10100082 CITY OF CUPERT[NO BUILDING PERMIT
BUILDING ADDRESS: 7540 BOLLINGER RD CONTRACTOR:ROYAL SERVICES PERMIT NO: 10100082
P•"NER'S NAME: G.SUN 4398 NICKER CT DATE ISSUED: 10/12/2010
NER'S PHONE: 6502915135 SOQUEL,CA 95073 PHONE NO:(408)972-2452
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r- ELECT f— PLUMB
License Class6-Z Lic.# �7/6� / MECH F RESIDENTIAL F COMMERCIAL
Contractor Date
JOB DESCRIPTION:RE-BUILD CHIMNEY SHOULDER UP
I hereby affirm that I am licensed under 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 declaration:.:
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:$3000
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:35924004.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
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 relati rg 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 of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
8.
9.1 V
S°natureature Date_a
RE-ROOFS:
❑ 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
1 hereby affirm that I am exempt from the Contractor's License Law for on(of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensati 3n, 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 o ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
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
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
I certify that in the performance of the work for which this permit is issued,I sha Il
not employ any person in any manner so as to become subject to the Worker's Owne ' mthor' agent: DMZ Iv
Compensation laws of California. If,after making this certificate of exemption,f l�11�"`� _Date: r�(Y
become subject to the Worker's Compensation provisions of the Labor Code,I n rust
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
-)n the above mentioned property for inspection purposes.(We)agree to save
•mnify and keep harmless the City of Cupertino against liabilities,judgment:, ARCHITECT'S DECLARATION
—sts,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,Sectiot
9.18. Licensed Professional
Signature Date
CITY CSF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : :,5924004 . 00
DATE ISSUED. . . . . . . : :_0/12/2010
RECEIPT #. . . . . . . . • : BS000011706
REFERENCE ID # . . . . :-0100082
SITE ADDRESS . . . . . : '7540 BOLLINGER RD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA
OWNER . . . . . . . . . . . . . 13. SUN
ADDRESS 7540 BOLLINGER RD
CITY/STATE/ZIP . . . . 2UPERTINO, CA 95014
RECEIVED FROM ANTHONY XAVIEL
CONTRACTOR TONY XAVIEL LIC # 22767
COMPANY ROYAL SERVICES
ADDRESS 4398 NICKER CT
CITY/STATE/ZIP . . . : SOQUEL, CA 95073
TELEPHONE (408) 972-2452
i
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- ---------- ----
1BCBSC VALUATION 3, 000 . 00 1.00 0 .00 1. 00 0 . 00
1BSEISMICR VALUATION 3, 000 . 00 0 .50 0. 00 0 .50 0 .00
1CHIMNEYRE EACH 1. Oc 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 .E0 #20778
-------------- -
TOTAL RECEIPT 508 .E0
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------------------------- -- -
101 FOUNDATION 312 CHIMNEY REBAR & STRAPS
517 FINAL CHIMNEY
M. n r Air Quality and Finishes
1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQIHealth pts y=yes 0
S.Use tawft VOC Adhasivss 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes p
6.Use Exterior Grade Plywood.for Interior Uses 1 IAC#Health pts y=yes 0
7i$W4-1 eal or OF 41AQ/Health pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 ! 1
N.Flooring
1.Select FSC Certified Wood Fiooring 6 Resource pts y=yes 0
2.Use flapidly Renewable Fboffing MaiwWs 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQMealth pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
S.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 ! 1
Total Points Avallable� 401 1301 57
Total Points Project Received 01 0 0
G:data/pro islgreenbuldmgguidelines/remodelerslgreenpointsfina1212D4protected.xis
,
CITY O CUPER 111 \O
CUPEKT1NO GENERAL BUILDLNG
PERNUT APPLICATION FORM
APN# <� c� .� Date: 6 — 12 10
Building Address:
Mailing Address (if different from building address;):
Are Hazardous Materials being used as part of.:his project? Yes ❑ No
HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA
Owner's Name: Phone #:
&., s�v� Asa �9
Contractor: S Phone:
20I VrL �V(C� Fax:
Contractor License#: -7 Lf I W I
Cupertino Business License#:
Contact: �� Phone:Fax: �'d-
Residential Commercial ❑
Job Description:
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ E/MN-A ❑ II/III B, IV-HT, 7-B
Valuation: 3qob Square Footage:
Project Size: Express 2' Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green B iRding/LEED Checklist & attach it
to the application or if applica;)le, include in plan set & the sheet index.
oints Achieved:
For help, contact Build it Green at www.builditixeen.org
Revised 07/14/09