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11050014 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10319 MARY AVE CONTRACTOR:JON R CRASE PERMIT NO: 11050014 CONSTRUCTION INC OWNER'S NAME: ROBERT VACHALEK 164 GILMAN AVE STE A DATE ISSUED:05/03/2011 ER'S PHONE: 5105995281 CAMPBELL,CA 95008 PHONE NO:(408)370-1485 ❑ LICENSED CONTRACTOR'S DECLARATION �/ BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lie.# 611 S/ MECH I— RESIDENTIAL COMMERCIAL r Contractor 42404cere dv^✓ Date Jr- 1� sof hapter 9 JOB DESCRIPTION:REMOVE WOOD BURNING FIREPLACE REPLACED WITH I hereby affirm that I am licensed under the provisio (commencing with Section 7000)of Division 3 of the Business&Professions DECORATIVE GAS APPLIANCE Code and that my license is in full force and effect. N ereby affirm under penalty of perjury one of the following two declarations: ave 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:$4000 be,tify ion 3700 of the Labor Code,for the performance of the work for which this PC is issued. APN Number:32652003.00 Occupancy Type: APPLICANT CERTIFICATION 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-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by: Date: Signature Date 2 tt i_. 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. 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, 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 Owner or thor' d agent: 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 h eb that there is a construction lending agency for the performance of work'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 in,`nnify and keep harmless the City of Cupertino against liabilities,judgments, nd expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION g. .-,ng 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 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINC3 (408)777-3228 • FAX(408)777-3333•buildingncuper ino.org MISC ❑PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS/ D�`p M~ A/E APN OWNER NAME e��, � �we LK PHONE E-MAIL STREET ADDRESS/D �✓� CITY VATE ZIP�CxnNO FAx CONTACT NAME T PCHOONNE g_MAII * �� e �✓,�v,4�..� 3a f oP 96�oSy STREET ADDRESS CITY,STATE, ZIP FAX 6 Y 6/u^�i*r' ewe" ea•yioc-U c yo/• ? - oz 3 ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT n-�COCTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAMF,C. LICENS NUMBER LICENSE TYPE BUS.LIC# �IC.fi S ig SYS 43 COMPANY NAME E-MAIL FAX C r�$PCo.s�vd Ov.CU STREET ADDRESS CITY,S TE,ZIP PHONE 6 !��rA.�*+�✓ rt✓L Cites,�rJru 3 • /X18 S ARC rECTIENOINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE 1SE OF SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK ,�( ovGr r.�oor� t3c�itr�rr*,16 F!� �/+✓�+RG�-�1 cJ ZED C t�v - Sc-�t-u-�J TOTAL VALUATION: �- RECErilED BI - -------------- By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property 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 nstruc I a resentatives of Cupertino to enter the above-idem ed property for inspection purposes. Signature of Applicant/Agent: Date: O !/ SUP ME INFORMATION REQUIRED WEizl�*STtLfITi4RD+ £ s r MEPMisc4pp_2011.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10319 mary ave. DATE: 05/03/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$4,000 "PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RMAP1 USE: PERMIT TYPE: WORK remove wood burning fireplace replaced with decorative gas appliance. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Other Appliance/Equip 113APPLOT 1 # $63 TOTALS: $63.00 Mech.Plan Check --1hrs $0.00 Mech.Permit Fee: IMPERMIT Other Mech.Insp. 1 0.0 1 hrs $42.00 NOTE. Thesefees are based on the preliminaty information available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS (P'ee Resolution 09-051 ]. f. ' 1.'"10FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $63.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes O No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: 1 $148.50 $0.00 TOTAL FEE: $148.50 Revised: 04/29/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: p "000,ve ,eve PERMIT# 041 411 OWNER'S NAME: 0&,& PHONE # f4. 961. GENERAL CONTRACTOR: ,r,� d&X) 77+wc77oW BUSINESS LICENSE# Gk &/1SLI7 ADDRESS: CITY/ZIPCODE: Cf�ryP/�e tf *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. 6/L/// I am not using any subcontractors: Si nature Date Please check applicable subcontractors arcco ete the following information: 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