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04010064lre2 _Go ets�e ZaN n�nt �ylU ;os no KmLL Limen —ZN EFo 0 z CITY OF CUPERTINO _ Z, Q 0 � Q F V W y h ,z ^-� DrvlsloN PERMIT CONTRACTOI'gNFORMATION ,`, BUILDING FS Y ° rt W 3..T§v.' oMxcev.r,1 BUILDING ADDRESS: `1 ?1 r14ADWICK PL LEON MASONRY INC PERMIT ND04010064 OWNER'S NAME: CAROL BRUSH 24n m0qF.T,T,T?. rT PERMIT ISSUE DATE 2004 'ONE: SANITARY NO. CONTROL NO, 4 ARCIIITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing P with Section 70M) of Division B of the Business and Professions Codc, end my license is in full f and We�L2a7 1.233 Tar? infullClass e CHIMNEY REPAIR SHOULDER np n Class Lien 7If/-1 CumraclofI Date -77 � Iu��andmy piARCHITELTS DEpu 1 understood my plans shall be used as public records FEB (30.2004 — V Licensed Pmfessi... I OWNER -BUILDER DECLARATION I)�n 1 hereby affirm that 1 am exempt from the Contractor's License Law for the Pagl� U ®81�,1}e BUILDING NG following reason. (Section ]11]1.5, Business and Professions Code: Any city or county IY tV which "tires a permit to construct, alter, improve, demolish, or repair any structure poor to its issuance, also reGYlfei the applicant for such permit to file a signed statement Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section y0i10) of Division J of the Business and Prorcesc Coife)ur Nat he u exempt therefrom and IW buss for the alleged exemption. Any= of 3 f"Qr0 0 Occupancy Type Section 703 1.5 by any applicant for a permit subjects Ne applicant to a civil penalty of not more than five hundred doll,.. ($500). 1, as owner of the pmperty, or my employees with wages as their sole compensation, Required Inspections will do the work, and the swewre is not intended or offered for sale (Sec. TOM, Business and Profession. Code: The Contractor's 1Jectne Law does not apply to an owner of progeny who builds or improves thereon, and who doessuch work himsef orthrough his own employees, provided thatsuch improvements are not intended croRered for sale. If. however, she building or improvement is sold within one year of completion. he owner builder will have the bund,. of proving Ntl W did mol Wild or improv for pension of sale.). I, as owner of the property, am exclusively contracting with licensed contractors to construct to project (Sec. 9(dA, Businm and Professions Cade:) The Contractor's Li centre law does not apply to an owner of property who Wilds or improve thereon, and who contracts for such projects with a contractors) licensed pursuant she Conuactar'o Lma. law. 0 1 am exempt under Sec. B h P C for this ..on . Own Data WORKER'S COMPENSATION DECLARATION I hereby affirm under p,Carry of perjury one of the following dicesrations: I have and will maintain a Cem icale of consent to self -insure for Worker's Compere tion, as Provided for by Section 1900 of the Labor Code. for Ne performance of the for which this permit is issued. �work Ka ' have and will maintain Worker's Compensation Insurance, ef required by Section 37W of she Labor Coils, for de performance of Ne work for which this permit is issued, My Worker's Compensation Insurance ,artier and Policy number art: Cartier: 5+Ata, nNJI Policy No.: l ' CERTIFICATEOFEXEMP IONFRO WORKERS' COMPENSATION INSURANCE (oris samion need not becomNemd ifthe permit is fororchundred dellara (sire) to, ins.) I certify Nat in the performance of the work for which this permit is issued, I shall not employ any person in any manner yµs to become subject m the Workeri Compensation Laws of California. Dam // Applicant �� NOTICE TO APPLICAA� If, after making this Cenif¢am of Exemption, you should become subject to the Worker's Compensation pmrisioru of IW labor Code, you muse f.Mwith comply with such provisions nr Nis permit shall he deemed invoked. CONSTRUCTION LENDING AGENCY 1 hereby that more is a maumclinn agency lin the performance of which 7. Ging the work for which this permit is issued (Sm. J09'1, Civ. C.) Lender's Name lard,rs Aadm.. 1 certify that I have read his application and sea¢ that IM .Who information is cossect. 1 agree to comply with all city and county ordinarmn and shoe laws relating to building construction. and hereby anthoriaa reproserionocs of Nis city to enter upon the .hove -mentioned property fm inspection purposes. (We) agme to save, indemnify and keep harmless the City of Cupertino against Liabilities.judgments, costs and expenses which may in any way accrue agmnflaud City in commueree of the granting of this permit, APPLICANT UNDERSTANDS AND WILL COMPLY WITH L N N -POINT Issued by: Date OURCE RE�T10NS. ,s j r!/ C)"( v l Re -roofs Type of Roof I gnaw fA anUConuacmr Date — HAZARDOUS MATERIALS DISCLOSU E Will she applicant or forum 1, ding vrcupam store or handle havvJou amrial as defined by de Cupertino Code, Chapter 9.13, ..it the Heal d Safely Carlo. seed.. zssaz(a)'r All roofs shall be inspected to an roofing material beim Installed. ❑ma No prior P P Y g g If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or rata Wilsoncam art vu equipment or devices which ' s� a havamrtra air,.n'n ith., JcuncJ by Ibe Bay Ata Air Quality Management all new materials for inspection. ❑ Ycs Nu 1haverevtheI uWmsmaterialsmquim=ntsunderCNpwr6.95ofNeCalifor- niaHealN&Safely Cp .Secd.n 505.25533aw35534. lundersundlhztiflM Wilding Nes net currently hast a tenant that it a my resposechniflyp nod,fy the occupant of the ' paq.�nenxwho maaWpetpriorff.y Signature of Applicant Date /agOfpkn� 1 of/C All roof coverings to be Class "B" or better OwdCernr Norieedaggecunt((/ Date CITY OF CUPERTINO ra CITY OF CUPERTINO PERMIT APPLICATION FORM 2�aa� 1 of 3 I APN # Date: 1 ey/ O 41 Fee Group Building Address: 1 P L BAPPLOTHER / A C�1 r4c�tn/ t c 1C MECHANICAL Owner's Name: C32DS Phone #: (oD Bldg Permits . foot Contractor: i-�r��1 VYl RSc�Nae- sniC License #: (v� 3 3 � BBOILERI Contact: Cupertino Business License#: BBOILER2 Boiler> 100K to 500K Btu MECHANICAL Building Permit Info: BBOILER3 Bld $ Elect ❑ Plumb ❑ Mech ❑ MECHANICAL Job Description: BBOILER4 Residential ❑ r p - i Commercial ❑ MECHANICAL Sq.Ft. Floor Area: $/Sq.Ft.: Boiler> 1.75M Btu MECHANICAL BCONSTAX Cost of Project: � O O O Occupancy r u T-. Ali- Type of Co struction: Ind/Off/Comm/Quasi 2�aa� 1 of 3 I QuantityFee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 2�aa� 1 of 3 I SEMI CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2of3 Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING �I BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING - BPSPRINK Lawn Sprinkler ackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Devi ce/A aratus ELECTRICAL 2of3 aam% CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING BMISCELL Building Mise Fees BUILDING 3 of 3 i 1 J a