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11090082 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21886 WILSON CT CONTRACTOR:MP3 MASONRY PERMIT NO: 11090082 OWNER'S NAME: LINTHICUM JAMES A AND CAROL D 4530 FAIRVIEW RD DATE ISSUED:09/13/2011 C -'ER'S PHONE: 4084463958 HOLLISTER,CA 95023 PHONE NO:(831)637-6663 ❑ LICENSED CONTRACTOR'S DECLARATION /� BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class1— '6) Lic.#�� MECH RESIDENTIAL COMMERCIAL Contractor�/� dSOI7/'y Date I hereby affirm that I am licensed under the provisio s of Chapter 9 JOB DESCRIPTION:REPAIR EXISITNG MASONARY CHIMNEY FROM (commencing with Section 7000)of Division 3 of the Business&Professions FOUNDATION Code and that my license is in full force and effect. 1 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 Sq.Ft Floor Area: Valuation:$5900 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:32649019.00 Occupancy Type: 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 indemnify and keep harmless the City of Cupertino against liabilities,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- " ource regulations the Cupertino Municipal Code,Section 9.18. Issued by: Date: Signatu �."` ? _--..- Date OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, 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 penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 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. I 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 will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. 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 O 1 er orifi r rt: 1 become subject to the Worker's Compensation provisions of the Labor Code,I must / ' Date: forthwith 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 wrk's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, `s,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION _nting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32649019. 00 DATE ISSUED. . . . . . . : 09/13/2011 RECEIPT #. . . . . . . . . : BS000014739 REFERENCE ID # . . . : 11090082 SITE ADDRESS . . . . . : 21886 WILSON CT SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : LINTHICUM JAMES A AND CAROL D ADDRESS . . . . . . . . . . : 21886 WILSON CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1245 RECEIVED FROM . . . . : MARILYN MILLER CONTRACTOR . . . . . . . : PATRICIA GERE LIC # 27197 COMPANY . . . . . . . . . . : MP3 MASONRY ADDRESS . . . . . . . . . . : 4530 FAIRVIEW RD CITY/STATE/ZIP . . . : HOLLISTER, CA 95023 TELEPHONE . . . . . . . . : (831) 637-6663 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 5, 900 . 00 1. 00 0. 00 1. 00 0 . 00 1BSEISMICR VALUATION 5, 900 .00 0.59 0. 00 0 .59 0. 00 1CHIMNEYRE EACH 1 .00 523 . 00 0 . 00 523 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 524 .59 0 . 00 524 .59 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 524 .59 MC --------------- TOTAL RECEIPT 524 .59 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 101 FOUNDATION 312 CHIMNEY REBAR & STRAPS 517 FINAL CHIMNEY I toc\ 00E �L, CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333• building(Dcupertino.org CUPERTINO "" ❑NEW CONSTRUCTION ❑ ADDITION 9-<—TERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROTECT ADDRESS >1 , i � . A- # 1 OWNER NAbf7p /Aag `N ^ll GUlZ� IP& _ ;;TTMAfI. STREET ADDRESS ` ' /J /�.� CITY, STATE,ZI FAX CONTACT NAME n� P J &� EMAIL STREET ADDRESS e vi ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT 11 ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME r LICENSE LI( SE Til P BUS.LIC# 7 C COMPANY NAME E MAIL "/,e FAX STREET ADDRESS � r, � CITY,STA C I>�� PHONE I ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK - ' tYK�a EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(5) EXLSTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET.AREA BATHROOM KITCHEN OTHER / REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ATTACH #DWELLING UNITS: IS A SECOND UNIT []YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION: PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO / _ By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the✓✓prrperty owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin Idi construc' thorize representatives of Cupertino to enter the above-i entified property for inspection purposes. Signature of Applicant/Agent: Date: ��-✓ SUPPLEMENTAL INFO ON REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for CL--ff�R-THE-COUNTER LJ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN 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 ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21886 wilson ct. DATE: 09/13/2011 REVIEWED BY: APN: BP#: VALUATION: 1$5,900 ;�PERMIT TYPE: Minor Building Permit JPLAN CHECK TYPE: Chimney/Chimney Repair PRIMARY SFD or Du lex PENTAMATION 1CHIMNEYR USE: p PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES Chimney Repair 1CHIMNEYR 1 $523 TOTALS: NOTE. This estimate does not include fees due to other Depts(i.a Public Works,Sanitary Sewer District,School District,etc.). Thesefees are based on the preliminary in ormadon available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS Fee Resohrtion 11-053 Eff. '%1,%11) FEE QTY/FEE MISC ITEMS F7 Permit Fee: $523.00 Work Without Permit? 0 Yes No $0.00 A Strong Motion Fee: IBSEISMICR $0.59 Select an Administrative Item L131dg Stcls Commission Fee: 1BCBSC $1.00 SUBTOTALS; $524.59 $0.00 TOTAL FEE: $524.59 Revised: 09/02/2011 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: ,S' " ' PERMIT# OWNER'S NAME: 'rvo'-—1`j i GU cvt< PHONE# 31 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND AL CONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. %' 1 am not using any subcontractors: Sig tur 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