
❑OWNER ❑ OWNER-BURDER ❑ OWNERAGENT ❑ CONTRACTDR ❑CONTRACIORAGENT ❑ AACHRECT ❑ENGINEER ❑ DEvELOPER ❑ TENANT
CONTRACTOR NA.MBLICENSE NUMBER [UCDJSE TYPE BUS.LC A
E
COMPANY NAME E-MAIL - FAX
STREET ADDRESS CITY,STATE ZIP PHONE
ARCHITECT/ENGINEER NAME n LICENSE NUMBER BUS.LIC 0
COMPANY NAME- �7 E-MAIL FAX
STREET ADDRESS CITY,STATE ZIP PHONE
USE OF *-SM.,DUPLEX ❑ MIfLTI-FAMILY PROIECTINWBDLND ❑ YES PROTC-1'N' ❑ YES IS THE B[DG AN ❑ YES
BUIIDPIG: COFLMERCLV. URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO ECHI'Ji HOME+ ❑NO
DESC=ON OF WORK -
TOTAL VALUATION: �D� RECEIVED BY:
By my signature below.I certify to each of the following: I am the property owner or authonzed agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct I have toad the Description of Work and verify it is accurate. I agru to comply with all applicable local
ordinances and state laws relating m g cotu a I�autthhonzn repro=mtivm of Cupertinc:c anter rhe abovee--ident f3cdpmpc �Cor inspection purposes.
Signature of Applicant/Agmt V 4JK��+' Date: ( — " ZU Z
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OVER-THE-COUNTER
F
❑ EXPRESS
Y
U
❑ STANDARD
U
❑ LARGE
❑ MAJOR
A,EP,W'ucApp_2011.doc revised 06121111 -
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333- building5cuoertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS 7LI6/ 14 �r� r APN (' (� BPtI
OWNER NAME aj rA(G IENM\ OWNER ADDRESSU�Q < �
DESCRIPTION OF WORK: 7 SCJ J
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address Indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
Y�21. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
W2. 1 understand building perils are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
`Vk-i 3. I understand as an"Owner-Builder' I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
V' ,4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
P�715. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an"employer under state and federal law.
Tfl& I understand if I am considered an "employer" under state and federal law, I must register with the state and
Federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
i
T I understand under California Contractors' Slate License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
W18. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OH'Re,Bldlde,Fol"OI ?010.doc re,fsed04114/10
ub9. I understand I may obtain more information regarding my obligations as an "employer'from the Internal
Revenue Service, the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.Gsib.ca.gov for more information about licensed
contractors.
1*/10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
0?_ 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
k5 2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' Stale License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint.Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be Issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's si natur
Property Owner's Signature:- } Date: I
---- -- --- ---------- - --- ---------h--------------------------- - -- ----- ------------- ....- ---------- ...-------- ------
(NOTE: The following Authorization Form s required to be completed by the property owner only when designating an
agent of the property owner to apply fora construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OrrnerBuilde,Form ?010.doc revised 04114110