10050136 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21691 COLUMBUS AVE CON'FRACTOR:ARGONAUT WINDOW& PERMIT NO: 10050136
DO01;,INC
'NER'S NAME: MACINTOSH JOSEPH R AND SUE C 1901:;BASCOM AVE STE 800 DATE ISSUED:05/17/2010
OWNER'S PHONE: 4082530746 CAMPBELL,CA 95008 PHONE NO:(408)378-4018
❑ LICENSED CONTRACTOR'S DECLARATIONF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r- RESIDENTIAL f- COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE 4 WINDOWS IN HOME
(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.F:Floor Area: Valuation:$2738
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 Number:35618036.00 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, 80 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 Issut d by Date:--C/
9.18.
ature Date
RE-ROOFS:
! OWNER-BUILDER DECLARATION All rc ofs shall be inspected prior to any roofing material being installed.If a roof is
instal ed 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 inspe;tion.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, SignEture 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 ha,,a 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 Calif 3rnia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the coml liance 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 cont:minants 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
Heal &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 04thori (7— f C)
Compensation laws of California. If,after making this certificate of exemption,I GLP #t�_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 herr by affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lem er'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 Lent er's Address
the above mentioned property for inspection purposes.(We)agree to save
.mify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I und:rstand my plans shall be used as public records.
with all non-po'nt source re ulations per the Cupertino Municipal Code,Section
9.18. �jLicensed Professional
Signature Date ��
CITY OF CUFERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35618C36 . 00
DATE ISSUED. . . . . . . : 05/17/2010
RECEIPT #. . . . . . . . . : BSOOOC10423
REFERENCE ID # . . . : 10050136
SITE ADDRESS . . . . . : 21691 COLUMBUS AVE
SUBDIVISION . . . . . .
CITY CUPERT INO
IMPACT AREA . . . . . .
OWNER MACINTOSH JOSEPH R AND SUE C
ADDRESS . . . . . . . . . . : 21691 COLUMBUS AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4710
RECEIVED FROM . . . . : JOSEPI: MACINTOSH
CONTRACTOR . . . . . . . : CHRIS ETTEMA LIC # 22820
COMPANY ARGONkUT WINDOW & DOOR, INC
ADDRESS 1901 BASCOM AVE STE 800
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) : 78-4018
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----- ----- ---------- ---------- ----------
1BCBSC VALUATION 2, 738 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 2, 738 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1WINREP EACH 8 1 . 00 :180 . 00 0 . 00 380 . 00 0 . 00
----------- ---------- ---------- ----------
TOTAL PERMIT _,81 . 50 0 . 00 381 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- - ------------------
CREDIT CARD 381.50 Al1EX
---------------
TOTAL RECEIPT 381 . 50
j 5
CITY OF CU PERTINO
CUPEkTINO GENERAL BoUILDING
PERMIT APPLICATION FORM
APN # Date:
Building Address:
COLurn �t15 V� �4P�lLTI �!o
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 es, provide letter from HOA
Owner's Name. Phone#:
Lv1/od 7-5-2 --8y
Contractor: /' , one.
�G b�/.¢4-7-' I ,4 0/0 w Quo.? Fax: V 76 tr/-o ! 9
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial ❑
Job Description: `7 (,J t,,�oio s l k 14o n( E-,
Building Permit Info:
Bldg [�� Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V-B El-- lk 1
Valuation: �y Square Footage:
S1
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, in,--lude in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgreen.i!r
Revised 07/14/09
CITY OF CL PERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEf�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stu;co application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
IEPERMITFEE Electrical Per.nit Fee E
1MPERMITFEE Mechanical P:xmit Fee M
1PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1 PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-standalone
1BCBSC Cal Bldg Star.dards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Resiclential B
1BSEISMICO Seismic Commercial B
1TRAVDOC Travel &Documentation B
1BUSLIC Business License B
5 of';
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
LIZI Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUB(:ONTRACTOR LIST
JOB ADDRESS: ,';;-7 9 / <f6 4/tf t6 A/e- PERMIT# 6-,7
OWNER'S NAME: PHONE# V
GENERAL CONTRACTOR: BUSINESS LICENSE #
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city 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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete 1 he following information:
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
6/
Owner/Contractor Signature Date