13070064 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19730 MERRITT DR CONTRACTOR:HUSSEY BROS INC PERMIT NO:13070064
OWNER'S NAME: RAJ KUMAR TUPLUR&AKILA S KANNAN 903 GEORGE ST DATE ISSUED:07/10/2013
OWNER'S PHONE: 5104614180 SANTA CLARA,CA 95054 PHONE NO:(408)733-6360
❑ LICENS�E-D CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIALE]
License Class vC/ L' .# ADD(N)A/C UNIT TO SIDE YARD INCLUDING(N)COIL&
CONDENSING UNIT
Contractor. Date
I hereby affirm that I a icensed under the provisions�hapter
(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:$4000
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:31629045.00 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 FR CALLED INSPECTION.
indemnify and keep harmless the Cityof Cupertino against liabilities,judgments,
costs,and expenses whicgon
acc against said City in consequence of the a
granting of this perm the applicant understands and will comply Iss Date:with all non-point urce er the Cupertino Municipal C de, ection
9.18.
RE-ROOFS:
Signature Date 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(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 e ' ment r devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by th ay rea ' QualityNjanagement District I
performance of the work for which this permit is issued. will maintain compliance with a Cu rtin u ' Code,Chapter 9.1 n
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S tions 505, ,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
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
�J
GENERAL PERMIT APPLICATION
:d.
o EP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•building(a-cupertino.org �O
misc
CUPERT 0
EI PLUMBING CHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS APN#
OWNER NAME �HofS70 i :/' .✓r��//�' �VO- //! E-MAIL
STREET ADDRES§ . . CrrY,STATE,ZIP .FAX -
CONTACT NAME I I'! PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
. ❑ OWNER ❑ QWNER�BUHAER- ❑OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR N s s LICENSE NUMB �) LICENSE TYPE BUS.LIC#
COMPANY NAI" E-MAIL ( FAX
ST D S CITY,STATE,ZIP PH
ARCI3 TECT/$NGi�EER NAME LICENSE NUMBER BUS.LIC#
� I C'II II
COMPS NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE'OF i ❑SFD.i DUPLEX '� ElMULTI-FAMH.Y PROJECT INWILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUII.DINCr..l [:]C OMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE [3NO EICHLER HOME? ❑NO
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T9T VAIJ[IATIOI�I I i
B I' fy:to each of the o g: I e operty owner or authorize agent to act on the property ehalf. I have read this
y my slgnatuie below I certl I
applicatloti and the Inforinanon I;have provi .d is correct. a xd the Descri tion k and verify it is accurate. agre o comply'with all applicable Iocal
=S� dstate.taws relating';tQ build' g constructio representatives of Cupertino to enter the above-i ntif property for inspection purposes.
ofiApltcan Agent Date:
S, L TAL INFORMATION REQUIRED
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�,. MEPMiscApp_2011.doc revised 06/21/11
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CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 19730 MERRITT DR DATE: 07/10/2013 REVIEWED BY: MELISSA
APN: 316 29 045 BP#: *VALUATION: 1$4,000
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Du lex PENTAMATION FURN/AC
USE: p PERMIT TYPE:
WORK ADD N A/C UNIT TO SIDE YARD INCLUDING N COIL & CONDENSING UNIT
SCOPE
APPLIANCE/EQUIP TYPE FEE H) QTY UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $70
TOTALS: T $70.00
mill
Mech.Plan Check 0.0 hrs $0,.00 Plumb.Plan Check Elec.Plan Check
Mech.Permit Fee: 1MPERMIT Plumb.Permit Fee: Stec. Permit Fee:
LOther Mech.Insp. 0.0 hrs $47.00 Other Plumb Insp. Li
Other Elec.Insp.
.Insp.I,cv: Plumb. Insp.Fee: Elec.Insp..Fee:
NOTE: This estimate does not,include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These-fees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 11-053 Eff. 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Sup])1. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $70.00
PME Permit Fee: $47.00
C`onstruction :Tax:
Administrative Fee: IADMIN $44.00
Work Without Permit? ®Yes (j) No $0.00
Advunced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $47.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg.Stds Commission Fee: IBCBSC $1.00
I
$209.50 $0.00 $209.50
Revised: 07/01/2013
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Shnplified Prescriptive Certificate of Compliance:2008.Residextiul HVAC Alt erations. CF-1R-ALT-AVAC
Climate Zoues 1 and 3-7
57teAdInEntforcemmdAgency: D Permit.
e,. Mh
c30X06
Conditioned Duct insulation
Eql3iPM=t TYPId L'cC'Mmiiim Efilcien 12oor'Aiea" re enE Thostat
Packaged Unit, 40 8 ofducts
umnace ® COP
[ $gtback
door Cog Qstt OjiSPF Serves-y��' added arreplaced in naru�r
Condensing Unit 13 EER E3 itesistasice unconditioned space,
(If early present must be
E3 R 6 (CZ I,3-5) �
1.Equipment Type:Choose the equipment being installed;ifmore than one system,mise another CF-1R-ALT-AVAC for each system.
2.NTnimum Equipment E ficiencim 13 SEER,78%AFUE,7.7HSPF for typical residential systems.
Contractor(Documentation Author's/Responsible Designer's Declaration Statement)
e I oectify that this Certificate of Compliance documentation is accurate and couipiete:
• I am eligible under Division 3 of the California Business and Professions Code to accept;espansibiiity for the design identified on this
Certificate of Compliance.
• 1 certify that the energy features and performance-spec'dications for the design identified on t3iis Certificate of Compliance conform to the
requirements of Title 24,Parts I and 6 of the California Code of Regulations.
• The design features identified on this Certificate of Compliance are consistent v4th the info +' cumented on other applicable
compliance forms,worksheets,calculations,plans and specifications submitted to cement agency for approval whim the permit
Name: &ISim
Company: Date:
P .-2,
AddrT
City/State/Zip: 'Phone:
70
ey: o IN
'" 2008 Residential Compliance Forms.doc revised 04/10/12