22706 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect identification PERMIT NO.
Building Address: 22706m-D
Phase. __ATTER!22gyo E CEDES
foREST !Aoa1, A A .
CITY OF CUPERTINO-BUILDING DIVISION d11
Contractor's Name: e as Lm.Nn: APPLICATION / PERMIT
T.0, sqrk F.FI"So�✓ 6Rx/ BUILDiNGELECTRICALI'LIJMBINGMECIIAMCAL CATEGORY CONTROL
Architect/Engineer. Lie No:
r QT-Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aitdress'C(SE Td INA, pq kl ELL PFRMITISSUANCE O ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm that lam licensed under pmwimowof Chapter9(commmc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
B...hSection Imes f Dlvlelon3 ofthe Buslriessand ProfesaionsCode,and my
B...Is oc fellhm form and dfea. s/ PANELS
Limn.Class Lie.a 65 J16y
Date Contractor UP TO 2DO ANTS
ARCHITECT'S DECLARATION 701-IWO AMPS
N7_ I understand my plans shall be used u public records. OVER IOOOAMIS _ $/SQ.FT.
uO .�0�,v
Licensed Professional SIGNSELECTRICAL a �8�
OWNER-BUILDER DECLARATION SPECL1LCItCUIT/MIST Ihereby affirmthat lam exeMmpt from the Contractor'sLicense Lawforthe following reason.(Section 7031.5,Business and professions Code: y city or
F county which require a permit to construct,alter,improve,demolish,orrepalr TEMP.METER OR POLE INST. of
_0A rE
anystmv mpHortoita WuancgaMreq imstheappBantforsuchpermitto POWER DEVICES
cu file a signed statement that he E licensed pursuant to the provisions of the
O a Contractors License Law(Chapter 9(commencing with Section 7000)of Divi-
k,�05 .don3ofthe Buslnessand ProfenbmCode)orthathebexemptthemfmmand SWPihBNGIWLELECTRIC VALUATIO d
X' the basis for the Q alleged exemption. Any violation of Section 70315 by any OUTLE7SSWITCHFSFIXTURFS (j
appBantfor a permit subjects the applicant to tlWl penalty of nut more than
r. o five hundred dollars($500). NEW RESIDENTIAL ELECTR
❑1 as owner of the SQFT. STORIES TYPE CONSTRUCTION
, property,d my empbyen with wages as their sole
�7
compensation,70KBusiness the work andthestructure ft,set e;TheClntende or License
for
Law
;J ,O sale mart 76ily to Business of Professi
Code:The Contractor's Limn.Law
p$S don not Mach oak owner of throng property who nempe lids oymp providedthat,and OCC.GROUP RES.UNITS
0.
who does
mentsa orkhimself edorough h3sowne.If,ho ever,thebuilatsuch
improvements arc not Intended earofred for sale.the o nveq theism ilI haw TOTAL:
improvement issold within oneyearo(completloR the mvner-bullderwill have
the Men of proving that he did ant build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
1,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to cowtroct the project(Sec.70K Btatimas and professions Code: PERMIT ISSUANCE
The Contractor's License Law does net apply to an owner of property who ALTER-DRAW#VENT-WATER(EA)
WE& or Improves thereon, and who contracts for such pkojects with a FEE SUMMARY
�gDt(ador(s)Bernard pursuant en the Contractors License Law. BACK FLOW PROTECT.DEVICE
Lf 1 am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y_ N_
Owner Date RECEIVE N
WORKMANCOMPENSATIONDECLARATION FIXNRES PFR TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that 1 have a cerdBam of consent to elf-Inure,or
AECEIPI'N
certificate ofWorkeri Compereation Insurance ora certified copy thereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Policy lib C.). ,y _a� RECEEPT#
Policyp 7 GAS FA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
Com any
ErCertlfled copy Is hereby furnished. GREASE/INDUS[RL WASEINIT:F(CFPTOR PLANCHECK FEE
❑Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANII.ARy-SR7RM EA HAFT
(TFlssncti m need net be completed if the permit is for one hundred dollars Date Recti [N
E$100)or less') WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
1 mdifythat b the performance of the work for which tMs permit b beta,
I shall not employ any person In any manner u as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Glifomis,Date PAID
O Z Applicant NEWRESIDENTIAL PLMB. SQhT. Date Remi t#
Z O NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you
Fshould becomesubject to the Workers'Comperetation provisions of the Labor TOTAL: -
W Code,you must forthwith comply with such provislom orthb permit shall be BUILDING '
deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE l
a Ihereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
Z ante of the work for which this permit U Issued(Sec.3097,Civ.C.)
U O Undoes N. PLUMBING FEE
k= Lenders Address QTY. MECHANICAL PERMIT FEE
O W Icertifythat l have read this application and state that the abovoinime'union MECHANICAL FEE
bcorrect.Iagree to comply with all tlty.ml county oMlnanons and state laws PERMIT ISSUANCE FEES PAID:
} W relatl ng to building conatruction,and hereby authorize representatives of this
(— city to enter u pon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cu ped inn Date Receipt#
V
against liabilities,judgmentgcosts a nd expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
said City in con an"of the granting of this pertnit.
r q Q AIR HANDLING UNIT(OVER 10,OWCIM) CONSTRUCTION TAX
0mreo Appliant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingecarant store or handle hazardous HEATING UNIT(TO IME00 BTU) Date Receii t#
material as defined by the Cupertino Municipal Code,Chapter 9.17.and the
Health and Safety Code Section 25532(a)r HEATING UNIT(OVER 100,000 BTUs TOTAL: L
0 Yes M No
Will the applicant orfumre building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit haves Mous air matamivms m de#nU by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
Y" ❑No
4
4havereadthe bazar�iousmaterials requirementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health A Safety Code,Sections 25505,25533 and 2553X.1 s(��j
understand that if the building does net currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFI'. =
respowibility to notify the occupant of the requirements which must be met TA
prior to issuance a.Certlfiateof Occupancy.
Owner r authorized agent Data TOTAL: ISSUEDB .
OFFICE COPY
J.H. STEFFENSON TERMITE CO.
195 E. Sunnyoaks
Campbell, CA 95008
(408) 379-5245
• AGREEMENT
J.H. Steffenson Termite Co. Is authorized to proceed with the work outlined in Items
of their Inspection Report # 002080 at 22840 MERCEDES ROAD. CUPERTINO
for a total sum of $ . This amount will be due and payable upon completion of work. It Is understood
that the contract price does not Include the charge of the STRUCTURAL PEST CONTROL INSPECTION REPORT OR
RE-INSPECTION FEES.
J.H. STEFFENSON TERMITE CO. AGREES:
1. To guarantee all repair completed by this company for one year from date of completion except for plumbing,
grouting, caulking, and re-setting of toilets, which will be guaranteed for 30 days. We assume no responibillty
for work performed by others.
2. To be bound to perform this work for the price quoted In our cost breakdown for a period not exceed 30 days.
3. To use reasonable care In the performance of our work but to assume no responsibility for damage to any
hidden pipes, wiring, or other facilities or to any shrubs, plants or other life.
OWNER OF OWNER'S AGENT AGREES:
1. To pay for services rendered including any additional services requested, upon completion of work.
2. To pay for service charge of 1.5 per cent per month or portion of any month beyond the 30 days after completion.
,i 3. Owner grants to J.H. STEFFENSON TERMITE CO. a security Interest In the above described real property to
` secure payment of the sum for work and Inspection fee completed.
4. In case of non payment by owner, reasonable attorney fees and costs of collection shall be paid by owner
• whether suit be filed or not.
BOTH PARTIES AGREE:
1. If additional damage is discovered by J.H. STEFFENSON TERMITE CO. in the performance of the work,
company agrees to notify owner or agent of the amount of the damage and the amount of additional work
necessary to be done. This work will not be performed until owner or agent agrees In writing.
2. If any additional work is deemed necessary by the local building Inspector, said work will not be performed
without additional authorization from owner or owner's agent.
Circle the Items you wish performed by J.H. STEFFENSON TERMITE CO. below and enter total amount above:
ITEMIZED COST BREAKDOWN (Refer to hems on the report)
? The cost of each Item on this report Is:
SECTION . 1: 10A. 7080. 00
SECTION 2 : NONE.
TOTAL SECTION 1 ITEMS=$ 7080. 00
NOTICE TO OWNER
Under the California Mechanics Lien Law, any structural pest control operator who contracts to do work for you,
any contractor, subcontractor, laborer, supplier or other person who helps to Improve your property, but is not paid
for his work or supplies, has a right to enforce a claim against your property. This means that after a court hearing,
your property could be sold by a court officer and the proceeds of the sale used to satisfy the Indebtedness. This
can happen even if you have paid your contractor in full if the subcontractor, laborers or suppliers remain unpaid.
' • 'To preserve their right to file a claim or Ilan against your property, certain claimants such as subcontractors
or material suppliers are required to provide you with a document entitled "Preliminary Notice". General contractors
and laborers for wages do not have to provide this notice. A Preliminary Notice Is not a Ilan against your property.
Its purpose is to notify you of'persons who may have a right to file a lien against your property If they are not paid.
•WNER OR OWNER'S AGENT DATE J.H. STEFFENSON TERMITE CO.
X BY:
X
X ESCROW CO:
X ESCROW #
X
1
ADDRESS OF �
PROPERTY
INSPECTED 22840 MERCEDES ROAD CUPERTINO
. BUILDING NO. STREET CITY
569822R 08/22/91 002080 BM
STAMP NO. DATE OF INSPECTION CO. REPORT NO.
A complete inspection was not made. This report is limited to
front bathroom. We recommend inspection of the complete structure at
an additional charge. This was done at the request of
Forest Carroll.
J.H. STEFFENSON TERMITE & PEST CONTROL INC. , GUARANTEES ALL REPAIR
WORK COMPLETED BY THIS COMPANY FOR ONE YEAR FROM DATE OF COMPLETION.
EXCEPT FOR PLUMBING,GROUTING,CAULKING AND RE-SETTING OF TOILETS, WHICH
WILL BE GUARANTEED FOR 30 DAYS. WE ASSUME NO RESPONSIBILITY FOR
REPAIR WORK COMPLETED BY OTHERS.
SEE ATTACHED SHEET FOR COST BREAKDOWN
J.H. STEFFENSON TERMITE AND PEST CONTROL DOES NOT RE-TEXTURE,
WALLPAPER OR PAINT ANY AREA THAT REQUIRES OTHER WORK.
10 O HER. . . INTERIOR
10A. FINDING: Fungus damage was noted to the subflooring below the
front bathroom. This damage was caused by water
leaking through the shower floor.
• RECOMMENDATION: Remove shower walls, floor and bathroom floor tile.
Then remove and replace all damage wood members.
After all damage has been replaced install a water
proof barrior at bath floor and shower pan. Install
new sheetrock and 4x4 ceramic tile to correct. THIS
IS A SECTION I ITEM.
NOTE: If the damage extends into the enclosed wall a supplemental
report and bid will be issued.
3
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