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12090030 CITY OF CUPERTINO BUILDING PERMIT RIIILDINC ADDRESS: 937 COTTONWOOD DR CONTRACTOR: PFRNIIT NO: 12090030 OWNF,R'SNAMEI: NADER RAVENI 0r DATE ISSUED:09/052012 OWNER'S PHONE: 6502189979 PHONE NO: LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r1 PLUMB (- License Class 2 Lic.4 C J r ED J RESIDENTIAL COMM1IERCIAL Contractor S0(0 Date 5 _ I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CHIMNEY REPAIR (commencing with Section 7000)of Division 3 of the Business S Professions Code and that my license is in fall force and effect. hereby affirm under penalty of perjury one of the following ton declarutions: 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 pemnit is issued. I have and will maintain Worker's Compensation Insurance,ars provided for by Sq.FI Floor Area: Valuation:$2800 Section 3700 of the Labor Code,for the perfomtance of the work for which this permit is issued. ,\I'N Number.3691704400 Occupancy Type: AI'1'LICAN'1'CEIi'1'IFICA'I-ION I certify that I have read this application and state that the above infornmtion is correct.1 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 PERMIT E ES.IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save j indemnify and keep harmless(he City ofCupertino against fiabllities,judgments, WITHI 6 7 AYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City inconsequence of the 180 DA ROM L ST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9,18. Issued by: v Date: Signature Date v ❑ O\\'NIiR-R1111.DER I11:CL.\R.\'PION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 1,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, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). AL1.ROOF COVERINGS TO RE CLASS",\"OR BETTER hereby affirm under penalty of perjury one of the following three IIA/ARDOUS MATERIALS DISCLOSURF- declarations: - 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 S Safety Code,Sections 25505,25533,and 2-5--534. 1 will maintain performance of the work for which this permit is issued, compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I 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 ofthe Labor Code,for the performance of die work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined be the Bay Area Air Quality\lanagemenl District I will P maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Heallh& afely Code, ections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,ager making this certificate of exemption,1 Owner r authorized become subject to the Worker's Compensation provisions of the Labor Code,I must Date: / C..- 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 I 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 mid county ordinances and state laws relating Lender's Name to building construction,and 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 ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date coE�' 6 ' 01� GJ� CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRE • DATE: 09/05/2012 REVIEWED BY: GARY APN: BP#: 'VALUATION: $2,800 *PERMITTYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1CHIMNEY USE: PERMITTATE: WORK chimney repair SCOPE dlech, Plan Check Phuuh. Plan Check Flec. Plan Check Mech. Permit Fee: Plumb.Permit Fee: Flec.Permit Fee: Other Hech. Insp. Other Plumb Insp. Ll I Other E1ec.Insp. ,Hach. Insp.Fee: Plumb, hisp. Fee: Elce.htip.Fee: NOTE: This wimate does not includejees due to other Departments(i.e. Planting, Public Works, Fire,Sanitary Sewer District,School District,etc. . These fees are baser/on the prelitninan information mailable and are only an estimate. Contact the Dept for addn'I info. FEE ITEMS (Fee Resolution 11-053 Efl 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # Chimney/Chimney Repair Suppl. PC Fee: Q Reg. Q OT FO.0 hrs $0.00 $534.00 ICHIMAINEYR Chimney Repair PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tar: Administrative Fee: O Work Without Permit? C) Yes Q No $0.00 0 Advanced Planning Fee: $0.00 Select a Non-Residential E) Travel Documentation Fees: Building or Structure i Strong Motion Fee: IBSEIS,HICR $0.50 Select an Administrative Item Bide Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $534.00 TOTAL FEE: $535.50 Revised: 07/01/2012 I CONSTRUCTION PERMIT APPLICATION ZJC( O C) r COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 • FAX (408)777-3333• buildinaancuoertino.oro ❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# \ PROJECT ADDRESS 9 3� G'T APN q ` OWNERNAME MflNa 1�A>3�e p L\ PHONE65, LI l/ �_J171 E-MAIL �orPNRBef /✓A6�K 6h. rc {� STREETDRES$ CITY" STATE.ZIP FAX eq-T CONTACT NAMs—t-aPxoN fw Asa'-�Io-moi`rLJ3 E-MAIL -�-a�y STREET ADDRESS • 'N 1 r CITY.STATE,ZIrL(.L. ! ^ r 0 FAX r (Z O OWNER ❑ OWNER-BUa.DER O OWNERAGENT XCONTRACTOR O CONTRACTOR.AGENT O ARCHITECT ❑ENGINEER O DEVELOPER O TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC a 1Iig5oNIL G 2=' 8"7 K3 C -29 COMPANY NAME E-MAILF rO� ! I f-t) d3� STREET ADDRESS IDZ9 ( ITY ,�tj r DR. CAST�LPL� � � ^ ��� P X75 ,. ARCHITECTIENGINEER NAME LICENSE NUMBER f� BUS.LIC 0 lI COMPANY NAME E-MAIL FAX STREET ADDRESS CITY.STATE,ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSI'R TYPE k5TOR0:S USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: OETACH ❑ATTACH M DWELLING UNITS: ISA SECOND UGIT OYES 5ECONDSTORY ❑TTS OEING ADnt:U• ONO ADDITION' 1Ca"O PRE-APPLICATION OYES IF YES.PROVmE COPY OF I ISTIMBLDOAN 0 m TRECEIVED.BY'T'^" 'i4``, *. ?\"�^ % TOTAL VALUATION: PLANNN'GAPPLM (5aNO PLANNING APPROVAL LETTER I EICHLERHOME. qNO �l' �rt-_.•.fY 1 , aWi�4.�r.,'J _ sa�YC e• .'.tj L- �� By my signature below,I certify to each of the followine: 1 am the property owner or authorized agent to act on the property owner's behalf. 1 have read this application and the informatio Tor is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin ildtltg construction. I authorize representatives of Cupertino to enter the a�pQ{ve-ide(dill d p1roperty far inspection purposes. Signature of Applicant/Agene Date: 1 v 7 — l7i SUPPLE\1ENTAL INFORI`1ATION RE UIRED I_ o =L ;"�=" si:IR°�_� _ New SFD or Multifamily dwellings: Apply for demolition permit for rho\ei .-,,BUILDING RI\1 a 2 ax existing building(s). Demolition permit is required prior to issuance of building permit for new building. ILI, Rt'ss r x `3 l] 11.y1\\i\C 1'LA\RE\IE\ -z r 1 F e .1tir v l �t�b •'Ft r�`�a a� t•iii �.t� 9�j _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure r❑ 'Isrtn nRu -✓•'a [�Itl UBLICNVORlsl form if any Hazardous Materials are being used as part of this project- yir�0 c u ;, 'h "Y �_�t- i 1 a; ❑f LARGI 1 _ o I TIRE DEITI pi I _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ ATA 10 P`v� jY i4 ilav y©�S\\ITA RI,SFNFR DISTRNIC submittal of Building Permit application. - <° r a([ua., rm�t -s A I „IiI ^VIRONML^TAL IIEAI"THli��i BldgApp_2011.doc revised 06/21/11