08100200 CITY OF CUPERTINOr« � , 'Yrs%r `�` %'�°''° 'b" ,`•`'
BUILDING DIVISION PERMIT CCINTRAG'£ORI1�'I`f�RMAT'jf�J�-N r"
BUILDING ADDRESS: PFAMTT NO.
7597 KIRWIN LN FIREPLA
OWNER'S NAME: PERMIT ISSUE DATE
o
ONE: A O. CONTROL NO.
(650) 967-8800
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
! 'BLDG ELECT PLUMB - MECH
0 0 0 0
uOZ LICENSED CONACTOR'S DECLARATION Job Description
FOC DR
1 hereby that y affirre +t 1 licensed under provisions of Chapter 9(eom uce,ml P
�DU
whit section 7")of Divitlon Sof the Business and Proresdaru Code,stud my It..I.
" y in full force and affect. REPAIR CHIMNEY INSTALL NEW GAS LINE, INSTALL GAS
? c Datevc°aaa ccomaaor FIREPLACE, MECHANICAL
n W ARCHITECTS DECLARATION
( 7 1 understand my Pins shall the useu
e d public records
;6u
`off Licerucd Pmfesaovl
OWNER-BUILDER DECLARATION
Coy 1 Tome msec Nei i 1. exempt from the Contrac or,IJemm taw for to
Coo following masse emuon 703 coon. Business and Professions Cade:MY ritY m musty
which its a permit m consumt eller,improve.deroolih permit U or repair andotcomsomeone
pd., isl cenwd u aqui ftpmapplieanlforsummwisLi=film sisrodsulcmem
a (cmumlicensed pursuant mdse pmvivian,of.rtheBat.at;wn¢taw(@aptar9 Sq.Ft.Floor Area Valuation
E�p (commencingwidesectiw 7(DO)ofanddo Divuiofr the
ticeged evand
ption.Anyessi vi Cade).,
that he u eumpl deertrrotn and IIs bssu for Lha algcd ewnptiau Any vklatim of 3 0 0 0
Section 7031.5 by arry applicant for m permit sabjau We applicant m a civil penalty of APN Number Occupancy Type
nor more than five hundred dollars(SM 35921009 . 00
❑L u awtn of tiro pepmy,m my wplayeo Wth wagca ss lhe'tr sok compewtion,
and dorhework.and We he ComunotSLaoso Law does
a4,Boer of
and easy wh ons Codc The Contactors Lfmse Law doe,net apply f rt owner of Required Inspections
none
Wildmorimprovesthemprove Who docasmhwmkh rroff or throughhis
own em.oym,provided Nat such improvements amrotinarMN m leerd formic.IL
builder the Wilding mImpmvemmnissoldwithinane)earofcompletion,Weowmr-
buildm will have Ne Wham of proving that he did an,Wild or improve for purpose or
Van as owner of the PropenY•am exclusively w rmcting wide licensed mnuanan an
construct the Mjca(See 7044,Business and P,eressimus Cade:)The Cmmnoc's l-
ame Law does mot appy to an owms of propenY rho Wilds or iefnow Wermer,and,
who cmuaeu for such projects wide a mntacnm(s)licensed purswnt on the Contractors
License Law.
1 mer exempt under
Sm .B&P�C mWu reason
OwnerI x/ L-W-a"A'er-� Data a�
NORKER'S COMPENSATION DECLARATION
1 hereby alfum under perWty of perjury ow or dm following deeWtiov:
1 hsve and will maintain aCertifiuteof Covent to self-boom fm WorluesCmnpery
"m,ss provided fm by Section 37W of We Labor Code.for We perform.of the
work for which this permit is issued.
0 1 have and will maintain Workers Compenution Insurance,as tcquhud by Section
37(30 of the Labor Codt for the performance of the work formich this Permit is issued. .
My Workers Compensation Wer.carrier and Polity number tae:
ctuder, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Olds maim mod,mthecanplemd tithe Permit is(mom hundred do0an($100)
ori ss)
I m tify that in the performance of the work(w which this permit Is Wood.1 shall not
employ any person in my m t�r ssgb came subject to tim wmkers'Compmeames,
Laws of California.Dam
NOTICE TO APP CAI If,&Acer making Nis cniRcase of Exemption,you should
become subject W We Workers Compensation provisions of dee labor Code,you am
.J O
EfoMwide comply with such proviaov m this permit shall be doomed revoked.
Z r! CONSTRUCTION LENDING AGENCY
I hereby arum this them is a construction lending agency for de,performance of
We work for which this permit h Wood(Sec.3097•Civ.C.)
6Wi Q Landers Name ,
M Z tenders Address
U Q I mnifY that 1 have mad this applicatim and sum dust the move information Is
(L E cortex I agree m=reply with all city and county ontinances and sum laver mining m
C) Wilding construction,and hereby authorize repmemlaim of this city an enter upon the
Lu cove-mwGomd Moporty fm inspection Purposes
gap (We)agree to save,indemnify and keep harmless the City of Cuper ire agaimt
rp liabilities•judgment,costa and expenses which may in any my merne against said City
U ,Z in conseqmnce of the grunting of this permit /r/a
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date 9Yr/'/--
SOURCE REGULATIONS.
fino00,co ha/46g Re-roofs
Signsfma of licmVCan Di
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding mmupann,mre or rear llc haardons materia
as defined by We Cupertino Municipal Code.Chapter 9.13.aro the Health and Safety
Code,Socdm 25532(.)T ` / All roofs shall be inspected nor to an roofing material being installed.
❑Yet ®Na P P Y g g
Will dee applicant or future Wilding occupant me equipment m dooms which If a roof is installed without first obtaining an inspection,I agree to remove
It b. no air commummus an defined by the Bay Area Air Quality Management all new materials for inspection.
stdctT \
i
C3 ye, No
m
I have ad We hummk/era--- rnmaaalsmquiremenu under CTupter6,95 of dm corm-
nu Health&Samy,Code,Smriw2550.25533 and25534.1 undraswd dunifto building
dura net currently have a nwmL dost it Is my responsibility m notify the occUpanr of Ne
to cnu whin sal be met prior no issuanceof a Ccrtirmam of mpamy' Signature of Applicant Date
owmrm t nmedagcm dZam- All roof coverings to be Class's"or better
CITY OF CUPERTINO
• 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35921009 . 00
DATE ISSUED. . . . . . . : 10/30/2008
RECEIPT #. . . . . . . . . : BS000006509
REFERENCE ID # . . . : 08100200
SITE ADDRESS . . . . . : 7597 . KIRWIN LN
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHECKMAN HARVEY B AND INA
ADDRESS . . . . . . . . . . : 7597 KIRWIN LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4338
RECEIVED FROM . . . . : HARVEY B CHECKMAN
CONTRACTOR . . . . . . . : CLINT WALKER LIC #29544
COMPANY . . . . . . . . . . : FIREPLACE CONTRACTORS
ADDRESS . . . . . . . . . . : 519 SAN PIERRE WAY
CITY/STATE/ZIP . . . : MOUNTAIN VIEW, .CA 94043
TELEPHONE . . . . . . . . : (650) 967-8800
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- -------- ------- ----------
1BSEISMICR VALUATION 3 ,'000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1CHIMNEYRE EACH 1 . 00 490 . 00 0 . 00 490 . 00 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1MPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
TOTAL PERMIT 612 . 87 0 . 00 612 . 87 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- ------- --------------------
CHECK 612 . 87 #0279
---------------
TOTAL RECEIPT 612 . 87
•
Community Development
10300 Torre Avenue
sa
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
OCUPEkTINO
Building De artment
JOB ADDRESS: 7 57 -7 f::�z P vv ZN L-V PERMIT #
c e a a:t( A.ro s o f(00
OWNER'S NAME: /{ r c PHONE # go
GENERAL CONTRACTOR P kc4.-o— Ccs y FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
CUPE(�TINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date:
511 21 on 9.Oo / - 30�a-
Building Address:
s 17 Kiuvlzti Lame C. t4pLp- ( ffI Cp gSoIL
Mailing Address (if different from building address):
Owner's Name: Pho e #:
H Q pv i=�{ CPC C K Ivkp N -0�2 7 7 6— 3 0 3 3
Contractor: 1`r2t PLhC� Go✓7RA� rd2s Phone: GS r 96 SOa
Fax:
Contractor License#: -711 j zf L�
Cupertino Business License#: '2 `� 5 41
Contact: C LI N i W N L tL;L 2 Phone: v
• Fax:
Residential Commercial
Job Description: REPAIR CNIMNEY� IN STNLL NEW GIDS LJAI �
XNsrnt- c VIQEPLACC ZNSEVtT) /7N 1) M[cN/ONI cNL
Building Permit Info:
Bldg 9� Elect Plumb C Mech ❑
Type of Construction (Usage Class): Occupancy Type:
I-A, I-B E] II/IIIN-A ElIL/Ill B, IV-HT, V-B ❑� l
Valuation: Square Footage:
Project Size: Express D—Standard ❑ Laze ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgreen.org
Revised 10/20/08