27241 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUR - PERMIT NO.
APPLICATION/PERMIT BUILDING LUMBING-
ENFICAL
FIC
BUILDING DIVISION UUILDING PaodECT mEN'npIGATurN '
27241
PUILDING A-DDRES , SANITARY NO. APPLICATIONSUBMI TALDATE
LOIN 1
OW
PHONE: NTRACDR'S NAM LIC NO: 1•
4 ' N/C CONTROL#
\RCHITECf/ENGINEER: LIC NO: KESS: s T�- ,n ❑
M1 D L.
Otto
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. r t ELEGIRIGPERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p0z n,70 Division evelimnBu inns and isioreof..Cods and mmendng with
W�y+,10{r0rs--� fall Section, Divisio2, Be Business and Pofessiorep Co(fd`-�'e,and^^m��'y licrnuia in PANELS
QV" LElennCanadeaect. LIC.# 4Y/ 70do_,l UPT0200AMPS
sFis�d Du1E Convaztor 101-IOOO AMPS
F'Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $JSQ.F1'.
OOZ� 1 understand my plans shall be used as public record¢. OVER 1000 AMPS
F'y B SIGNS ELEC IUCAL
QQyy � Licensed Professional
L ft 'v OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O y 1 licfollowing
as affirm that I am eumpt from the Co Professions
Ca Lies.Any law for the
30vF which inguiresa Permit
to commit.sinessand Professions Co dc:Any city nor county TEMP.MEIE0.O0.POLE MST.
(:65�� which requiresapermitocoutmcL atter,improve,demolish,mrepa'v any structure POWER DEVICES
i n prior to its issande...lso requites theepplicamtI...ch permit to Ble a,igned 9wement
<C) that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
e,yX'MK 9(commencing with Section 7")of Division 3 of the Business and Profusions Code) SWIMMIN LP CTRIC V4f.UAT10N
W-.y omhat he is exempt herefrom and the hags forthe alleged exemption.Any violation of OUTLEfS-S XTURES
LV} Section 1031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not mare than Eve hundred dollars(4500). NEW RESIDENTIAL SQ.PT, TORIES TYPECONSTRUCf10N
m ❑ Luewner hOhepoperY•orveotimenyeeswithwege9Mthe(Sec.cW,Bumiess
1F or
p, a TH Profea the cionswarknd e:The Cont rano is Lic a se Law
dosed not apply pi an o,rar of
and enty wh ow Code:The Contractor's License Lew does not apply lf an owner is '
ownenywyers,pdsor videdtrovuchereomandwhodoss ar,notsuch wmthimxlfor though his GROUP RES.UNITS
however.mebuildi building
improvement
ovemuch mpis sold msere not earrof amplrered ficoodatheow.H,
huilder ..the building a den ovemem is old within one year or improve
omm efor Neooner-
bale.). will have the burden of proving that he did not build or improve far purpose of
ante.),
❑ L as ownerofthe property,amexclusively contracting with licensed chneacors to QTY; PLUM NC PERMI FEE FLOG ONE APN
construct the pmject(Sec.1054,Busineaa and Prof.uin r.Cade:)The Con scorn
LicenselawdocsnotaWlymmowrterofMo nywhobuildshrimpovnth n,and PERMIT ISSUANCE
who comreca for such projects with a conuacmt(s)licensed pursuant tome Contractors
License Law. ALTER-DRAM&VP ER(EA)/7 FEE SUMMARY
FEES
❑ 1 am aempt under Sec. ,B&P C for thu reason BACK FLOW PROTECT.DEV I i w OUTSIDE
SANITARY Y N
Owner Dam I.DRAINS-FLOOR, P.ARF.A,C RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofeadenuo self-insure,or a certificate of FIXTURES-PERTRAP RECF.IPTM
Workers'Compcnsuionlnsudnceor a certified copy theeaf(Sco.380),Lab C.)which PARK FEE Y N
covers all emp.eyee'e under this permit. GAS-EA.SYSTEN44 INC.4 O RECEIPT n
Policy# BUILDING DIVISION FEES
Company GAS-EA.SVS 4 7 PLA CHECK FEE
(2 Codified copy is hereby famished.
[3 Certified copy is filed with Ne city insp.cvon division. GREAS TE USTRL WAS1 ERCEPTOR GRA G FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GR' AP Y440 SOUS FEE
COMPENSATION INSURANCE
(This section need not becomplemd ifthepermit is forowe hundred dollars($10(d) SEWER-SANTTAR .j=. OENERGY FEE
or las.)
I unify that in the perfomwtm of the work for which this permit is issued,lahall WATER HEATER W/VENT/ELECTR
not employ any person in any summer¢o at to become subject to Ne Worked' PAI[).
Compensmionlawsof CaliforniaM/
. Date WATER SYSTE1' 'I Data Receipt#
O Applicant
NOTICE
7 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
r'� y hccane subjauo be Workers Compensation provisions of The Labor Code,you must
a5: forthwith comply with such provision,or this permit¢hall be deemed revoked. BUILDING FEE
L2a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby afMn that there is a construction leading agrncy,for the performance of TOTAL: ELECTRIC FEE
O she work for which this Penni,I.issued(Sec.3091,Civ.C.)
I<ndwe.Name
W lsndcls Andrea, - Q'FY. ;� * MECHANICAL PERMIT PEE PLUMBING FEE
{U 1 certify tht
aI have reed this epplicuion aM sate that ahc about information is - MECHANICAL FEE
Q. rrect..agree tncomply with dl city antl county hNirwus sod¢tate laws rclmingo a. PERMIT ISSUANCE
-' Tn building construction,sed hereby au9hume represenmtivuo(this city to enter uponahe - CONSTRUCTION TAX
L) z above-mentioned property for impaction purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep harMeas the City of Cupertino against
liabilitirosudgments.cusd snde.penseswhich may in any way acermoininst aid City AIR HANDLING UNIT(TO CO."CFM)
m c nexpic of the gdntiwg of this permit.
AI0.HANDLING UNIT(OVER 10.000CM)
Signaorcof APplic moracmr Dau EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dau Receipt
Will the applicom or future building occupant store or hatdle limitations material HEATING UNIT(OVER 100,000 BTU) TO L:
u defined by the Cupertino Municipal Code.Chapter 9.12,sod the Health and Safety
Cale,Section 25532(a)1 VENTILATION FAN(SINGLE REMD)
❑Yes ❑No
BOILER-COMP(3HP OR 100,000 BTU) NrFSS A[JCEDDATE
Will theoppliconwr(murebuildingottupvntaseequipmemor device whichemit V' 1
hoxardous air comaminanss as deemed by the Bay Area AG Quality Management BOILER-COMP(OVER 100,000 BTU)
strict, ❑ OCT 91
Yes ❑No NEW RESIDENTIAL MECH. SQ.Ff. '(�(Ia
1 have read Incautious vaous materials rcyu ramems under Chapter 6.95 of the C1¢( 1��
California I lea do&Safety Code,Sections 25505,25533 and 25534. 1 undedand Nat
if the building does not currently have a arrant,that it is my responsibility to notify the Lurthl 1N
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner m authonmd agent Oat. TOTAL: ISSUED BY:
OFFICE
MR . CHIMNEY TEL N0 .408-866-1575 Nov 07194 12 :49 P .03
rTAfl
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p lam wmlN YbM We. ,0l PCftl Ml.YPII MCN NAW PROTPT.DI:NI(]I
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WORKMAN COMPMM71ON DOMARATYM T'A Y�N—
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Policy• NUILDINO DIVISION PNBS
Canpmy OAS•BA.AY67AIdOVB(1 a(NA) R.wNCFWK HE
maw am is ft"NNIMO.
CKWMwpyi.AldwMYrdTlnlpmimlddM. aaeASnnNDUSTRL WAS781N'I'BIlCN1OR ORAOM RIB
CERTIFICATE UP MB]U'ITON MxJM W(YIAIw•' ORBASU7RAP SOLLS PUD
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tRIdI.Nh aaryly+101 anr!pm.UkN tlM prDex IMtl b beam w.RYat eun.DIND PNe 1
Q ClRVN71(IICf10N IfWINIVO A("CY
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amwd .... .-
aawAraot"M Pam"k bad(•a.3m,CN.f.,)
IcnOaa Wrist F{.UW NIO PEe
L.drYAddm. •fYICMANIOAL,''PBAMR ..f�E
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amaal.Irptlm•anply dA dl Gly and mny aWmlm ad.rw k.anlWnfm PIIIIMRISfIIANf:R
<A Mdlln{ealwtlaYm.ad RcNMY•WWnnpmwmi.wdMGW mmm.pm lb. (IIJNSIYUCIIW.'1'AI
.k.r(W.)VSmm ".Wmt*whpnpm.. ALTNN OR ADD TO MBclI. –..-.. .
(WI•pm mow,kdr(MIIyP bep 7rmkm h(]ry d[Ypotlm a/akr( ARNANDLINGUN1T(TO10.00)CPMI
U.MIIIW.)daaee((S00eeNppaae((ffromaaMo .bkhmykap.yao•.pbmaddC(ly
IA ar 1'o'I"O dAl.peNlll. ' /1
AIR HANDLING I1NITtDYBR IOODOM)
10
1pro•a App Ngd.r �/CVia, MAW HOOD(WIDUCII PAID
IIAKARDWMMATYwIAIAWSCLORIIRE )(RATMupercmicoAm ETv)
•.ldWnlddby ggllqm mNwma klPag casA.aCpT.mpwNmPs.ImU,MNMmIMM ludibmnWMaRlUd NRATIOUNT(OVm11011,K) TOT L:
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O
To O Na
TE
WNdmyplkaNaNNNbIIdMpoaapol m•Yuiplolwb.ba..bkSaN1
eONBI.00MF(]N►M 11111101100 BTU) ISSUANCEA
MMaV dr amudmam M Ana N &RAW by do May M QW11,NalyeRMd RDILM-COMP(OVM 10um BTO) P A I Y�
V
'16•InT O Yq D Na NBtY minowma MBa. M Pry o•S •.
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O.nxv wAairrl.Pma IMa TOTAL: list NY:
MR . CHIMNEY TEL N0 .408-866-1575 Nov 07 ,94 12 :48 P .02
�� 7830od
- WA� Atpp.
Mdntenenoe a Repair a Type of Fireplace: ❑Pre•feb ®'Masonry ❑Modular
CNa ing lPApsksrRebulld• a No. of Stories: 16`3 4 e No.of Flrepia0ee02 3 4
c,eowt•R•InoVel r Oampen
• rar•C*p •Woodstove: ❑Insert ❑Free Standing ❑Pellet
Ron Eaeu knpesdww
Z00=111111114 a Flue Size: 0 B"x B" ❑e"x 13" ❑ 13"x 13' M6110r
- says - Campbell,CA 95MI
'Can The esu' t t.Lb.I{7etwa Li 13"x 17" Round W Round C3_
oug Tluec dWr" . 3 Pho-li
Addrecee stateZip COMMENTS:
•s J.
Phone S ,
Daft Time
oma- ww,.nna.ale.cna�o.00nnmwewuna,uem.r.lp.r,vwn" ���j�il;GL� �yJ� � �"'�'
taenia
Pa•awoo,ndawwnaoeer•ot amw•dia{++r.c.nan.noN //y� ; ((// /� .. _ a� f
fl lu•U041 Wang appeaseN.
CONDITION
REPORT x/1/0f, '-
.teal
OIAMNEY
Chimney Height
2Vhlmney Cep/Spark Ar
3. n/Wash
4. rk/Mortar
5.FlashIN
e.Flue'M .*-&N.1y,fdlf�ref.� Aik—.410j,
7.Moialure'R letanee CIMM MBR VBRIFillawN
faoU Contmaloni are regulated by the Centmatere'Stab Uoeeflo
ee erd.
FIREPLACE tiler gloss Oodhe Read,aeerettteato,CA ewae
a.Smoke Cham n As owner w mepomfW party I oho my ooheem to perform a Wass
tall earthquake 9y81,1111 on my Chimney strueNre. Mr. Chimney Ie
D.Damper, w released from all pablWies from damage they eney umuar.
19.Firebox/Orate t x
O Cuetonter repast no was tw w.ws out net oomm{Moneataryw
11:Ash Container Imegrltyaseuotum.Cuetorner &W"d.
12,Spark Screen/Doors UN Flreplaw and ahlmney should be Inspected yearly for any
auuctural faults and leaned after awry cord of wood.
13.Throat Plate Technidan's Signature
14,Hearth Protection Autitorization to perform work X04&I
15.11tillse.: Mathod of Payment —Cash —Cheri £sorow
WOODSTOVE OR FIREPLACE IAPgRT OMRIPTION PRIM!
16.Stove Pipe Condition (woodstov
i
17.NFPA Approved Flue Connection sen)
18.Installation/Thimble/Clearances
OTHER ITEMS
W.
tiuBTOTAL
20.
21. TOTAL
Note; • e ark N tutanosed ted. dsNMe m WertlmenMlp and at Flats
DATE DOf4PLE1EC
Nr one year unls{s mherwa roue. 'All somata past eu•aoegeemwelemmaskpwmond,lnueeaaharw.
•plu@G"blown off by wind--manstelledwhhln pedaysonly at roaherps. adalibrol olees aasrp•a and all ealleaaon ono Neal Ion should they
MR . CHIMNEY TEL N0 .408-866-1575 Nov 07 .94 12 :48 P .01
- MR. CHIMNEY J'lstuo, e'rPC BOX #111114
• CAMPBELL, CA. 95011 &N(400)
N 1y'A
(400) 666-1575
ST. LIC_ 0678803
11/4/94
TO: TERRY FILICE / JUDY CONRAD
RE: CONTRACT CANCELLATION / CHIMNEY REBUILD
22117 CLEARCREEK CT.
CUPERTINO, CA. 95014
THIS DOCUMENT IS TO RELEASE MR. CHIMNEY- FROM ANY
FURTHER WORK OR ACTIVITY AT 22117 CLEARCREEK CT.
CUPERTINO. CUSTOMER HAS DECIDED TO SEEK ANOTHER
CONTRACTOR'S OPINION. WE UNDERSTAND THIS AND WISH HER
LUCK WITH HER PROJECT. CUSTOMER REQUESTS A BILL TO DATE
FOR WORK PERFORMED. WE CAN ASSURE YOU THAT EVERY EFFORT
WAS MADE TO PROVIDE 6000 SERVICE AND HELP SAVE MONEY AS
WELL. WE ARE SORRY THAT THIS HAS OCCURRED AND WILL
DISASSEMBLE SCAFFOLD ON SATURDAY 11/5/94 AS SOON AS THIS
• DOCUMENT IS SIGNED. STATE CONTRACTOR'S LAW PROHIBITS
US TO VACATE UNLESS WRITTEN AUTHORIZATION IS RECEIVED.
NO OTHER CONTRACTORS ARE ALLOWED ON OUR JOB SITE FOR
COMPETATIVE REASONS OR OTHERS WHILE OUR CONTRACT IS IN
FORCE. THIS IS NOT AN ETHICAL PRACTICE WITH THE CON-
TRACTORS STATE LICENSE BOARD. AFTER WE ARE RELEASED YOU
MAY DO AS YOU WISH.
IF THIS NOTICE IS NOT SIGNED, BY LAW WE MUST CONTINUE
AS CONTRACTED. WE HAVE NO CHOICE.
THANK YOU FOR YOUR CONSIDERATION IN HIRING US. IT WAS
A PLEASURE TO SERVE YOU EVEN IN LIGHT OF THE CIRCUM-
STANCES. A BILL FOR SERVICES TO DATE IS ENCLOSED_ PAYMENT
MUST BE RECEIVED IN FULL TO INITIATE RELEASE
RESPECTFULLY,
MAC MCCARTY
. CUSTOMER'S SIGNATURE
(TER FILICE)
CC: STATE CONTRACTORS LIC. BOARD
CUPERTINO BLDG. DEPT. / FAX 777-3333