10110050 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1184 ELMSFORD DR CONTRACTOR:Tom^-T--:n 3Z PERMIT NO: 10110050
bF41;D LINED
Q�a�
^WNER'S NAME: GLORIA OVERHISER LEAKINS TRUSTEE DATE ISSUED: 11/08/2010
-►'VNER'S PHONE: 6508146517 PHONE NO:
Iff LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
License Class C 2 Lic.# REPAIR CHIMNEY TO ROOFLINE
/I `` c *SEE NOTES*
Contr)aCtp �'`�R���J' �'t�s�D Date
I hereby affirm that I am IY iicceensed 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. Sq.Ft Floor Area: Valuation:$1400
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
APN Number:36209006.00 Occupancy Type:
permit is issued. /41V
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the -----7
granting of this permit. Additionally,the applicant understands and will comply Issued Date:
with all non-point source regulation he Municipal Code,Section
9.18.
RE-ROOFS:
signature /13l Date ( (CJ' 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:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25 aryl5 l
Section 3700 of the Labor Code,for the performance of the work for which thisOwner or authorized agent: Le<� --'� Date:
permit is issued.
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
-)n the above mentioned property for inspection purposes.(We)agree to save
-mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 1184 elmsford dr. DATE: REVIEWED BY:
APN: BP#: *VALUATION: 1$1,400
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY 1')7.41 PENTAMATION 1CHIMNEY
USE: SFD or Duplex /'r t)«tart ;, PERMIT TYPE:
WORK
SCOPE
Cb, T7 _77777.
r _ k
NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 09-05/ E6. T"b"10Z FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 L_I_j # Chimney/Chimney Repair
Suppl. PC Fee: 0 Reg. 0 OT 1 0.0 hrs $0.00 $507.00 ICHIMNEYR Chimney Repair
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-.0 Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Conn Irlwtion 1'ctaF-1 I
Acoustical Fee: 0 Yes 0 No $0.00 0
Work Without Permit? 0 Yes 0 No $0.00 0
Planning lee: $0.00 Select a Non-Residential 0
Building or Structure 0
7i-rn of C>t�crrir;e�zt��tir,rl /°G�t'.4.
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $507.00 TOTAL FEE.-T $508.50
Revised: 11/08/2010
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36209006 . 00
DATE ISSUED. . . . . . . : 11/08/2010
RECEIPT # . . . . . . . . . : BS000011944
REFERENCE ID # . . . : 10110050
SITE ADDRESS . . . . . : 1184 ELMSFORD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER GLORIA OVERHISER LEAKINS TRUST
ADDRESS . . . . . . . . . . : 1134 ELMSFORD DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : BLOOMFIELD CUSTOM
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1,400 .00 1. 00 0 .00 1. 00 0 . 00
1BSEISMICR VALUATION 1,400 . 00 0.50 0. 00 0 .50 0 . 00
1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0. 00
1CHIMNEYRE EACH 1 . 00 507 . 00 0 . 00 507 . 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 622 .50 0 .00 622 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 622 .50 3451
---------------
TOTAL RECEIPT 622 . 50
M. n oor it ualrty and eros es
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal aU Exposed Particleboard or MY 4 IAQ/Health. pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 1
Total Points Available: 1401 130 57
Total Points Project Received: 01 0
G:data/progs/greenbuilcingguidelinestramodelerslgreenpointsfina12.12.04proteoted.xls
i
CITY OF CUPERTINO
CM OF
CUPS T1NO GENERAL BUILDING
PERNUT APPLICATION FORM
6 /00 S-6
APN # Date:
cNea 0c1 o0(0- 00 ap d
Building Address:
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes No
No ❑ If yes, provide letter from HOA
Owner's Name: Phone #:
Co'41ntractor: � �� �� Phone:
� �c ` G S ON i Fax: --
Contractor License#: (t t S' O
Cupertino Business License#:
Contact: Phone: j , Z73,
E0,0 C, -- e�. Fax: Z
-,esidential Commercial
Job Description:
Building Permit Info:
' Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ H/=V-A ❑ II/III B, IV-HT, V-B
Valuation X Square Footage:
Project Size: Express tandard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green ff ' ding/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
-)ints Achieved: -
or help, contact Build it Green at www.buflditgreen.org
Revised 07/14/09