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10090084CITY OF CUPERT]_NO BUILDING PERMIT BUILDING ADDRESS: 7750 CARRIAGE CIR CONTRACTOR: ROYAL SERVICES OWNER'S NAME: MAY SHERMA 4398 NICKER CT +IER'S PHONE: 4088290594 SOQUEL, CA 95073 r U L} LICENSED CONTRACTOR'S DECLARATION License Classn - � 1 �I ic. # `7W66 c( Contractore _C,,26u1Cd Date s, 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. hereby affirm under penalty of perjury one of the following two declarations: have and will maintain a certificate of consent to self -insure for Worker's ompensation, as provided for by Section 3700 of the Labor Code, for the .rformance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance, as provided for by x:tion 3700 of the Labor Code, for the performance of the work for which this :rmit is issued. cz� APPLICANT CERTIFICATION :ertify that I have read this application and state that the above information is rcrect. I agree to comply with all city and county ordinances and state laws relating building construction, and hereby authorize representatives of this city to enter )on the above mentioned property for inspection purposes. (We) agree to save demnify and keep harmless the City of Cupertino against liabilities, judgments, fists, and expenses which may accrue against said City in consequence of the anting of this permit. Additionally, the applicant understands and will comply ith all non -point source regu ti s per the Cupertino Municipal Code, Section 18. ? A gnature Date (/ I Li 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 stricture 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 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 unify and keep harmless the City of Cupertino against liabilities, judgments, 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. Signature Date PERMIT NO: 10090084 DATE ISSUED: 09/13/2010 PHONE NO: (408) 972-2452 BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r— RESIDENTIAL r— COMMERCIAL r JOB DESCRIPTION: REBUILD CHIMNEY SHOULDER UP Sq. Ft Floor Area: I Valuation: $3000 APN Number: 35906052.00 I Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued kr: Date: —� 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 inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety 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 maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Se ' s 25505, 25533, and 25534. Owner or orize agen .(� Date CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 3 ITEMS OF 3 CITY OF C'UPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........1. 35906052.00 DATE ISSUED.......: 09/L3/2010 RECEIPT #•.•••..•.: BSO)0011444 REFERENCE ID # ...: 100)0084 SITE ADDRESS .....: 7750 CARRIAGE CIR SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OWNER AJAY SHERMA ADDRESS . 7750 CARRIAGE CIR CITY/STATE/ZIP ...: CUFERTINO, CA 95014 OPERATOR: patg COPY # : 1 RECEIVED FROM ....: ANTHONY XAVIEL CONTRACTOR .......: TODY 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 0.00 1.00 0.50 0.0 0.00 1BSEISMICR VALUATION 3,000.00 0.50 507.00 0.00 507.00 1CHIMNEYRE EACH 1.00 ---------- ---------- ------0_00 ---------- 508.50 0.00 508.50 0.00 TOTAL PERMIT METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 508.50 --------------- 508.50 VOICE ID DESCRIPTION -------- --------------------- 101 FOUNDATION 517 FINAL CHIMNEY REFERENCE NUMBER -------------------- #20856 VOICE ID DESCRIPTION -------- - -------------------------- 312 CHIMNEY REBAR & STRAPS CITY OFCUPERTINO FEE ESTIMATOR — BUILDING DIVISION VI AIAPN: ADDRESS: I DATE: REVIEWED BY: P/an ClIc"A BP#: *VALUATION: 1$3,000 *PERMIT TYPE: Minor Building Permit PL kN CHECK TYPE: Chimney / Chimney Repair PRIMARY SFD or Duplex USE: 707111 PENTAMATION ICHIMNE I PERMIT TYPE: WORK Permit Fee: SCOPE supp/. hisp Pee APPLIANCE / EQUIP TYPE I FEE ID I Chimney Repair j 1CHIMNEYR I TOTALS: NOTE. These fees are based on the preliminary information ivailable and are only an estimate. Contact the Dent for addn'l info FEE ITEMS (Fee Resolution 09-051 llcdl, Nan Uh,:( I!, P/an Ch"', k P/an ClIc"A P, ma F"( supp[ Fl-!(" I I P/lilll/).l,,,al-[,(,c/t.""1:/(_,(- Plull Check: NOTE. These fees are based on the preliminary information ivailable and are only an estimate. Contact the Dent for addn'l info FEE ITEMS (Fee Resolution 09-051 FEE QTY/FEE MISC ITEMS P/an ClIc"A I I A supp[ Fl-!(" I I P/lilll/).l,,,al-[,(,c/t.""1:/(_,(- Plull Check: Permit Fee: $507.00 supp/. hisp Pee I i (.-nit Fee: Consiruction Tc7x "ICOUSIiCcll Rcvic11, Work Without Permit? 0 Yes E) No $0.00 Travel 00clorict-dation Fart's: Strom Motion Fee: IBSEISAHCR $0.50 Select an Administrative Item 1 BldgIBCBSC Stds Commission Fee: $'' .00 SUBTOTALS: $508.50 $0.00 TOTAL FEE:T $508.501 Revised: 9/01/2010 1. Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 2. Use Low VOC, Water -Based Wood Finishes 2 IAQ/Health pts y=yes 3. Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 4. Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 5. Use Engineered Sheet Goods with no added Urea 5 IAQ/Health pts y=yes Formaldehyde 61AQ/Health pts y=yes 6. Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 7. Seal all Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes B. Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 9. Use Finger -Jointed or Recycled -Content Trim 1 Resource pts y=yes 10. Install Whole House Vacuum System 3 IAQ/Health pts y=yes N. Flooring 1. Select FSC Certified Wood Flooring B Resource pts y=yes 2. Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 3. Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 4. Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 5. Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 6. Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes Total Points Available: Total Points Project Received: 140 130 57 G:data/progs/gre:nbuildngguidelines/ramodelers/greenpointsfiina1212.D4proteoted.zls CUPERTINO CONTRACTOR/ SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: W PERMIT # T �n OWNER'S NAME: yF $' PHONE # - GENERAL CONTRACTOR: C ? U' S BUSINESS LICENSE # ADDRESS:, t oeyOPjyte I CITY/ZIPCODE: 7 *Our municipal code requires all businesses working in the city to nave a t-ity o< %-,uperuuu 1-3111-3 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: ` Signn ature Date Please check aanlicable subcontractors and complete the following information: �3- 0 Jner / Contractor Signature Date 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 �3- 0 Jner / Contractor Signature Date i(`� IabTN CITY OF C UPERTINO CITY Of CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # 59 c)0 5 �- Date�1-41 3----f0 Building Address: Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes N& / HOA: Exterior work only) Yes ❑ No ❑ If yes, provide letter fromHOA Owner's Name: Phone #: A- A- sAe r a 6?-q Contr ctor:n,` ' P) k �fcc f Phone: Fax: Y06 Contractor License #: •-7Y j Y 0 Z OL Cupertino Business License #: Le Contact: �1 I v w �06 ` qV- W5 -P- Phone: Fax: Residential Commercial ❑ Job Description: rc P�Ujld �(yAoej s� 6U(A Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class):Occupancy Type: 1-A, 1-B F]IPIII/V-A ❑ II/111 B, IV -HT, V -B Q/ .. Valuation: — Square Footage: Project Size: Ex ress ©Standard ❑ LargeEl 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.buildit2reen.or Revised 07/14/09