12050219r
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10642 FARALLONE DR CONTRACTOR:ROYAL SERVICES PERMIT NO: 12050219
OWNER'S NANIF-: MICHAEL MARCELLA 1 2253 MAYWOOD AVE
DATE ISSUED:05/308012
OWNER'S PHONE: 4088050033 SAN JOSE.CA 95128 PHONE NO:(408(972-2452
LICENSED CONTRACTOR'S DECLARATION
�,/ BUILDING PERMIT INFO: BLDG r ELECT r PLUMBr
License Class Com_ Lic.B Irt�(a'V`/
n� r MECH (— RESIDENTIAL r COMMERCIAL r
Contmctor�p��-5 ,SO/UfCG'� DateD'�-Z.
I hereby affirm Ihal l am licensed under the provisions of Cho pter9 JOB DESCRIPTION: REPLACE AND REBUILD Cl IIMNEY FOR SINGLE FAMILY
(commencing with Section 7000)of Division 3 of the Business&Professions DWELLING
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.
1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Fluor Area: Valualion:$3300
Section 3700 of the Labor Code,for the performance of the work for which this
Permit is issued.
APPLICANT CERTIFICATION APN Number:36933043.00 Occupancy Type:
1 certify that I have read this application and stale that the above information is
correct I agree to comply with all city and county ordinances and stale laws relating
to upon buildinghabove mentioned property for inspection
repion purposes. W )of agree
to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said d anad
consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands d will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued Date:
Signaturc__Q Date ,,ff&�P`Q_a
❑ O%VNER-BUILDER DECLARATION � RE-ROOFS:
hereby affirm That 1 am exempt from the Contractor's License Lew for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons:the without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the properly,or my employees with wages as their sole compensation, 1°speclion.
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Dale:
Business&Professions Code)
L as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penally of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's 1 have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this peril is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the health&
1 have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should I store or handle hazardous material.
Section 3700 of the Labor Code.for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued, contaminants as defined by the Bay Area Air Quality Management District 1 will
I certify that in the performance of the work for which this peril is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
nHealth&Safety Code,Sections 25505.25S33.and 25534.
not employ an
p y y person in any manner so as to become subject to the Worker's �
Compensation laws of Cal ifomia. If,after making this certificate of exemption,I Owner or au horized agelt:
become subject to the Worker's Compensmion provisions of the Labor Code,1 muss A Date: 41yg� 0. /,Z—
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that 1 have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct I agree to comply with all city and county ordinances and stale laws relating Lender's Name
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this peril Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all nun-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
SignatureLicensed Professional
Dale
CITY OF CUPERTINO
3 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36933043 .00
DATE ISSUED. . . . . . . : 05/30/2012
RECEIPT #. . . . . . . . . : BS000016954
REFERENCE ID # 12050219
SITE ADDRESS . . . . . : 10642 FARALLONE DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MICHAEL MARCELLA J
ADDRESS . . . . . . . . . . : 10642 FARALLONE DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4408
RECEIVED FROM . . . . : ANTHONY XAVIEL
CONTRACTOR . . . . . . . : TONY XAVIEL LIC # 22767
COMPANY . . . . . . . . . . : ROYAL SERVICES
ADDRESS . . . . . . . . . . : 2253 MAYWOOD AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95128
TELEPHONE . . . . . . . . : (408) 972-2452
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 3., 300 .00 1 . 00 0. 00 1 .00 0 .00
1BSEISMICR VALUATION 3, 300.00 0. 50 0. 00 0 .50 0. 00
1CHIMNEYRE EACH 1 .00 523 . 00 0.00 523 .00 0. 00
---------- ---------- ---------- - ---------
TOTAL PERMIT 524 . 50 0. 00 ,524 .50 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 1, 049.00 #21679
---------------
TOTAL RECEIPT 1, 049.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
---- -- -- ---------------------------- -------- -------------------- ---- -- --
101 FOUNDATION 312 CHIMNEY REBAR & STRAPS
517 FINAL CHIMNEY
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10642 farralone dr. DATE: 05/30/2012 REVIEWED BY: bobs.
APN: BP#: `VALUATION: 1$3,300
*PERMITTYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1CHIMNEY
USE: PERMIT TYPE:
WORK replace and rebuild chimney for sfd.
SCOPE
Ilech. Ilan Check Pharrh. Plwi Check fire. Plan Chock
blrrb, /'until Fee: Phanh. Perma Fce: Elec. Permit Fre:
Odw, Mcch. Insp. Odmr Plumb Insp. Othe, /ileo.lisp.
.1/crh. hi,p. Pec: Phanh. harp. Fro: Blot.hiap.Fer:
NOTE: This estimate does not include fees due to other Departments(ie. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prelimina information available and are only an estimate Contact rite Dept for addn 7 info,
FEE ITEMS(Fee Resolution 11-053 EL 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Chimney/Chimney Repair
Suppl. PC Fee: 0 Reg. Q OT FO.OThrs $0.00 $523.00 ICHIMNEYR Chimney Repair
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee1q Reg. Q OT p,p hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
C'an.sn-aclion Tax:
Adu�iui,enzuire 6�rc: Q
Work Without Permit? O Yes Q No $0.00
Advanced Plannine Fee: $0.00 Select a Non-Residential
Building or Structure O
Travel Doainnenla/ian Fees: A
Suone Motion Fcc: /BSEISMICR $0.50 Select an Administrative Item
Bld,Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $523.00 TOTAL FEE: $524.50
Revised: 05/01/2012
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333• buildinGfaacuoertno.orD
CUPERTINO
❑NEW CONSTRUCTION ❑ ADDITIONTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT g
PROJECT ADDRESS /\/ �1 O` 1✓Arrc ^O"✓e ro - 55-- c4�
Sobo � Q PHONE E-MAIL
STREET ADDRESS I j)/t_ LF ra/ & � CT'. STATE. FAX
CONTACT'NAME � '1 �(�// Lj/V�� PHONE (�7 E-MAIL
STREETADDRESS '�1/j G CITY,STATE ZI C'3 2 FAX
❑OWNER ❑ OWNER-BUILDER )❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHRELT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAMEV1 'IIJI-E�. LICENSE NUMBER LICENSE TYPE BUS.LIC'
COMPANY NAME O l(rrj-J c f E-MAIL FAX
STREET ADDRESS CITY.STATE PHONE
C
ARCHITECT/ENGINEER NAME LICENSE NUMBER ( BUS.LIC'
COMPANY NAME E-MAIL FAX
STREET ADDRESS CRY,STATE LP PHONE
DESCRIPTION OF WORK I I �- Y,1
42
EXISTING USE PROPOSED USE CONSTRTYPE I 'STORIES
USE TYPE OCC. SQFT. VALUATION(5)
EXMTG NEWFLOOR DEMO TOTAL
AREA AREA ARAREA NET AREA
BATHROOM KITCHEN OTHER
REMODELAREA REMODELAREA REMODEL AREA
PORCHARIA DECKAREA TOTALDECK/PORCHAREA GARAGE AAFA DETACH
ATTACH
'DWELLING UNITS: 15 A SECOND UNIT 13YES SECOND STORY ❑YES
BEING ADDED? []NO ADDTION: ❑NO
PRE-APPLICATION OYES IF YES.PROVIDE COPYOF Is TBE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION:
PLANNDJGAPPL' []NO PLANNING APPROVAL LETTER EICHLER HOME? [3 NO
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prpperty owner's behalf I have read this
application and the information I have provided is coma. f reed the Description of Work and verify it is accurate. 1 agree to comply With all applicable local
ordinances and state laws relating to building construction. a orize representatives of Cupertino to enter the above/-identified property for inspection purposes.
Signature of Applicant/Agent: Daze: !1L
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit forovER-IID=.-cotrvTER HIrD.DrNG PT.Ary REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ ExPREss ❑ PLANNING PLAN REVIEW
_ m
Cornercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS
Tom if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. ❑ MAJOR S.iNfiARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
B/dgApp_2011.doc revised 06/21/11