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10080184 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21588 FLINTSHIRE ST CONTRACTOR: PERMIT NO: 10080184 OWNER'S NAME: CHUCK WORLEY&MARY JO SULLIVAN A. w�� /g�n DATE ISSUED:08/26/2010 NER'S PHONE: 4084462980 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r I— BUIL1)ING PERMIT INFO: BLDG ELECT PLUMB License Class ! Lic.# l /66�5 MECH r RESIDENTIAL r COMMERCIAL r Contractor Date /J I hereby affirtm at I am licensed under the provisions of Chapter 9 JOB IC ESCRIPTION:REPLACING 7 WINDOWS,SAME SIZE&LOCATION (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 1-loor Area: Valuation:$10798 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. APN N umber:35620025.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 1F,O DAYS FROM LAST CALLED INSPECTION. 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 Issued by< Date: O 9.18. Signature Date lJ RE-ROOFS: OWNER-BUILDER DECLARATION All roo's shall be inspected prior to any roofing material being installed.If a roof is installe i without first obtaining an inspection,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspect on. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signatc re of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's Califm nia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compli ince with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contan iinants 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 Health&Safety Code,Sections 25505,25533,and 25534. 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 Own 9r iz agent: Compensation laws of California. If,after making this certificate of exemption,I Date: 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. CONSTRUCTION LENDING AGENCY I hereb i affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for whi�h this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender•'s Name 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 Lendei•'s Address upon the above mentioned property for inspection purposes.(We)agree to save iPA-mnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION b _.mg of this permit.Additionally,the applicant understands and will comply I under hand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licens:d Professional Signature Date CITY OF CUPERTINO 3 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lo',: APN . . . . . . . . : 35620025 .00 DATE ISSUED. . . . . . . : 08/26/2 )10 RECEIPT #. . . . . . . . . BS00001L289 REFERENCE ID # . . . : 10080181 SITE ADDRESS 21588 F--JINTSHIRE ST SUBDIVISION . . . . . . . CITY CUPERTI ATO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : CHUCK W:)RLEY & MARY JO SULLIVA ADDRESS . . . . . . . . . . : 21588 FLINTSHIRE ST CITY/STATE/ZIP . . . : CUPERTIMO, CA 95014 RECEIVED FROM . . . . : JEFF MARTIN PERMITS CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUIST PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- --- 1BCBSC VALUATION 10, 798. 00 1. 00 0 .00 1. 00 0 .00 1BSEISMICR VALUATION 10, 798 . 00 1 .10 0. 00 1.10 0 .00 1WINREP EACH 8 7 .00 3E0 . 00 0 .00 380 .00 0 .00 ------ ---- ---------- ---------- ---------- TOTAL PERMIT 3E2 .10 0 .00 382 .10 0 . 00 a2aa-- CITY OF CUP_ERTINO CUPEI�TINO GENERAL BUILDING PERMIT APPLICATION FORM APN # _ Date: E Z i6 po C) Building Address: zmpg Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes No HOA: (Exterior work only) Yes ❑ No � If yes, provide letter from HOA Owner's Name: Phone#: 4,4. fk, I �og OV4 Contractor: Phone: ' r Fax: SIC y o gra Contractor License#: 0 Cupertino Business License#: Contact: Phone: CIO Wo 4,170 Fax. residential Commercial Job Description: Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-B R-' Valuation: Square Footage: Project Size: Ex ress El—standard ❑ Large ❑ Major ❑ [GreenBuilding: Please complete relevant portion of the Green Bu' ding/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.ortV Revised 07/14/09 12- CITY OF CUPERTINO FEE ESTIMATOR- BL ILDING DIVISION ADDRESS: 7D REVIEWED BY: APN: BP#: `VALUATION: 1$10,798 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex OVER THE PENTAMATION USE: COUNTER? Q Yes Q No PERMIT TYPE: WORKCRJUS SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. R-3(Custom) II-B,111-B,IV,V-B 0 $0.00 $0.00 TOTALS: 0 $0.00 r � MEHO 4 w { `� m r t Yes :QQ PY;UMB;TdTRLY- 'Q Yes Q `No`sEr. CI U1CtL ' J ° YA�`YC P/air Check r .:;; l'.,rrii�/�,. 1 „>;i, l r,rr„r,:,::: l•.Yrr l'rrr�u7/. er la<r Inv, Pi,C NOTE. These fees are based on the preliminary information availabl?and are only air estimate. Contact the De t or addh 7 info. FEE ITEMS(Tee Resolution 09-051 E(f 7.1110) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 7 # Window/Sliding Glass Door Suppl. PC Fee: E) Reg. Q OT 0.0 hrs $0.00 $380.00 1 WINREP Replacement PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee..10 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 nii,,lrr;criun Tc;.+ Acoustical Fee: Q Yes 0 No $0.00 Q Work Without Permit? 0 Yes E) No $0.00 Plannin j Fee: $0.00 Select a Non-Residential Q Fcc'.� Building or Structure Q i Stronk Motion Fee: IBSEISMICR $1.08 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 F771 ., ' AiSUBT�QTALS: $2.081 $380.00 TOTAL FES $382.08 Revised: 8/17/2010 i __jc L �� --- (J APr'f�(;VE [) IN AC( ORi?AN( f ,V1 T! THE CITY OF RTINO CODE;,AN ORDINANCES f� DATE__ SIGNED � This set of plains a 'se/c ifications- be kept on the fob at all times and fit ss unlawful to make any No charn!es or alterations on same without written F ermission from the Building Department, C it of Cupertino. The stamping of this plana id specifications SHAH NOT be hefd to pe mit or to be an approval of the,violai on o' any provisions of any Crty OrdmanCP r. ;tate L aw. UA to G d � s I N 03P -� .A Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CU PERTI NO Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: -Z\ PERMIT# OWNER'S NAME: „ PHONE# a 00 GENERAL CONTRACTO : BUSINESS LICENSE# ADDRESS: "gyp g in the citCITY/ZIPCOD] S *Our municipal code requires all businesses rkiny to have a City of Cupert o business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPFCTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 7 J I am not using any subcontractors: _ Signature ate Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NA ME 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 wner/Contractor Signature Date