11100085CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10270 MIRA VISTA AVE I CONTRACTOR: ROYAL SERVICES I PERMIT NO: 11100085 I
OWNER'S NAME: HERLTH WILLIAM A AND VIRGINIA 12253 MAYWOOD AVE I DATE ISSUED: 10/12/2011 I
0)"4ER'S PHONE: 4082522894
* C _ � LICENSED CONTRACTOR'S DECLARATION
License Class
✓✓ C-2 I Lic. # ` 7 w b"
%/
�^- _ '
Contractor � l�/ �O �yI CC5 Date 0�ff f � �
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.
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.
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
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source re ations per the Cupertino Municipal Code, Section
9.18.
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, 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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
SAN JOSE, CA 95128
PHONE NO: (408) 972-2452
BUILDING PERMIT INFO: BLDG r- ELECT PLUMB F
MECH RESIDENTIAL COMMERCIAL r -
JOB DESCRIPTION: CHIMNEY REPAIR,REBUILD CHIMNEY SHOULDER UP
Sq. Ft Floor Area: I Valuation: $3000
APN Number: 35702026.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
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 Owner horiz cut:
Compensation laws of California. If, after making this certificate of exemption, I Date:
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
1 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
co— and expenses which may accrue against said City in consequence of the
ig of this permit. Additionally, the applicant understands and will comply
dal non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
I hereby affirm that there is a construction lending agency for the performance of vwrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
3 ITEMS OF 3
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35702026.00
DATE ISSUED.......: 10/12/2011
RECEIPT #.........: BS000015023
REFERENCE ID # ...: 11100085
SITE ADDRESS .....: 10270 MIRA VISTA AVE
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OPERATOR: patg
COPY # : 1
OWNER HERLTH WILLIAM A AND VIRGINIA
ADDRESS ..........: 10270 MIRA VISTA AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-2705
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
----------
3,000.00
----------
1.00
----------
0.00
1.00
0.00
1BSEISMICR VALUATION
3,000.00
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
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
524.50
---------------
524.50
VOICE ID DESCRIPTION
-------- ----------------------------
101 FOUNDATION
517 FINAL CHIMNEY
REFERENCE NUMBER
--------------------
#21362
VOICE ID DESCRIPTION
-------- ----------------------------
312 CHIMNEY REBAR & STRAPS
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildingC@cupertino.org
CUPERTINO
❑ NEW CONSTRUCTION ❑ ADDITION �KLTERATION/TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS J f 0;% O (A� Q � UI > � ��
1 (�)i
� # ^ v A lJ
0WNERNAME 1„/ yl� J j� ��c In
PHONE 28W
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
CONTACT NAME -T- `I
PHONE f� Vj
E-MAII
STREET ADDRESS (" /a_, ,
CITY, STATE, ZIP S>— + (?
FAX
❑ OWNER ❑ OWNER-BUn.DER ❑ OWNER AGENT /CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME L ( f ��
L 1
LICENSE NUMBER Wl 6_
'Y VV
LICENSEEE
BUS. LIC #
K V1
COMPANY NAME t (' I
E-MAIL
FAX
STREET ADDRESS S3 /�/1 1 v* / a--
Com, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE. ZIP
PHONE
DESCR]PTION OF WORK
e& M Q
EXISTING USE
PROPOSED USE CONSTR
TYPE
I # STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
'7
-�
/
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
FORCH AREA
DECK AREA
TOTAL DECKIPORCH AREA
GARAGE AREA DETACH
I
❑ ATTACH
I
# 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
�^ l /� �'�
By my signature below, I certify to each of the following I am the property owner or authorized agent to act on the pr,perty owner's behalf. I have read this
application and the information I have provided is correct. I havecZad the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I.M tho ze representatives of Cupertino to enter the above-identid property for inspection purposes.
otzl (_ r
Signature of Applicant(Agent Date:
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CRECK TYPE
ROUTING SLIP
_ New SFD or Multifamily dwellings: Apply for demolition permit for
❑ sT7IIDING PLATT 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 WORM
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ =E bm-r
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANUARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
ivuir UC►T7M A 9r"I? — 1121TIT .TIINfi' DIVICION
APPLIANCE / EQUIP TYPE FEE ID QTY BP FEES
Chimney Repair 1CHIMNEYR 1 $523
TOTALS:
1'iJ •-• Lvs
ADDRESS: 10270 mira vista
DATE: 10/12/2011
REVIEWED BY: bob s.
10
BP#:
"VALUATION: $3,000
APN:
PERMIT TYPE: Minor Building Permit
PLAN CHECK TYPE: Chimney / Chimney Repair
PRIMARY
SFD or Duplex
PENTAMATION 1CHIMNEYR
PERMIT TYPE:
USE:
WORK
cnimney repair
SCOPE
APPLIANCE / EQUIP TYPE FEE ID QTY BP FEES
Chimney Repair 1CHIMNEYR 1 $523
TOTALS:
OnTF. Tb;o—6sm"fo dnoe nnf inrtude tees aIle to otner uevartments me. rlannlnx, X-uauc ►►v►nu, c, �u,nsu•.y .��•...• �•...• •�•r - �•-��-
District, etc.. Theseees are based on the relinina information available and are onlyan estimate. Contact the De t or addn'[ ino.
FEE ITEMS (Fee Reso/ution 11-053B ,'; l%11) FEE QTY/FEE MISC ITEMS
F7
Permit Fee: $523.00
Work Without Permit? Yes No $0.00
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $524.50 $0.00 TOTAL FEE:. $524.50
Revised: iu/ul/1ul
L
Li
OnTF. Tb;o—6sm"fo dnoe nnf inrtude tees aIle to otner uevartments me. rlannlnx, X-uauc ►►v►nu, c, �u,nsu•.y .��•...• �•...• •�•r - �•-��-
District, etc.. Theseees are based on the relinina information available and are onlyan estimate. Contact the De t or addn'[ ino.
FEE ITEMS (Fee Reso/ution 11-053B ,'; l%11) FEE QTY/FEE MISC ITEMS
F7
Permit Fee: $523.00
Work Without Permit? Yes No $0.00
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $524.50 $0.00 TOTAL FEE:. $524.50
Revised: iu/ul/1ul
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: 0 1 C StO`
PERMIT #
OWNER'S NAME: 6 cA flsrt
PHONE#
GENERAL CONTRACTOR: Q �C
BUSINESS LICENSE #
ADDRESS:
CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Uupertmo business ucense.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. XW,27-/; OJ6 I/
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
intractor Signature Date
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
intractor Signature Date