11090181 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 5855 BOLLINGER RD CONTRACTOR: PERMIT NO: 11090181
OWNER'S NAME: WORKMAN GARY R AND HELENE S P TRUST CHIMNEY CLEAN DATE ISSUED:09/26/2011
OWNER'S PHONE: 4085052299 UU, INQ. PHONE NO:
L LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
C l MECH RESIDENTIAL COMMERCIAL
Contractor Cc,�p N Date zC
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL GAS LINE FOR NEW GAS FIREPLACE INSERT,
(commencing with Section 7000)of Division 3 of the Business&Professions ADD
Code and that my license is in full force and effect. NEW OUTLET ABOVE FIREPLACE
I hereby 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.
I 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 is issued. Sq.Ft Floor Area: Valuation:$8843
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:.37535017.00 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 allno -point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
(_ ( �
Signature &`�
Date� `� L ( Issued �— Date:
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-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 remove 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).
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS 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
1 have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I 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 Health&
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 which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any 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 California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,1 must
te or i
forthwith comply with such provisions or this permit shall be deemed revoked. h ize Date:— �& ,
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 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 liabilities,judgments,
,nsts,and expenses which may accrue against said City in consequence of the Lender's Address
sting of this permit.Additionally,the applicant understands and will comply
,h all non-point source regulations per the Cupertino Municipal Code,Section
9.18. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
8 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37535017. 00
DATE ISSUED. . . . . . . : 09/26/2011
RECEIPT #. . . . . . . . . BS000014855
REFERENCE ID # . . . : 11090181
SITE ADDRESS . . . . . : 5855 BOLLINGER RD
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER WORKMAN GARY R AND HELENE S P
ADDRESS . . . . . . . . . . : 5855 BOLLINGER RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DENNIS JUSTUS
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . :
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 2 . 00 82 . 00 0 . 00 82 . 00 0 . 00
1BCBSC VALUATION 8, 843 . 00 1. 00 0 . 00 1 . 00 0. 00
1BREMRECEP NO. OUTLETS 1 . 00 44 . 00 0. 00 44 .00 0. 00
1BSEISMICR VALUATION 8, 843 . 00 0 . 88 0. 00 0 .88 0. 00
1EPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
1PGASRES OUTLETS 1 .00 65. 00 0 . 00 65. 00 0 . 00
1PPERMITFE FLAT RATE 1 . 00 44 . 00 0. 00 44 .00 0 . 00
1TRAVDOC FLAT RATE 1. 00 44 . 00 0. 00 44 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 324 . 88 0 . 00 324 .88 0 . 00
/ 01I0l4�/
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
r'UPERTINO (408)777-3228 • FAX(408)777-3333• building(3cupertino.org MISC
ZPtU19—ING ❑MECHANICAL fletteT%CAL ❑MISCELLANEOUS
PROJECT ADDRESS ! �S n 0 APN#C _ G� ✓ U /
OWNER NAME E-MAIL
STREETADDRESS W (� CITY, STATE,ZIP FAX
CONTACT NAME PHONE
J E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME /I r LICENSE NUMBER % 7d9(' LICENSE TYPE/'�C� BUS.LIC#
COMPANY NAME ` W E-MAIL Ip 6 (- i FAX
STREET ADDRESS /� v V G CITY,STATE,ZIP
PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OFor DUPLEX ❑ MULTI-FAMII Y PROJECT IN WILDLAND ❑ YES PROTECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
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TOTAL VALUATION: Isle RECEIVED BY:
By my signature below,I 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 information I have provided is correct.�1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relati bui ' construction`.`I r!;�ze represents f Cupertino to enter the above-identified property for inspection pu{poses.
\C.'
Signature of Applicant/Agent: Date: //
SLTPPLEWENTAL INFORMATION REQUIRED OFFICE USE ONLY
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❑ EXPRESS
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MEPM=App_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 5855 bollinger rd. DATE: 09/26/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: 1$8,843
PERMIT TYPE: Building Permit j PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1GENRES
USE: PERMIT TYPE:
WORK install gas line for new gas fireplace insert add new outlet above fireplace.
SCOPE
Plumb.Plan Check 0.0 1 hrs $0.00 Elec.Plan Check 1 0.0 1 hrs $0.00
[Plumb.Permit Fee: 1PPERMIT Elec.Permit Fee: IEPERMIT
Other Plumb Insp. 0.0 hrs $44.0 Other Elec.Insp. 0.0 Jrs $44.00
NOTE: This estimate does not include fees due to other Depts(i.e.Public Works,Sanitary Sewer District,School District,etc.).
Thesefees are based on the preliminary infor available and are only an estimate. Contact the Dept-for addn 7 info,
FEE ITEMS (Fee Resohition 11-053 E 1,-11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl. PC Fee: Reg. OT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00 0 # Plumbing
Permit Fee: $0.00 $65.00 IPGASRES Piping, Gas<=4 Outlets
Suppl. Insp. Fee Reg. 0 __T OT 0.0 hrs $0.00 1� Electrical
PME Unit Fee: $0.00 $44.00 IBREMRECEP Recep/Switch/Outlets
PME Permit Fee: $88.00
Administrative Fee: ]ADMIN $41.00 0
Work Without Permit? 0 Yes (F) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential Q
Travel Documentation Fee: ITRA VDOC ( $44.00 Building or Structure
A
Strong Motion Fee: 1BSEISMICR 0.88 =hrs Admin./Clerical Fee
Bldg Stds Commission Fee: IBCBSC $1.00 $41.00 IADMIN
SUBTOTALS: $174.88 $150.00 TOTAL FEE: 1 $324.88
Revised: 09/02/2011
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
:UPERTINO
CONTRACTOR/ SUBCONTRACTOR LIST
MGENERAL
SS: 6(—Lt PERMIT# �l
AME: a2
ONE
ONTRACTOR: C� M f� /�C BUSINESS LICENSE#
5 CITY/ZIPCODE:
X municipal code requires all businesses working in the city to have a City of Cupertino business license. HE
UNTIL
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S)HAVE OBTAINED AHCITY OF CUPERTINO
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS
BUSINESS LICENSE. a�&710 ,r
I am not using any subcontractors: ignature 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
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Date
Owner/Contractor Signature