15100034 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22540 RICARDO RD CONTRACTOR:CALIFORNIA DELTA PERMIT NO: 15100034
MECHANICAL INC
OWNER'S NAME: MICHEL JOHN JORDAN TRUSTEE 6056 E BASELINE RD STE 155 DATE ISSUED: 10/05/2015
OWNER'S PHONE: 4082559990 MESA,AZ 85206 PHONE NO:(866)692-5273
LICENSED CONTRACTOR' JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL F1S DECLARATION
Q S/ REPLACE(E)FURNACE,SAME LOCATION
License Class C'2O Li,.4 U` `��
Contractor Date
1 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. sq. Fi Floor Area: Valuation:$15770
1 hereby affirm under penalty of perjury one of the following two declarations:
i. I have and will maintain a certificate of consent to self-insure for Worker's k PN Number:35601007.00 Occupancy Type:
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
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 PERMIT EXPIRES IF WORK IS NOT STARTED
permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSP C ION.
I certify that I have read this application and state that the above information is r
correct.I agree to comply with all city and county ordinances and state laws relating ���(�� �O S '� ��s
to building construction,and hereby authorize representatives of this city to enter Issued by: v Date:
upon the above mentioned property for inspection purposes. (We)agree 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 and will comply with RE-ROOFS:
all non-point source regu ' per the Cupertino Municipal Code,Section 9.18. 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
Signature Date 1 D inspection.
Signature of Applicant: Date:
❑ OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
r. I,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE
compensation,will do the work,and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the
sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
2. 1,as owner of the property,am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
construct the project(Sec.7044,Business&Professions Code). Safety Code,Section 25532(a)should 1 store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
1 hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District 1 will
r. I have and will maintain a Certificate of Consent to self-insure for Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation,as provided for by Section 3700 of the Labor Code,for the Health&Safety Code,Sections 25505,25533,and 25534.
performance of the work for which this permit is issued. Owner u gent:
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by Date: /'0 f
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. CONSTRUCTION LENDING AGENCY
a. 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 I hereby affirm that there is a construction lending agency for the performance of work's
Compensation laws of California. If,after making this certificate of exemption,I for which this permit is issued(Sec.3097,Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name
must forthwith comply with such provisions or this permit shall be deemed Lender's Address
revoked.
ARCHITECT'S DECLARATION
APPLICANT CERTIFICATION I understand my plans shall be used as public records.
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 licensed Professional
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 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 with
all non-point source regulations per the Cupertino Municipal Code,Section 9.18.
Signature Date
GENERAL PERMiIT APPLICATION 15 ocO3y MEP
COMMUNITY DEVELOPMtENT DEPARTMIENT-BUILDING DIVISION
imam 10300 TORRE AVENUE- CUPERTINO, CA 95014-3255
(408)777-3228 FAX(408)777-3333• building ancuoertino.orcl M10
CUP�RTINO
❑PLIJ1,SNG ®MECTioATICAZ ❑ELECTPJCA.L ❑hIISCELLA NTOUS
PROJECT ADDRESS n AIN 4 O{
CAVN'R NAME ' l / C ��- PHOT s S, 9 E•I✓�L Z
STREET ADDRE CITY, ST c,ZIP FAX
�f0 /IGC�r D 1-LC
CONTACT NAME / / n 'N' E•1 L�.II
ST "TPD�RESS
CITY,STATE, ZIP FaX
JC Q
❑ OM'.NM- ❑ OWNER-BUILDER ❑ WANIR AGMI-r ❑ COA*TRACTOR ❑C01.7RACTOR AGMdT ❑ ARCHITECT ❑ E-NOD=zR ❑ DE%ELOPER ❑ Tom. 7
CONTRA TCRNAJM / LI SE y1 - LICEN l BUS.LIC r
CO 3.AN2 '
r 4E-M?.IL FAX
CC C'-
Z'= RESS � CITY,S A E,ZIP /��Qf/��(/�
D P✓O U `� �C,
ARCHITECTME GAEER N.AI.E LICE?SE NUMBER i BUS.LIC n
COMPANY NAME E-MAM FAY, -—-
STREETADDRESS I CITY,STATE,ZIP PHOWE
USE OF sr-D or DUPLEX ❑ JAULTI•FAI LY PROJECT LN WI DL&ND ❑ YES PROTECT LN ❑ YES IS TF-�BLDG.AN
BLTI DNG: r7C01'9�aRCIAL LM 3A N1 rN=ACE AREA [32"0 FLOOD ZONE ❑ NO MCHI.ER HOME? ❑ A0
DESCP.IPTION OF WORK
i cv
TOTALVA.LUATION: •00By my signature below,l certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 have read this
application and the infonnarion I have provided is correct. have read the Description of 1Alork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building con on. I au horize tv--s-o-Mupertinoo to enter the above-ident15ed property for inspection purposes.
Signature of Applicant/Agent: Date: /(J f- /S'
SL-PPL 1ENtTAL INTFORIvIATION REQUIRED o ICE Ls>
MEPMiscAPP_2011.doc revised 06121/11
CITY OF CUPERTINO 151 flOOCrY�-
FEE ESTIMATOR - BUILDING DIVISION
[ADDRESS: 22540 Ricardo Rd DATE: 10/05/2015 REVIEWED BY: PAUL
PN: 356 01 007 BN#: `VALUATION: 1$15,770
°°PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION FURN/A
USE: PERMIT TYPE: A
WORK Replace E furnace Same Location
SCOPE
APPLIANCE / EQUIP TYPE FEE ID (1T1 UNITS BP FEES
Furnace, Forced-Air 1MFR=<100 1 # $143
TOTALS: $143.00
Mech.Plan Check0.0 hrs $0.00
Mech.Permit Fee: 1 MPERA111
Other Mech. Insp. 0.0 hrs Ll
Ll Ll
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works,Fire,Sanitary Sewer District,School
District etc. . These ees are based on the prellmfnar information available and are only an estimate. Contact the Dept for addn'1 info,
FEE ITEMS(Fee Resolution 11-053 E& 7111131 FEE QTY/FEE MISC ITEMS
Plait Check Fee:
`'trppl. PC'Fee
PME Plan Check: $0.00
i �/IIIiI Fee:
Slippl. hl'sp Fcc —T-77
PME Unit Fee: $143.00
PME Permit Fee: $48.00
C_'onsiruclioti 7nx:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? O Yes (j) No $0.00
lchc�nc rl Phil tin F(IC.e:
Travel Documentation Fee: ITRAVDOC $48.00 A
Stronp, Motion Fee: IBSEISMICR $2.05 Select an Administrative Item
Bldg Stds Commission Fee: ]BCBSC $1.00
SUBTOTALS: $287.05 $0.00 TOTAL FEE-.7 $287.05
Revised: 07/02/2015
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WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
(408)777-3228• FAX(408)777-3333• buildingg-cupertino.org
Owner Name -�J O H A/a7d lzzxp►J jl CC Permit No—.—/ I O D D�_T
Address 2 ZS +O_ _ fRJ CIA n �-���EfL AJ D
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of fonn.
XNo 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 110 1.1 through 110 1.8 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.
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.
J< No 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 1.101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
Yes 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 one 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-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
❑ My property is a multifamily residential 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).
❑ 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.
Orr 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 irnprovernents).
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 110 1.1
through 1101.8,the cur-rent 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,
Owner or Owner Agent's Signature: Date: 11
Upon completing and signin ertifrcate,please return it to the Building Division in order to final your building permit.
SB407 2015.doe revised 0812611.5