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13090073 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21595 MONROVIA ST CONTRACTOR:JONES MASONRY PERMIT NO:13090073 OWNER'S NAME: NEISS RICHARD W AND BARBARA J 14629 BRANHAM LN DATE ISSUED:09/11/2013 OWNER'S PHONE: 4084729330 SAN JOSE,CA 95124 PHONE NO:4083777512 ❑ LICENSED CONTRACTOR'S DECLnARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL License Class (* n ,� `Lia# �� p� "1 CHIMNEY REPAIR FROM SHOULDERS(E)REBAR Contractor C7r.L S r 1 �J Date-/ y Ll I hereby affirm that I am licensed under th 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:$3800 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 APN Number:35623038.00 Occupancy Type: permit is issued. 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 D LED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expe s ich may accrue against said City in consequence of the granting of this ermit Additionally,the applicant understands and will comply Issued by: Date: with all non-p t sou ce,regulations per the Cupertino Municipal Code,Section 9.18. / / RE-ROOFS: Signature Date f 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 I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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) 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. 1 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 2 32(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,shoal use quipmcut or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined the Ba Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance wit the Cu ertino Municipal Code,Chapter 9.12 nd I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se ti s 25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agen 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 upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, 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 CONSTRUCTION PERMIT APPLICATION 15 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•building a-cupertino.org U CUPERTINO [:]NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS APN# C , OWNER NAME ( k 4 PHO ` Qc/qn qQ� E-MAIL STREETADDRESS l� CITY,ST TE,ZIP -( , .J � FAX CONTACT NAME PHONE F-MALL STREET ADDRESS CITY,STATE,ZIP FAX OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE ER Coe- LICE? E TIF BUS,LIC 3� COMPANYNAME E-MAIL rO d FAX x� STREET ADDRESS ` ( CITY,STATE,ZIP qN � 1 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# T J COMPANY NAME - E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL _ AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA I DECK AREA TOTAL DECKMORCH AREA GARAGE AREA: DETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UNrr ❑YES SECOND STORY []YES BEING ADDED? ❑NO ADDITION? []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES - - "' TOTAL VALIjOTION: PLANNING ADPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO By my signature below,I certify to h of the following: I am the property owner or authorized hent to act on the property owner's behal_f7. I have read this application and the information 1 h v rovided is correct. I have 1pd the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating 'Id' construction. I orize representatives of Cupertino to enter the a ove- entified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTALINVOPA77ATION REQUIRED _New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 5 form if any Hazardous Materials.are being used as part of this project. �a _Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. 9 B1dg4pp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21595 monrovia st DATE: 09/11/2013 REVIEWED BY: Mendez APN: BP#: *VALUATION: 1$3,800 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1CHIMNEY USE: PERMIT TYPE: wORK chimnev repair from shoulders a rebar SCOPE y filed"'. ''tf;a Che({:A:� ) p 1'I,av!). 111a;•f C'd%.c't'k J:i£ec%1°r1t7i {' i.i l- •71. 3£,'1"F}'•.Ib.£." £�: d L7 tiii i. 3 F:'f-T't:�{":{"£Y.•: <l r.1;�'?wfir r:.. Other ln7 pp� 1Yd.p, Li I 0;her Ele(',lnsp, Ll L 'lrar f>.L�s t' Dec. h: p> 1-,,;, NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These Ts are based on the prelimina information available and are only an estimate. Contact the De t or addh 7 info, FEE ITEMS (Fee Resolution I1-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # Chimney/Chimney Repair Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 $557.00 1 mmNEYR Chimney Repair PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee:( Reg. 0 OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? ® Yes No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential ?'M,e1 I)OC"",mt°ntalion, Fees Building or Structure 0 i Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 p A� � � may" 9 .. •. r $1.50 $557.00 TOTAL FEE: $558.50 Revised: 08/01/2013