15060170 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 867 FERNGROVE DR CONTRACTOR:VALLEY HEATING& PERMIT NO: 15060170
COOLING
OWNER'S NAME: MOORE JOHN C AND CATHERINE K 1171 N 4TH ST DATE ISSUED:06/25/2015
OWNER'S PHONE: 4082194419 SAN JOSE,CA 95112 PHONE NO:(408)294-6290
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
/'� �- INSTALL(N)HP A/C MINI SPLIT SYSTEM IN REAR YARD.
License Class `� Lic # �3 0�) �,
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.
1 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:$8603
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:37539048.00 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,and expenses which may accrue against said City in consequence of the ���� �
granting of this permit. Additionally,the applicant understands and will comply Issued by: fff ��`r! �GZ Date: 46J
with all non-point so a regulations per the Cupertino Municipal Code,Section
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
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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)
1,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
1 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 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2 5,2
553334.
Section 3700 of the Labor Code,for the performance of the work for which this 255 �+��f�f
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
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,
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 PERMIT APPLICATIONRII VON E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CUPERTtNO ��
(408)777-3228 • FAX(408)777-3333 •building(a)cuoertino.orcl o&/ 17
❑PLUrMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 1 n i� �n `a� APN R oqa
OWNER NAME PHONE t�o(� Z J / �� E-MAIL
STREET ADDRESS n M p CITY, STATE,ZIPCluc
�(! en <p J�1 FAX
CONTACT NAME ,_^ + `r PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP I FAX
❑ OWNER ❑ O)A`NER- UILDER ❑ OWNERAGEN.'T ❑ CONTRACTOR ❑CON'TRACTORAGEI,'T ❑.ARCHITECT ❑ENGL'.TEER ❑ DEVELOPER ❑ TE-NA.\TT
CONTRACTOR NA ffi LICENSE NUI,SER �j� rA LICENSE TYPE U0 BUS.LIC
COMPANY NAME \ W E-MAIL D u FAX
STREET ADDRESS CITY,STATE,ZIP �6- PHONE(f✓X � ! ()f o
/
ARCHITECTNGINEL-R NAME LICENSE NUMBER BUS.LIC,'+ 1,
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF �FD or DUPLEX ❑ MULTI-FANULY PROJECT IN WILDL.AND ❑ YES PROTECT IN ❑ YES IS THE BLDG AN ❑ YES
ULIDLN'
BG: COMMMCLAL URBAN ATTERFACE AREAO FLOOD ZONE 0 EICHLER HOME? 0
DESCRIPTION OF WORK T0 ^ 1 c
l — s r
_ L V", J'Ga.
TOTAL VALUATION: D RFC
By my signature below,I certify to each of the following: I am the property owner or authorize agent to act cn the pro half. I have read this
application and the information I have provided is correct I have read the Description of Work and verify it is ac e. I g;s p y v,1 a ap able local
ordinances and state lay.,s relating to build co ction. authorize representatives of Cupertino to en i enti ed prope fo>/ ection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INTFORMATION REQUIRED � sSr
IW14R k
AIEP1fiscApp_2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 867 FERNGROVE DR DATE: 06/25/2015 REVIEWED BY: MELISSA
APN: 375 39 048 BP#: 'VALUATION: $8,603
'PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/AC
USE: I PERMIT TYPE:
WORK INSTALL N HP A/C MINI SPLIT SYSTEM IN REAR YARD.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
A/C Units (<=1 OK cfm) 1BREMAIR 1 # $72
TOTALS: $72.00
Mech.Plan Check 0.0 1 hrs $0.00 Phnaah. Plan Check Elec.Plan Check
Fmech. Permit Fee: 1MPERMIT Plumb. Pcrm" I;lec Permii Fee
Other Mech.Insp. 0.0 hrs t $48.00 0thee Plumb Insp. Other Elec. Insp. Lj
Vlech. Insp. Fee: Plumb. hasp. Tee: Llec. Insp. Fee:
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 prelimina information available and are only an estimate. Contact the Dept/or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7,%1:73) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. P('Fee
PME Plan Check: $0.00
Permit Fee:
5u
pp Insp Fee
PME Unit Fee: $72.00
PME Permit Fee: $48.00
Construction Tax:
Administrative Fee: 1ADMIN $45.00
Work Without Permit? Yes (j) No $0.00
:4c/tiince(/Pl:anuing Fees:
Travel Documentation Fee: ITRA VDOC $48.00
Strong Motion Fee: 1BSEISMICR $1.12 Select an Administrative Item
Bldg*Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $215.12 $0.00 TOTAL FEE: $215.12
Revised: 05/07/2015
"to
JUN 2 4 201
Pn re-01-
Alc
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VW1 2013 CPr
o6 co f)
PL-4 PLAT P NS CH p
DATE
PLA NING DEP
CL PERTINO
OMMUNITY DEVELO D MENT DEPARTMENT
BUILDING DIVISI N - CUPERTINO
APPR VED
This set of plans and spec fi ations MUST be kept at the
job site during construction It is unlawful to make any
changes or alterations n same, or to deviate
therefrom, vvlthout ipprovafrom the Building Official.
The Slay-).ping of this plan an specifications SHALL NOT
approval of the violation
of any provisi ns of any City Or inance or State Law.
BY
DATE
PLOT PLANS GHEeKED BY PERMIT
DATE - -
PLANNING DEPT CUPERTINO OFFICE COPY-
i
STATE OF CALIFORNIA
ALTERATIONS - HVAC
CEC-CF1 R-ALT-03-E Revised 06/14 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF1R-ALT-03-E
Alterations-HVAC CZ 1,3 to 7 and 16(formerly CF-1R-ALT-HVAC) (Page 1 of 1)
Site Address: p Enforcement Agency: Date Pre ar : Permit#:
TO t,^Q / - /7-57(J
Equipment Type Equipment Efficiency New:Ducting,Plenums,Lineset Conditioned Thermostat
Required R-value Floor Area(sq ft)
Packaged System ❑Evaporator Coil OAFUE COP ❑ R-6 (CZ 1,3-7)Ducts Seared by system Setback
❑ R-8' (CZ 16)Ducts sq ft (if not already
❑ Split System ❑Condensing Unit SEER HSPF ❑ R-6(all CZ's)Plenums present,must
❑ Furnace ❑Lineset EER ❑ R-5 or R7.5 Lineset' be installed)
HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this
form 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, CF1R-ALT-02-E
Condenser Unit,Evaporator Coil, CF2R:MECH-01,MECH-20-HERS
Air Handler/Furnace CF3R:MECH-20-HERS
Installer Requirement:Dud leakage(:S_15%or,<10%to outside,or seal all accessible leaks)
Exempted from dud leakage testing if:
❑1.Dud system registered with HERS provider as previously sealed,or❑2.There is less than 40 linear feet of duct in unconditioned
space,or ❑3.Existing dud 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 Duds 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 dud systems are constructed,insulated or sealed with asbestos.
❑4.New Ducting over 40 feet Required Compliance Documents to be left on site for Final:
Adding or replacing ducts in unconditioned CF1R-ALT-02-E
space but less than All New Ducts' CF2R:MECH-20-HERS
CF3R:MECH-20-HERS
Installer Required to:Duct leakage L<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.
2 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. That the 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.
Resppnsibe esigner Name: n� � Responsible Desig ' nature: � Date Sign d: Uce�:
t
i
Company:
Address: /
/ Gty/stateMp. Phone*
�)ZV
e- it
For assistan a or questions regarding the Energy Standards,contact the Energy Hotline at:1-800-772-3300
SMOKE / CARBON MONOXIDE ALARMS F 9 IL E
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
iU P E(Ri.TI N Q
10300 TORRE AVENUE• CUPERTINO CA 95014-3255
�
(408)777-3228 o FAX(408)777-3333• building Wcupertino.orq
�N,
man-V5 8 �e,Y-Y'Xv �. � � t Ike: JCai;lr@jtA4bqnoNide:
PERTMIT CANNOT DE FINALED AND COMPLETED UNTIL THIS CERTIFICATE � Gc.Y..b a
HAS D F;N;;I NE AND FtT+f 1�+T iI'� THE BUILDING DIS► 5ION
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA SMOKE ALARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the X X
bedrooms)
On every level of a dwelling unit including basements X X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above-referenced property,I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
!have read and a ree to comp!2 with the terms and conditions of this statement
�OS�traret_rc�r Ow�ar Ag_en�s)Name:
-- "' `C>0 .ti's ne�u�e .. .. .. ..�. ...... .....................................Da_�'"`'t_e:- ...f... .�,!
.. ..... ..
Coma"bf&iName:
Siattire........................../.........................................Liffe . ....................................D'afe':'...................
Smoke anis CO forni.doc revised 03118114
'WATER-CONSERVING PLUMBING FIXTURES FlUm
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 f j 6 6 M ]U
(408)777-3228• FAX(408)777-3333 a buildin cu ertino.or _ +
Owner Name
�mor ermit No.
Address
1. Is your real property a registered historical site?
0 Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
[ No Go to Question 2.
2. Does your real property have a licensed plumber certifying that,due to the age or configuration of the property or its
plumbing,installation of water-conserving plumbing fixtures is not technically feasible?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
L�(No Go to Question 3.
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
JN Pilo Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
Lyes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Check orie of the three following statements and sign
bottom of form..
5. Please check ONE of the following:
My property is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water-conserving plumbing fixtures throughout the building. On or before January 1,2017, all non-
compliant plumbing fixtures shall be replaced with water-conservingplumbing fixtures (regardless of whether
property undergoes alterations or improvements). `_C) `—
El My property is a multifamily residential real property. ryr Code S4ion-`105
On and after January 1, 2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water-
conserving plumbing fixtures throughout the building(regardless of whether property undergoes alterations or
improvements).
❑ My property is a commercial real property. See Civil Code Section 1101.5.
On and after January 1, 2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building(regardless of whether property undergoes alterations or improvements).
1,as the owner or owner's agent of this property,certify under penalty of perjury that non-compliant plumbing fixtures will be
replaced prior to date specified above with water-conserving plumbing fixtures in accordance with Civil Code Sections 1101.1
through 110 1.8, the current California Plumbing Code and California Green Building Standards Code,and manufacturer's
installation requirements, and that the water-conserving plumbing fixtures comply with the requirements as indicated in the
table on the following page.;1A xl.
Owner or Owner Agent's Signaf� Date''-.-D
4-
Upon completing and signing thisrficate,please return it tot e Building Division in order to final your building permit.
SB407 2015.doc revised 08/26/15