13060115 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10241 PHAR LAP DR CONTRACTOR:MP3 MASONRY PERMIT NO: 13060115
OWNER'S NAME: JOHN&JENNY IKEGAMI
4530 FAIRVIEW RD DATE ISSUED:06/13/2013
OWNER'S PHONE: 4083135464
HOLLISTER,CA 95023 1 PHONE NO:(831)637-6663
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL U COMMERCIALE]
Lic.# REPAIR MASONARY CHIMNEY FROM PLATE LINE
License Clas /r----
Contractor /� Date
I hereby affirm that I am licensed un er 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.
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 Valuation:$3000
performance of the work for which this permit is issued. Sq.Ft Floor Area:
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 APN Number:32639049.00 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 WITIIIN 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 DAY M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, /
costs,and expenses which may accrue against said City in consequence of the Issued by Date:6
granting of this permit. Additionally,the applicant understands and will comply
with all non-point ource regulations per th upertino Municipal Code,Section
9.18. RE-ROOFS:
Signature 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 Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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) HAZARDOUS MATERIALS DISCLOSURE
I,as owner of the property,am exclusively contracting with licensed contractors to
I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project(Sec.7044,Business&Professions Code).
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 9.1.2 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the 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
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
the Health&Safety Code,Sc 25 5,2553 25534. Da �3 11
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent
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 CONSTRUCTION LENDING AGENCY
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 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.)
forthwith comply with such provisions.or this permit shall be deemed revoked. 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 04
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION L9
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 b
GUPI;fZ`fw1140 (408)777-3228• FAX(408)777-3333•building a)cupertino.orsl \5
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS � � � APN
OWNER NAME r Jd^,J v 4rn� PHONE l E-MAIL C.J
STREET ADDRESS � O / CITY, STATE,ZIP FF-X
CONTACT NAME PHO &MAII
STREET ADDRESS � i�iQ ?ems /J CITY,STATE,ZIP a �o �� FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICEN ER LICESIS'E E BUS.LIC#
COMPANY NAMEd r E-MAIL FAX
STREET ADDRESS PHONE
ARCHITECT/ENGINEERNAME /�CRQJ LICENSE NUMBER J' '^ _ BUS.LIC#
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 NETAREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: LJDETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT []YES SECOND STORY ❑YES
BEING ADDED? ❑NO ADDITION? []NO -
PRE-APPLICATION [3 YES IF YES,PROVIDE COPY OF IS THE BLDG AN C]YES -' � �� TOTAL ALUATION:
PLANNING APPL# Fl NO PLANNING APPROVAL LETTER EICHLER HOME? []NO - O
- N7 P10
By my signature below,I certify to each of the following: I am the property owner or autho zeent to act on the property owner's behalf. I have read this
application and the information I hav vided is correct. I havgsead the Description of Work d verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating buil in onstructittf ho ze representatives of Cupertino to enter the abov Identi ed property for inspection purposes.,
Signature of Applicant/Agent: Dater
SUPPLEMENTAL INFORMATI RE
ILANCHECKTYPE_ ROUTIING;$LIt' ,
_New SFD or Multifamily dwellings: Apply for demolition permit for �
;��-OVERTH1+rC0 R � �e�BUILDIlyGPLA�TREV,IE,A'�:
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. xPREs P �vcr> ;iuv
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure sTp }I� uBIIu�Rlzs
Tor—in if any Hazardous Materials are being used as part of this project. '
mss. 3. � FIItE*`�EPT�' LL
>;ARG
_Copy of Planning Approval Letter or Meeting with Planning prior to t
�� MAJOR �S ITAIiYiSEWERDIS RI .-
submittal of Building Permit application.
B1dgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10241 PHAR LAP DR DATE: 06/13/2013 REVIEWED BY: MENDEZ
APN: BP#: *VALUATION: $3,000
%PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Chimney/Chimney Repair
PRIMARY SFD or Duplex PENTAMATION 1CHIMNEYR
USE: PERMIT TYPE: i
WORK REPAIR MASONARY CHIMNEY FROM PLATE LINE
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES
Chimney Repair 1CHIMNEYR 1 $534
TOTALS:
UNPROVEN
Xlech.flan Check Plumb.Plan Check Elect.Fan(..heck
11ech. Permit Fee: I Plumb.Permit Fee: I Elec. Permit 1,ee,
Other Alech.Insp. Other Plumb Insp. Li Other Elec.Insp.
Allech.Insf).Fee: Plumb. Insp.Fee: I-;lcc.Insp.fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prelimina information available and are onl an estimate. Contact the Dept for addn7 info.
FEE ITEMS(Fee Resolution 11-053 E . 7/1/122 FEE QTYA MISC ITEMS
Plan Check Fee:
Suppl. PC.Fee
Plumb.11fech./Elec
Permit Fee: $534.00
Suj�pl.Insp Fee
Pluin b.11fech./E lec
Plumb./.' ech./Elec Per mit Fee:
Consttztction Tax:
Administrative.Fee:
Work Without Permit? 0 Yes (j) No $0.00
Advanced Planning Bees:
Travel Documentation Fees:
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bld¢ Stds Commission Fee: IBCBSC $1.00
.` 6u
$535.50 $0.00 � $535.50
Revised: 04/29/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT 1 N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST----".:
JOB ADDRESS: 9 !� PERMIT#
OWNER'S NAME: PHONE
GENERAL CONTRACTOR: $� BUSINESS=LICENSE#:
ADDRESS: CITY/ZIEC;ODE:
*Our municipal code requires all businesses working in the city to have'ii ic-*of.Gnpertino 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 an subcontractors:
Y
Signa re Date
Please check applicable subcontractors and complete the following information:
V 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
Owner/Contractor Signature Date