10100095CITY OF CUPERTINO F,UILDING PERMIT
BUILDING ADDRESS: 1515 POPPY WAY
OWNER'S NAME: SCOTT NELSON
'NER'S PHONE: 9168067117
❑ LICENSED CONTRACTOR'S DECLARATION
License Clasqq Lic. # c�'L U J 7 /
Contractor Date l 0 3
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:
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.
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
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,
costs, and expenses which may accrue against said City in consequence of the
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.
AA Date � 0
Signature l
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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
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.
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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ira-mnify and keep harmless the City of Cupertino against liabilities, judgments,
and expenses which may accrue against said City in consequence of the
g—sting of this pemut.,�dditionally, the applicant understands and will comply
with all non -point sourc regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
CON TRACTOR: JONES MASONRY
PERMIT NO: 10100095
1396 WESTMONT AVE
DATE ISSUED: 10/13/2010
CAMPBELL, CA 95008
PHONE NO: 4083777512
BUILDING PERMIT INFO:
BLDG F ELECT r PLUMB r
MECH r
RESIDENTIAL F COMMERCIAL
JOB DESCRIPTION: REPAIR CHIMNEY FROM ROOFLINE UP
**SEI: NOTES**
Sq. F t Floor Area:
Valuation: $3750
APN Number: 36615028.00
Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by'. Date:
RE -ROOFS:
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
inspe tion.
Signs ture of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I hai a read the hazardous materials requirements under Chapter 6.95 of the
Calif ornia Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
coml oliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safei y Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
mair tain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner autl ri d agent:
Date:
CONSTRUCTION LENDING AGENCY
I her ;by affirm that there is a construction lending agency for the performance of work's
for m hich this permit is issued (Sec. 3097, Civ C.)
Lem ter's Name
Lens ter's Address
ARCHITECT'S DECLARATION
I unc erstand my plans shall be used as public records.
Lice ised Professional
FM-7
CITY OF CLfpERTINO
FEE ESTIMATOR- BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS:
DATE:
REVIEWED BY:
71 d'crwil i�..
F
APN:
BP#:
*VALUATION: 1$3,750
*PERMIT TYPE: Minor Building Permit
PLAN CHECK TYPE: Chimney / Chimney Repair
PRIMARYr
USE: SFD or Duplex.
,� �[
�t
PENTAMATION
1CHIMNEYR
PERMIT TYPE:
WORK
Permit Fee:
SCOPE
Shipp. 111slo l°ec'
APPLIANCE / EQUIP TYPE
FEE ID
E .,%>_ I :._ _
QTY
71 d'crwil i�..
F
BP FEES
Chimney Repair
1CHIMNEYR
c't If7.Tf'.
1
—
$507
Permit Fee:
$507.00
Shipp. 111slo l°ec'
�'lzrtr�h.:I1< t:.iT,tc. t nif FCC,,
Plllnjh.i,llcch." lcc P crmil Fc,,,;
(�71 fi7tt`IiQi7 T l(v
Work Without Permit? 0 Yes (F) No
$0.00
TOTALS:
Ti-avu1 (ft)'Ie.'t71w"ol'i /° t cs.
Strom Motion Fee: IBSEISMICR
NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn 7 info.
F EEITEMS (Fee Resohrtion 09-051 Eff. T1/10)
FEE
E .,%>_ I :._ _
Fl€�t . M' If" C `; ck
71 d'crwil i�..
F
...s �P. P, F`J'c
Str p/. PC l (v
2l�i'r
c't If7.Tf'.
—
Pcc,
NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn 7 info.
F EEITEMS (Fee Resohrtion 09-051 Eff. T1/10)
FEE
QTY/FEE
MISC ITEMS
}
�hn C. �11cc'jj/'+.'w:
Str p/. PC l (v
f'frt�rrh.i;ll� c 1t. 0ec 6 hv? C 7tC c:l:
Permit Fee:
$507.00
Shipp. 111slo l°ec'
�'lzrtr�h.:I1< t:.iT,tc. t nif FCC,,
Plllnjh.i,llcch." lcc P crmil Fc,,,;
(�71 fi7tt`IiQi7 T l(v
Work Without Permit? 0 Yes (F) No
$0.00
Ti-avu1 (ft)'Ie.'t71w"ol'i /° t cs.
Strom Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
BldgStds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$508.50
$0.00 TOTAL FEE: »>
$508.50
Revised: 9/29/2010
3 ITEMS OF 4
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lct:
APN ........: 36615028.00
DATE ISSUED.......: 10/13/:010
RECEIPT #......... BS000011726
REFERENCE ID # 101000S'5
SITE ADDRESS 1515 POPPY WAY
SUBDIVISION ......
CITY CUPE RT :: NO
IMPACT AREA ......
OPERATOR: patg
COPY # : 1
VOICE ID DESCRIPTION
-------- ------------------------
101 FOUNDATION
517 FINAL CHIMNEY
VOICE ID DESCRIPTION
-------- ---------------------------
312 CHIMNEY REBAR & STRAPS
OWNER ............: SCOTT NELSON
ADDRESS . 1515 POPPY WAY
CITY/STATE/ZIP ...: CUPERTINO, CA
95014
RECEIVED FROM ....: JONES MASONRY
CONTRACTOR .......: JONES, GREG
LIC # 21205
COMPANY ..........: JONES MASONRY
ADDRESS : 1396 WESTMONT
AVE
CITY/STATE/ZIP ...: CAMPBELL, CA
95008
TELEPHONE ........: 4083777512
FEE ID
UNIT QUANTITY AMOUNT PD -TO -DT THIS
---------- --
REC
NEW BAL
----------
1BCBSC
---------------------------------
VALUATION 3,750.00 1.00
0.00
1.00
0.50
0• 00
0.00
1BSEISMICR
VALUATION 3,750.00 0.50
0.00
0.00
507.00
0.00
1CHIMNEYRE
EACH 1.00 c07.00
----------
----------
--
----------
E08.50
0.00
508.50
0.00
TOTAL PERMIT :
VOICE ID DESCRIPTION
-------- ------------------------
101 FOUNDATION
517 FINAL CHIMNEY
VOICE ID DESCRIPTION
-------- ---------------------------
312 CHIMNEY REBAR & STRAPS
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CUPERTINO Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 1 °5 5 `PO W
PERMIT # / J
OWNER'S NAME:
PHONE #>f-7
GENERAL CONTRACTOR:Z
BUSINESS LICENSE # b-0 I D S
ADDRESS: T'(3 ,tic ' eq
CITY/ZIPCODE: Ste' Q S S
*Our municipal code requires all businesses working in the--ity 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 NTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: 1011,3110
Signature Date
Please check applicable subcontractors and complete t ie following information:
Owner / Contractor Signature
Date
SUBCONTRACTOR
BUSINESS 1\ AME
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
U009 -z'
CITY OF
CITY OF CUPI:RTINO
GENERAL BUILDING
C U P E RT I N O PERMIT APPLICATION FORM
APN # f _ D�&'
Date: /C. -
Building Address:
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No Etl-
HOA: Exterior work only) Yes ❑ No 9-Xif yes, prc vide letter from HOA
Owner's Name:
/V e%C-N . ff
Phone #:
>/4 D, - 7117
Contractor: j` /' y
Phone:'
Fax:
Contractor License #: 3 e)r ,3T5T
Cupertino Business License #:
Contact:
S -
Phone: -t CS- 1-17-;z -V 3 3c� �
Fax:
Residential Commercial ❑
Job Description:
Building Permit Info:
Bldg Ud Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
12-5
I -A, l -B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B ��
Valuation: Square Footage:
x_37 s�.cc
Project Size: Express Q ---'Standard ❑ Lar e ❑ 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.builditgreen.org
Revised 07/14/09