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12080265 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21611 COLUMBUS AVE CONTRACTOR:ROYAL SERVICES PERMIT NO: 12080265 OWNER'S NAME: WU DONALD S AND GINA C 2253 MAYWOOD AVE DATE ISSUED:08272012 OW'NER'S PI IONE: 4083938608 SAN JOSE,C\ 95128 PI IONF.NO:1408),972-2452 ❑" LICENSED CONTRACTOR'S DECLARATION //�L/ BUILDING PERMIT INFO: BLDG r ELECT r PLUMB 0— License License Classy "I Lic.q !� n [-.�"-,� RIECH RESIDENTIAL � COMMERCIAL J Contractor _ /C.Uy(/}-1 _x,-at UICFf Date i ,27- (Z- 1 hereby affirm that 1 am licensed tinder the provisions of of Chapter 9 JOB DESCRIPTION: REMOVE AND REPLACE MASONRY CHIMNEY FROM (commencing with Section 7000)of Division 3 of the Business R Professions ROOF UP WITH SPARK ARRESTOR Cole and that my license is in full force and effect. 1 herehy 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. 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of die work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2370 APPLICANT'CERTIFICATION I certify that I have read this application and state that the above information is APN Number:35618031.00 Occupancy Type: 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. //�� Signature Ok Date �- �Z- Issued by:�/�J�:'I✓ /A�li� Date: k-a71 ❑ OWNER-BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Law for one of RF-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remote all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). hereby affirm under penalty of perjury one of the following three ALI•ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: 1 have and will maintain a Certificate of Consent to self-insure for Worker's IIA'%ARDOUS hl,\'1'FRLUS DISCLOSURE 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 read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Ilcalth&Safety Code,Sections 25505.25533,and 25.534. 1 will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilcalth& Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for ehich this permit is issued,I shall contaminants as defined by the Ray Arca Air Quality Management District I will not employ any person in my manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of Cali fomia. If,after making this certificate of exemption,I Ilcalth&Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,1 must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agen . ///+++,��Y Doty. ((err )7• APPLICAN"PCI?R'I'IFICA'1'I0N CONSTRUCTION LENDINGAGENCY I certify that 1 have read this application mid state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilitics,judgments, costs,and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCIIITECI"S DECLARATION 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional 120 0 2 cP CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 C U P E RTI N O (408) 777-3228• FAX (408) 777-3333• building Gecuoerlino.org ❑ NEW CONSTRUCTION ❑ ADDITION rh ALTERATION/TI ❑ REVISION//��DEFERRED ORIGINAL PERMIT' PROTECT ADDRESS / coIUM f-U� APN q �y`��1/1 — – 6 3' OWNER NAME ' , 1 (D (rJ I PHO`E 3L7 3 8 �J KKKE//E--MAIL STREET ADDRESS CITY, STATE,JZIP ^. �� C� FAX CONTACT NAME PHONE O Wyp E-MAIL STREET ADDRESS n .\^� M•1- �v CITY,STATEZIP _fz FAX 0 OWNER 0 OWNER-BUILDER Or OWNER AGENT �41COVTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER 0 TENANT CONTRACTORNAME `Q LICENSE NUMBER LICENSE TYPE BUS.LICA COMPANYNAME .,(�,�1) / EMAIL FAX STREET ADDRESS 4 tP A53 `^- rn Cri1An� ^.u CITY,STATE,ZI� C4 PHONE ARCHITECT/ENGINEER NAME 4 t�r^Y Y/W til LICENSE NUMBER BUS.LIC N COMPANY NAME E-MAIL FAX STREET ADDRESS ✓ CITY,STATE,ZIP y - -PHONE DESCRIPr10N OF WORK /^ ( N � V EXISTINCG USE PROPOSED USE CONSTR TYPE NSTORIES r l ��� V USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEJ10TOTAL ;737,,3 AREA AREA AREA "Er AREA `' ' / 3 dJ 37D — BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA I DECK AREA TOTALDECKIPORCH AAEA GARAGEAREA: DETACH O ATTACH M DWELLING[NITS: 15 A SECOND UNIT ❑YDS SECONDSTORY OYES IIEINGADDED! O ADDITION! 103110 PRE-APPLICATION OYES IF YES,PROVIDE COPY OF ISTBEBLDGAN OYES RECEIVE BYr4+ "t7..�,At ;�:,•. 7TOTALVALUATION: PLANNING APPL0 0 PLANNING APPROVAL LETTER MCIILER HOME" 0 d"[ .�' is Y By my signature below,1 certify,to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the informations have provided is correct. are 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 constructio . I uthorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature ofApplicant/Agenr Date: SUPPLEMENTAL INFORJNIATIONREQUIRED PZ- ri';+S�c11A`ec ,L_=�.(�- yOl1TING SLIPy3=-'f,_§y New SFD or Multifamily dwellings: Apply for demolition permit for z>_•'9i'�',�P,9. .F—s= -'? -:�s "'9' D\EIt rift COUNTER �( 4 �} BUI LZ2,111 AN RF\IEN' g�d'S existing building(s). Demolition permit is required prior to issuance of building s:S'i t"✓"c x -�T I ^' '-" -+E"fes `r=• permit for newbuilding. ©e 1 RessL- �' ✓ �' r`tY( i -ty't; S a`C i F1.. 3 ''ax'uu;i'�^'\i 0.•=-f�`1. _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure y© STANDARD) - yid a H, �.❑B f UBLIC\\ORRSFF .�+' C� T if any Hazardous Materials are being used as part of this project. �p7pv�d.Aace�'1 © FIR r_ ,1 _Copy of Planning Approval Letter or Meeting with Planning prior to ❑5'�iY�F,swNl torsi se\LR o,slwrr re- submittal of Building Permit application. C� • V S J i j(f. J- F S rr 4' ©LLN\IRONMENTAL`IIEALTII BldgADD 20/1.docrevised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 21611 Columbus DATE: 08127/2012 REVIEWED Bl': Sean APN: BP#: '1'ALUATION: $2,370 *PERMIT Tl'PE: Building Permit PLAN CHECK TYPE: Alteration I Repair PRIMARI SFD or Duplex PENTANIATION 1CHIMNEY USE: PERMIT Tl'PE: At WORK Remove and replace masonry chimney from roof up with spark arrestor. SCOPE Aieeh. Plan Check Plumb.Plan Check F.lec. Plan Check Ahfech. Permit Fee., Plumb. Permil Fee: Elec.Permit Fee: Other Afech.Insp. Other Plumb/nap. Other Elec.insp. Aaech. lisp. Fee: Phanh. lisp.Fee: Elco Insp.few: NOTE: This estimate sloes not include jeev clue to other Departments(i.e. Planning, Public Works, Fire,Sanitary Server District,School District, etc. . These feev are based on the prelintinart.•information available and are only an estintate. Contact the Dept for adrin'I info. FEE ITEMS (Fee Resolution 11-053 EZ 711111) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 # Chimney/Chimney Repair Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $534.00 lCillmiVEYR Chimney Repair PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-.0 Reg. Q OTE-6-1hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Conswilction Tax: Administrative Fee: Q Work Without Permit? 0 Yes (j) No $0.00 E) Advanced Planning Fee: $0.00 Select a Non-Residential E) Trace!Docrunentution Fees: Building or Structure A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Pee: IBCBSC $1.00 SUBTOTALS: $1.50 $534.00 TOTAL FEE: $535.50 Revised: 07/01/2012