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09090122 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21641 REGNART RD CONTRACTOR:JONES MASONRY PERMIT NO:09090122
OWNER'S NAME: DORIS BLIVEN 1396 WESTMONT AVE DATE ISSUED:09/16/2009
ER'S PHONE: 4082534153 CAMPBELL,CA 95008 PHONE NO:4083777512
Q LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r— PLUMB
License Class '2,9 Lic.# S"10 3S p1
`� MECH RESIDENTIAL COMMERCIAL�
Contractor �UV111? 1 \G�(/l�I "l Date VO)�_
I hereby affirm that I am licensed under the provisio sof Chapter 9 JOB DESCRIPTION:REPAIR OF CHIMNEY @ROOFLINE,2STORY-
(commencing with Section 7000)of Division 3 of the Business&Professions EXISTING STEEL
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:$3200
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:35622014.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.1 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting oft 'permit. Additionally,the applicant understands and will comply
with all non nt source regulations per the Cupertino Municipal Code,Section Issued 4r Date:
9.18.
f]:
Signature Date
RE-ROOFS:
.(J OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature 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).
HAZARDOUS MATERIALS DISCLOSURE
1 hereby affirm under penalty of perjury one of the following three
1 have read the hazardous materials requirements under Chapter 6.95 of the
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance 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
contaminants as defined by the Bay Area Air Quality Management District 1 will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Heal &Safety Code,Sections 25505,25533,and 25534.
1 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 O r or 0rized agent:
Compensation laws of California. If,after making this certificate of exemption,1 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 hereby 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 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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
i nify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35622014 .00
DATE ISSUED. . . . . . . : 09/16/2009
RECEIPT #. . . . . . . . . BS000008695
REFERENCE ID # . . . : 09090122
SITE ADDRESS 21641 REGNART RD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER DORIS BLIVEN
ADDRESS 21641 REGNART RD
CITY/STATE/ZIP CUPERTINO CA, 95014-4812
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, 200 . 00 1 . 00 0. 00 1 . 00 0 . 00
1BSEISMICR VALUATION 3, 200. 00 0 .50 0 . 00 0 .50 0 . 00
1CHIMNEYRE EACH 1. 00 507 . 00 0. 00 507 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 508 .50 0.00 508 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 508 .50 #18305
---------------
TOTAL RECEIPT 508 .50
0qo9 (D
CITY OF
CITY OF CUPERTINO
GENERAL BUILDING
C U P E RT I N O PERMIT APPLICATION FORM
APN # ,L56 �� 0 o Date' f 15 _� q
Building Address:
„ 2f6 Al/
�76 7
Mailing Address(if different from buil mg address):
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: Exterior work only) Yes [�No ❑ If es, rovide letter from HOA
Owner's Name Z,A V•en Phone#:
Contractor: Phone: 1*)S”
47..5 0"P-� Fax: G)-C-
Contractor License#: E� ;0.3-,<- 7
Cupertino Business License#: ,21 a Q<
011
Contact: Phone:
Fax:
Residential Commercial ❑
Job Description: -CSD�'ti-*�L-
Building Permit Info:
Bldg LAY Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ I1/III B, IV-HT, V-B a- -7
Valuation: Square Footage:
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, include in plan set& the sheet index.
Points Achieved:
For help,contact Build it Green at www.buildit reen.or
Revised 07/14/09
y CITY OF CUPERTINO
Cin OF GENERAL BUILDING APPLICATION
CUPEI�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
ACOUSTICAL
REVIEW
IACOUSFDW SFDWL/Duplex New B
IACOUSRESAD SFDWL/Duplex-Addition/Alteration B
l ACOUSCOM Multi-Family/Commercial B
CHIMNEY'S
1 CHIMNEY Chimney B
a
1 CHIMNEYR Chimney Repair B
FENCES
1 FENCE>6FT Non-masonry, over 6 ft in height B
1 FENCEMAS>6 Masonry, over 6 ft in height B
FIREPLACES
1 FIREPLMAS Fireplace Masonry B
1FIREPLFAB Fireplace Pre-Fabricated/Metal B
1 FLAGPOL>20 Flag pole (over 20 ft in height) B
1MODUSTRU Modular Structures B
FOUNDATIONS
1 FOUNDREP Foundation Repair B
1 PILECAST Pile Foundation Cast in place concrete B
1PILEDRIV Pile Foundation Driven(steel,pre- B
stressed concrete)
3 9f 5
CITY OF CUPERTINO
Cin OF GENERAL BUILDING APPLICATION
CUPEI�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 stucco 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)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M
1PLMBLNCK 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-stand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1BUSLIC Business License B
5 of 5
M.Indoor Air Quality and Finnishes
1.Use Low/No-V©C Paint 1 IAD/Health pts y=yes p
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes p
3.Use LDW No VI OC Adhesives 3 IAQ/Health pts y--yes p
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y--yes D
5.Use Engineered Sheat Goods with no added Urea
Formaldehyde 61AQ/Heab pts y=yes p
S.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes p
7.Saal A EWosad P olebcard or hGDF _ 4 IAQ/Health. pts=+es p
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes D
9.Use Finger-Jointed or Recyclad-Content Trim 1 Resource pts y=yes D
10.Install Whole House Vacuum System 3 IAQ/Health pis y=yes p
t 1 t
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes D
2.Use f3api0y Ranenr 2we Flooring Materials 4 Resource pts y=yes D
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Hean pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes D
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y--yes; 0
t t fi
Total Points Available: 1 1401 130 57
Total Points Project Received: 01 0 0
v�
G:data/pro_s/greenbuildnoguidelines/ramodelers/greenpointsfina1212Mproteoied.xis
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
,UPE�TINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: Nr\5 PHONE # g
GENERAL CONTRACTOR: Simla FAX #
I am not using any subcontractors:
Signature ate
Please check applicable subcontractors and complete the 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
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
