12050218CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10497 ANSON AVE
CONTRACTOR: ROYAL SERVICES
PERMIT NO: 12050218
OWNER'S NAME: WALTERS WORTH B AND LENA E
2253 MAYWOOD AVE
DATE ISSUED: 05/30/2012
OWNER'S PHONE: 6507142075
SAN JOSE, CA 95126
PHONE NO: (406) 972-2452
Cl--'rLICENSED CONTRACTOR'S
r r r
BUILDING PERMIT
/DEECLARATION
License Class C-7 Lic. M � i I W O
INFO: BLDG ELECT PLUMB
r r- r
MECH RESIDENTIAL
Contractor J�IR"l U(t-Cr Date
COMMERCIAL
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REPLACE AND REBUILD CHIMNEY FOR SINGLE FAMILY
(commencing with Section 7000) of Division 3 of the Business & Professions
DWELLING
Code and that my license is in full force and effect.
1 hereby affirm under penally 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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area:
Valuation: 53300
Section 3700 of the labor Code, for the performance of the work for which this
permit is issued.
APN Number: 32641110.00
Occupancy Ty pe:
APPLICANT CERTIFICATION
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
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
indernni fy and keep harmless the City of Cupertino against liabil ities, judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit Additionally, the applicant understands and will comply
with all non -point source reguI It per the Cupertino Municipal Code, Section
9.16.
Issued
Signature A —.Date
❑ OWNER -BUILDER DECLARATION
RF. -ROOFS:
hereby affirm that I am exempt from the Contractor's License Lew for one of
All roofs shall be inspected prior to airy roofing material being installed- If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
the following two reasons:
inspection.
I, as owncr 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,
Signature of Applicant: Date
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penally of perjury one or the following three
declarations:
HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self -insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health &
I have and rill maintain Worker's Compensation Insurance, as provided for by
Safety Code, Section 25532(a) should I stare or handle hazardous material.
Section 3700 of the Labor Code, for the performance of the work for which this
Additionally, should 1 use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Qualily Management District l will
I certify that in the performance of the work for which this permit is issued, I shall
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safely Cade, Sections 25505, 2.5.533, and 25534.
not employ any person in any manner se as to become subject to the Worker's
Compensationlaws ofCal ifomia. If, after making this certificate of exemption, I
Owner or uthorizeda
bcc0111c subject to the Worker's Compensation provisions of the Labor Code, I must
Dale:0'� Z-
forthwilh comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of work's
certify that I have read this application and stale that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
:orecl. I agree to comply with all city and county ordinances and state laws relating
Lender's Name
o building construction, and hereby authorize representatives of this city to enter
ipon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
ndemnify and keep harmless the City of Cupertino against liabilities, judgments,
;osts, and expenses which may accrue against said City in consequence of the
;ranting of this permit. Additionally, the applicant understands and will comply
ARCHITECT'S DECLARATION
Nith all non -point source regulations per the Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
).18.
Licensed Professional
signature Date
3 ITEMS OF 6
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32641110.00
DATE ISSUED.......: 05/30/2012
RECEIPT #.........: BS000016954
REFERENCE ID # ...: 12050218
SITE ADDRESS .....: 10497 ANSON AVE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
VOICE ID DESCRIPTION
-------- ----------------------------
101 FOUNDATION
517 FINAL CHIMNEY
VOICE ID DESCRIPTION
-------- ----------------------------
312 CHIMNEY REBAR & STRAPS
OWNER ............:
WALTERS WORTH B AND
LENA E
ADDRESS ..........:
10497 ANSON AVE
CITY/STATE/ZIP ...:
CUPERTINO, CA 95014-1346
RECEIVED FROM ....:
ANTHONY XAVIEL
CONTRACTOR .......:
TONY XAVIEL LIC #
22767
COMPANY ..........:
ROYAL SERVICES
ADDRESS ..........:
2253 MAYWOOD AVE
CITY/STATE/ZIP ...:
SAN JOSE, CA 95128
TELEPHONE ........:
(408) 972-2452
FEE ID
UNIT QUANTITY
AMOUNT PD -TO -DT THIS REC
NEW BAL
----------
1BCBSC
------------- ----------
VALUATION 3,300.00
---------- ----------
1.00 0.00
----------
1.00
----------
0.00
1BSEISMICR
VALUATION 3,300.00
0.50 0.00
0.50
0.00
1CHIMNEYRE
EACH 1.00
523.00 0.00
523.00
0.00
TOTAL PERMIT
---------- ----------
524.50 0.00
----------
524.50
----------
0.00
VOICE ID DESCRIPTION
-------- ----------------------------
101 FOUNDATION
517 FINAL CHIMNEY
VOICE ID DESCRIPTION
-------- ----------------------------
312 CHIMNEY REBAR & STRAPS
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
gaFADDRESS:
10497 anson ave. DATE: 05/30/2012
APN: BP#:
REVIEWED BY: bobs.
'VALUATION: $3,300
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
/i ltc. Ycrrnit Fte:
PENTAMATIOry 1CHIMNEY
PERMIT TYPE:
WORK
re lace and rebuild chimney for sfd.
SCOPE
Plunk. lr„/,. Fee:
NOTE: This ertimare does not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These lees are based on the preliminary information available and are only an estimate Contact the Dept for addn'l info.
FEE ITEMS (/ ec Resohirion II -053 Eff 7/I/II)
Alech. I'lon Chee 4,,
Phrmh. Pion Check
Flee. Plan Chuck
dhv:tr. I'e,"in Fee:
1'lunrh. Permit Fre:
/i ltc. Ycrrnit Fte:
011'er .11e. h. Imp.
Other Plumb Imp.Li I
(filer /ilex. Lrcp.
.blcelr. My, For:
Plunk. lr„/,. Fee:
tree. hrs/,. Fce•
NOTE: This ertimare does not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These lees are based on the preliminary information available and are only an estimate Contact the Dept for addn'l info.
FEE ITEMS (/ ec Resohirion II -053 Eff 7/I/II)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$523.00
Chimney / Chimney Repair
ICHIMNBYR I Chimney Repair
Suppl. PC Fee: 0 Reg. 0 OT
FO.OThrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:O Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
C'unstructinn Tax:
ildininist r tiie Fcc:
0
0
Work Without Permit? O Yes 0 No
$0.00
Advanced Plannine Fee:
$0.00
Select a Non -Residential
Building or Structure
0
t;�
7•rurr./ /)ncnntcovariun Fees:•
Strong Motion Fee IBSEISMICR
$0.50
Select an Administrative Item
13Ide Stds Commission Fee: 1BCBSC
$1.00
?' , i- ,_,' - SUBTOTALS:
$1:50
$523.00
TOTAL FEE:
$524.50
Revised: 05/01/2012
u
CUPERTINO
F1 NFw rc)NSTRI lr'
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950143255
(408) 777-3228 • FAX (408) T77-3333 • buildin°(a),cuoertino.oro
-ION n ADDTITON 14'ALTERATION / TI I1 REVISION /DEFERRED ORIGINAL PERMIT Y
PROIECTADDRESS (O 47-A�sov� QY
AFN1
OWNER NAME _A -f r 14 J
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PHONES '7Iy�O7)•
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STREETADDRESS n M
CITY, STATE, ZIP,V
FAX
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CONTACT NAME O
PHONE ( �2_
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❑ OWNER ❑ OWNER -BUILDER 11 0IWNEAI AGENT CrMt ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRAC`ORNAME p
LICENSE NUMBER
LICENSE TYPE
BUS. LICA
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COMPANY AMEn `
EMAIL
FAX
(1<� r
STREET ADDRESS �t 2
CITY. STATE, ZTPSfflA n
PHONE q r1�, •Y
S`✓ '� qU
ARCHITECT/ENGINEER NAME LICENSENUMBER
BUS. LICA
COMPANY NAME
EMAIL
FAX
STREET ADDRESS
CITY, STATE; ZIP
PHONY
DESCRIPTION OF WORK
EXISTING USE
PROPOSEDUSE
CONSTRTYPE
#STOR@5
I
USE
TYPE
OCC.
BQ.FT.
VALUATION (S)
EXLSTO
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
/
\
—]
_
`3 0 O
BATHROOM KITCHEN OTHER
REMODELAREA REMODELARFA REMODEL AREA
PORCH AREA DECKAREA
TOTALDECKNORCHARFA GAMGE AREA DETACH
I
ATTACH
I
a DWELLING UNITS:
ISA SECOND UNIT YES
SECONDSTORY OM
BEING ADDEDT ❑NO
ADDITION' ❑NO
PRE -APPLICATION []YES IF YES. PROVIDE COPY OF
IS TIME BLDG AN L] YES
RECEIVED BY: I
TOTAL VALUATION:
PLANNNG ADPL a []NO PLANNING APPROVAL LETTER •
wCBLER HOME' [JNO
_
O O
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the prpperty oWnces behalf. 1 have read this
application and the information 1 have provided is correct 1 have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and state laws relating to building construction. I auth representatives of Cupertino to enter the above identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
P CRECKTYPE
ROUTING SLE?
HIIDDQiG
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
OVER-THE-COUNTER
PLAN REVIEW
-
permitfornewbuilding.
❑ EXPRESS
❑ PLAN'NLYOPLAN! REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORKS
_
form if any Hazardous Materials are being used as part of this project.
❑
LARGE
❑ FIREDEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
EI SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENMONMHNTALMRAIT'H
B/dgApp_2011. doc revised 06121/11