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11090012 CITY OF CUPEATINO BUILDING PERMIT BUILDING ADDRESS: 21571 REGNART RD CONTRACTORr+B9- 41@ E PERMIT NO: 11090012 DET ED OWNER'S NAME: REYNEN FRANK R AND CHRISTINA L S j C' DATE ISSUED:09/02/2011 VNER'S PHONE: 4082532149 PHONE NO: ❑ LICENSED CONTRACTOR'S ECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALE] License Class ) Lic.# 114 V 970 REPLACE FURNACE ADD A/C C 671 * SEE NOTES Contractor J Date I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 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. Sq.Ft Floor Area: Valuation:$13500 1 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 ich this APN Number:35622007.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY RO LAST CALLED INSPE TI N. indemnify and keep h less the City of Cupertino against liabilities,judgments, costs,and expens w ich may accrue against said City in consequence of the granting of this er it. Additionally,the applicant understands and will com Issued by: Date: with all non- n ource regulations per the Cupertino Municipal C e,Se on with all no7n- n 9.18. RE-ROOFS: Signature Date / All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner 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, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined yl a ay Area Air Quality Management Distr'ct I performance of the work for which this permit is issued. will maintain compliance it h t Cupertino Municipal Code,Chapter 9.1 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Cog .Secti s 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this �- Owner or authorized agent: Date: permit is issued. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION -iemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. Ling of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS:24U. ' - PERMIT# V off. OWNER'S NAME: PHONE#gWf- GENERAL CONTRACT R: BUSINESS LICENSE# ADDRESS: „3 ,n,�ZvG Q?. CITY/ZIPCODE:6110"j-414(l .�0 *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCU CY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND AL ONTRACTORS HAVE OBTAINED A CITY OF UPER NO BUSINESS LICENSE. g I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V 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 Owner/Contractor Signature Date CITY OF CUPERTINO 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . . 35622007 . 00 DATE ISSUED. . . . . . . : 09/02/2011 RECEIPT # . . . . . . . . . BS000014658 REFERENCE ID # . . . : 11090012 SITE ADDRESS . . . . . : 21571 REGNART RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : REYNEN FRANK R AND CHRISTINA L ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4818 RECEIVED FROM . . . . : ABS HEATING 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 1. 00 41. 00 0 . 00 41 . 00 0 . 00 1BCBSC VALUATION 13, 500 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BREMAIRHA NO.UNITS 1 . 00 65 . 00 0 . 00 65 . 00 0 . 00 1BSEISMICR VALUATION 13, 500 . 00 1 . 35 0 . 00 1 .35 0 . 00 1BUSLIC FLAT RATE 1 .00 115. 00 0 . 00 115 . 00 0. 00 1MFR=<100 UNITS 1 . 00 130. 00 0 . 00 130 . 00 0 . 00 1MPERMITFE 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 441 . 35 0 . 00 441 . 35 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 441.35 12374 --------------- TOTAL RECEIPT 441 . 35 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL GENERAL PERMIT APPLICATION MEP IM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333• buildina(c.CUDertino.org misc Cl1PERTINO !!If 0 ,WWyyk� ❑PLUMBING &44MCHANICAL ❑ELECTRIdCALMISCE�ANEOUSg PROJECT ADDRESS 'f /. f7 / e111V D' APN OWNERNAME k ^ E M��L�` STREET ADDRESS �� / C TA el/ FAX CONTACT NAME PHONE �i E-MAM STREET ADDRESS CITY,STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT 00,CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAtfo L / LIC SE �O� LI SEr BUS.LIC# COMPANY NAME eSWMI�-_ E-MAIL FAX 6 &L. STREETM.�/'/ _/� /J CITY 5 l 4*7 ARCHTI'ECT/ENGINEER NAME (� '( LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET'ADDRESS CITY,STATE,ZIP PHONE USE OF C1 SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDI AND ❑ YESPROTECT IN ❑YES IS THE BLDG AN El YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO TFL OOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: RECEIVED BY: By my signature below,I certify to/buin fo owi/' I the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information s corre read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating onstruchorize representatives of Cupertino to enter the above-identified property for inspection pu[poses. Signature of Applicant/Agent: �"�`` Date: C l SUPPLE—NffiNTAL INFORMATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER ❑ EXPRESS Y U ❑ STANDARD U ❑ LARGE ❑ NIAJOR MEPMiscApp_2011.doc revised 06/21/11