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11070091 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10450 GLENVIEW AVE CONTRACTOR:ROYAL SERVICES PERMIT NO: 11070091 OWNER'S NAME: JIN XIE 4398 NICKER CT DATE ISSUED:07/14/2011 CI'-`TER'S PHONE: 4083290926 SOQUEL,CA 95073 PHONE NO:(408)972-2452 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class "� Lic.# -7-0v MECH RESIDENTIAL COMMERCIAL � Contractor Uj ate ( "'k I hereby affirm that I m licensed under the provision f Chapter 9 JOB DESCRIPTION:REBUILD CHIMNEY SHOULDER UP ON SFDWL (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 declar tions: 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:$3000 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. APN Number:36911017.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertin I bilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue aga said City in co sequence of the granting of this permit. Additionally a applicant un derst s and will comply with all non-point source regulati s per the Cupertino Mu cipal Code,Section Issued by: Date•7''�—/--�I 9.18. Signature Date RE-ROOFS: E OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this 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 P Health&Safety Code,Sectio 5505,25533,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 or authorized age Compensation laws of California. If,after making this certificate of exemption,I Date: dlL4 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 I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, r and expenses which may accrue against said City in consequence of the ARCHITEC'T'S DECLARATION ►g of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. w.m ail non-point source regulations per the Cupertino Municipal Code,Section 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 . . . . . . . . : 36911017. 00 DATE ISSUED. . . . . . . : 07/14/2011 RECEIPT #. . . . . . . . . : BS000014048 REFERENCE ID # . . . : 11070091 SITE ADDRESS . . . . . : 10450 GLENVIEW AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . JIN XIE ADDRESS 10450 GLENVIEW AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ANTHONY XAVIEL CONTRACTOR . . . . . . . : TONY XAVIEL LIC # 22767 COMPANY ROYAL SERVICES ADDRESS 4398 NICKER CT CITY/STATE/ZIP . . . : SOQUEL, CA 95073 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 AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 524 .50 #21051 --------------- TOTAL RECEIPT 524 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 101 FOUNDATION 312 CHIMNEY REBAR & STRAPS 517 FINAL CHIMNEY CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10450 glenview ave. —7DATE: 07/14/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$3,000 *PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Chimney/Chimney Repair PRIMARY SFD or Duplex PENTAMATION 1CHIMNEYR USE: PERMIT TYPE: WORK chimne re-build for sfd SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES Chimney Repair 1CHIMNEYR 1 $523 TOTALS: NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info. FEE ITEMS ( ee Resolution 11-053 J�j1� FEE QTY/FEE MISC ITEMS F71 A Permit Fee: $523.00 Work Without Permit? 0 Yes E) No $0.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $524.50 :$0:0±0 TOTAL FEE:' $524.50 Revised: 07/04/2011 --_......_......,w.�rnr -enact rnu L.o+iuss a.lYVviwuv.•...v�.-�-- ----- - - - "��--- --� ��_..L....� Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RTI N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: (r-# f e4(f PERMIT# f / (-. Z 0 C) OWNER'S NAME: j 0(/ )r67 PHONE# q06 `I?,1-,)Y GENERAL CONTRACTOR: i4r6J BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: - Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333•buildingCo)cupertino.org ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROTECT ADDRESS } 0 L/ APN#_::�>9-I ^ � OWNER NAME0-/� y i/� �oG � 0 fa 6 E-MAIL STREET ADDRESS SQ`\ CITY, STATE,ZIPt� A v FAX CONTACT NAME PHONE STREET ADDRESS 2-2�-J CITY,STATE, /ZIP ^ FAX ❑OWNER ❑ OWNER-BUILDER X13 OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUM$E`/� LICENSE TYPE BUS.LIC '44 `��1 i K7 COMPANY NAME E-MAIL FAX STREET ADDRESS ` ` m L� CITY,S'I'FT IP j O PHONE ARCHITECT/ENGINEER NAME vY�T LICENSE NUMBER f'* BUS.LIC# /[ COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES + USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO V 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 G 300 r-- 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 buildin cons rcI authorize representatives of Cupertino to enter the a ve-i ntified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL t701ttTION REQUIRED PLAN CHECK TYPE OUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit forOVER-THE-COUNTER 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_201 Ldoc revised 06/21/11