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09120067 CITY OF CUPERT1140 BUILDING PERMIT BUILDING ADDRESS: 22255 CANYON VIEW CL CONTRACTOR:FIREPLACE PERMIT NO:09120067 CONTRACTORS OWNER'S NAME: ROBERT AND DIANA WILLIAMS 519 SAN PIERRE WAY DATE ISSUED: 12/11/2009 VER'S PHONE: 4087258606 MOUNTAIN VIEW,CA 94043 PHONE NO: (650)967-8800 ❑ LICENSED CRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ REPLACE EXISTING WOODBURNING FIREPLACE WITH NEW License Clasc��Lic.# GAS BURNING FIREPLACE.MODEL 564 SS GREENSMART ' f^� FIREPLACE.RENEWED BL 12/10/09 Contractor 0-J—) kir W kkek Date l G— 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: Sq.Ft Floor Area: Valuation:$6000 1. 1 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. APN Number:36645015.00 Occupancy Type: 2. 1 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. PERMIT EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR 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 180 DAYS FROM LAST CALLED INSPECTION. 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, Issue Date: costs,and expenses which may accrue against said City in consequence of the granting of this permit. A 'tionally,the applicant understands and will comply with all non-point egu ti ns per the pertino Municipal Code,Secti 9.18. RE-ROOFS: Signature Date 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. OWNER-BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: 1. 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 HAZARDOUS MATERIALS DISCLOSURE sale(Sec.7044,Business&Professions Code) 2. I,as owner of the property,am exclusively contracting with licensed contractors to I have read the hazardous materials requirements under Chapter 6.95 of the construct the project(Sec.7044,Business&Professions Code). California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& 1 hereby affirm under penalty of perjury one of the following three declarations: Safety Code,Section 25532(a)should 1 store or handle hazardous material. 1. I have and will maintain a Certificate of Consent to self-insure for Worker's Additionally,should 1 use equipment or devices which emit hazardous air Compensation,as provided for by Section 3700 of the Labor Code,for the contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the performance of the work for which this permit is issued. Health&Safety Code,Secti s 25505,25533,and 25534. 2. 1 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 thisr aut i e t• permit is issued. Date: 3. 1 certify that in the performance of the work for which this permit is issued,I shall 4� not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,I I hereby affinn that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code,I for which this pen-nit is issued(Sec.3097,Civ C.) must forthwith comply with such provisions or this permit shall be deemed Lender's Name revoked. Lender's Address APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION correct. I agree to comply with all city and county ordinances and state laws relating 1 understand my plans shall be used as public records. to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Licensed Professional indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ing of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date CITY OF CIUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# Date:If////A0 015 Building Address: p- 2 ��25 GAS i Mailing Address (if different from building address): Are Hazardous Materials being used as part of thii project? Yes No HOA: Exterior work only) Yes ❑ No If yes, provide letter from HOA Owner's Name: , Phone#: v ��C? Contractor: r, Phone:t ,� 11� b;_1 a (LNC C.r Fax: Contractor License#: . 7 I �I Cupertino Business License#: T 7� (a Contact: Phone: LFax: Residential N] Commercial Job Description: wooL) P7L( 2t\(frill( -, �p 4 -(,Oq 55 6?0,�51WT Pik,41kc-6 �Ao 1)eL ! zS Building Permit Info: �, Bldg �- Elect Lam_..__...- Plumb I� Mech Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V-B ❑''�r 12 -q Valuation: d2- Square Footage: Project Size: Express ❑ Standard ❑ Large ] Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.builditgr,!en.or Revised 07/14/09 ;,. CITY OF C_.UPERTINO C U CITY OF O GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM ACOUSTICAL REVIEW IACOUSFDW SFDWUDuplex New B IACOUSRESAD SFDWL/:duplex-Addition/Alteration B IACOUSCOM Multi-Fainily/Commercial B CHIMNEY'S 1 CHIMNEY Chimney B 1 CHIMNEYR Chimney Repair B FENCES 1 FENCE>6FT Non-masonry, over 6 ft in height B 1 FENCEMAS>6 Masonry, over 6 ft in height B FIREPLACES 1FIREPLMAS Fireplace Masonry B 1 FIREPLFAB Fireplace Pre-Fabricated/Metal B 1FLAGPOL>20 Flag pole (over 20 ft in height) B 1MODUSTRU Modular Structures B FOUNDATIONS 1 FOUNDREP Foundation Repair B 1PILECAST Pile Foundation Cast in place concrete B 1 PILEDRIV Pile Four.dation Driven(steel, pre- B stressed concrete) 3 of 5 CITY OF (.UPERTINO C U CITY OF O GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea ,3 windows) 1 WINMEWSTR New Window-structural shear B wall/masc nry(includes plan ck fee) 1EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alc ne Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alc ne Mechanical Pln Ck (hrly) M 1 PLMBLNCK Stand Alc ne Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B when not over counter) hourly-staid alone 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1TRAVDOC Travel & Documentation B 1BUSLIC Business License B 5 of 5