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11070175 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1673 GALWAY DR CONTRACTOR:MR.CHIMNEY&AMSON PERMIT NO: 11070175 CONST. OWNER'S NAME: KEENLY RICHARD R AND CYNTHIA A 903 SANDRA ST. DATE ISSUED:07/27/2011 r ER'S PHONE: 4087716541 LOS BANOS,CA 93635 PHONE NO:(408)866-1575 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# /�! "— r MECH RESIDENTIAL COMMERCIAL Contractor -2� /' ,��-�/ I hereby affirm thaam licensed under the ovisions of Chapter 9 JOB DESCRIPTION:REPAIR CHIMNEY AT ROOFLINE,CONTRACTOR (commencing with Section 7000)of Division 3 of the Business&Professions CONFIRMS Code and that my license is in full force and effect. RE-BAR 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:$2500 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:36624028.00 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 ��o /�/C ate Issued by: Date ' Z 7 te, L. 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 I,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 I 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 1 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,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner, r authorized agent: t r 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 ip-' unify and keep harmless the City of Cupertino against liabilities,judgments, C ind expenses which may accrue against said City in consequence of the Lender's Address grai.tnng of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 1673 galway DATE: 07/25/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$2,500 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair PRIMARY SFD or Duplex -7 PENTAMATION 1CHIMNEY USE: PERMIT TYPE: WORK repair existing c imney at roofline contractor confirms re-bar. SCOPE NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info. FEE ITEMS (Fee Resolution 11-053 f(— ';'1.-I1) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # Chimney/Chimney Repair Suppl.PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00 $523.00 ICHIMNEYR Chimney Repair PME Plan Check: $0.00 Permit Fee: $0.00 Suppl.Insp.Fee<D Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes 0 No $0.00 0 Work Without Permit? 0 Yes 0 No $0.00 0 Planning Fee: $0.00 Select a Non-Residential 0 Building or Structure 0 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bld7 Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $523.00 TOTAL FEE: $524.50 Revised: 07/04/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 ELI] Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: > PERMIT# OWNER'S NAME: PHONE# yG' '— GENERAL CONT C. O_R BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: ` *Our municipal code requires all businesses w rking in the city to have a City of Cuperti o business license. 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. I am not using any subcontractors: fJ 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 'j L Let ner/Contractor Signat Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333 • building0cupertino.org CUPERTINO ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT`ADDRES i APN OWNER NAME r,.+ / PHONE /I' E-MAIL / V62e- i -(!i STREET ADDRESS CTY STAT ZIP CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUM ER LICENSE TYPE BUS.LIC# AMA-0_ 4 C CO=E ' E-MAIL FAX S T ADDRESS CITY,STATE,ZIP ` PHONE _ r. �// l. 1. 2 - i — ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE 7ESCRIPTION OF WORK + , 7 ( . 'IL EXISTING USE PROPOSED USE CONSTR E #STORIES S t `// ��o USE TYPE OCC. SQ.FI'. VALUATION(S) EXISTG I NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA J—PP � SoL9 Lc BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: DETACH []ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? ONO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATIONC,2)2)\ PLANNING APPL# ❑ ❑NO PLANNING APPROVAL LETTER EICHLER HOME? NO y�f y � , 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 relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL TNFaMATON REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for D-=R-TIS-COUNTER 11-IUII.DING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ ExPREss ❑ PLANNING PLAN REVUW _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 submittal of Building Permit application. ❑ MAJOR SANITARY SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11