03100164 CI'T'Y OF CUPERTINO
BUILDING DIVISION PERMIT CONT,JU TUR INFORMATION R'
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BUILDINGADDRCSS: BOB GERE MASONRY PERMIT N"03100164
1 441 MILLER AVE
OWNER'S NAME: 480 CROSSLEES DR PERMIT ISSUE DATE
EVJENTH 10/22/2003
ONE: (408) 972-1285 SANITARY NO, CONTROL NO.
ARCHITECi`ENGINEER: BUILDING PERMIT INFO
BLDG ELECr PLUMB MF.CH
;oo LICENSED CONTRACTOR'S DECLARATION
Ii I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job DCSCrIpt100
v no with SCI ion hereby ar of that I a of the Business and Pir.fprovisions
hapten 9(my commencing
Cenci is
tq„ in mufnrceand CHIMNEY REPAIR
Z Liccnu��CCCCllaIIaaaaassss ��Lic.g
Date TS DE
evp ARCIIITELTS OE //
L n� 1 understand my plans shat I housed as Puhlia rcenrds�/ 34y\s
Licensed Professional
OWNER-BUILDER DECLARATION
MI hereby affirm that I am exempt from the Contractor's License Law for the
eO following mason.(Section 70313,Business and Professions Code:Any city or county
3n which rtquira a cmd,m construct,alts,improve,dead luta,lir repair any structure7 8 8 5
z6 prior its issuance.also reclaims theapplieant forsoch permit to Bit.signed aammem
mm thatkislicensedpursueatmtheProvisionsoftheContractor'sUcsmulaw(Chaper9 Sq.Fl. Floor Area Valuation
ZF� (commencing with Section 7004))to Division 3 of the Business and Professions Codi or
$ that he is exempt therefrom and de basis for its alleged exemption.Any violation of 36915005 . 00
Section 7031.5 by any applicant for a permit objects the applicant to a civil penalty of APN Number Occupancy Type
not more Nan five hundred dollars ISM).
❑ I,as owner of the property,or my employees with wage.as their sole compenu0on,
will do the work,and the income is not intended oreffered forsale(Sec.7G114,Business
and Profession.Code:The Conwctm)License Law dolt not apply tea a atom,of Required Inspections
property who builds or improv tbeuon,and who does suchworkhimulf orthmugb his _
own employees,provided that such Improwmenu are,not intended oroRered for sele.Jr.
however,the building or improvement is sold within one you of completion,the owner.
builder will have the burden of proving but he did not Wild or improve for purpose of
stasis
❑1,a owner of thepmpeny,am exclusively contracting with licensed contractors to
construct the project(Sec.709,Business and Professions Code:)The Contractors Li.
cense law dea not apply to an owner of property who Wilds or improves thsreon,and
who comment for Such projects with a contractor(s)licensed pursuant to the Con actofs .
License Law. -
❑1 am exempt under Sec. .B&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby alrmn under pcmlty of perjury one of the following decluaions:
1 have and will maintain a Certificate of Consent o self-insum for Workers Compere
ation,as provided for by Section 3700 of be IaWr Code,for the perfmmame of Ne
weak for which this Permit is issued.
I have and will maintain Workers Compensation Insurance,is required by Section
of the labor Cade,far tk perfminnu of the.,it for which thi.permit is iaved.
My Worker's C�-otmpensation Insurance carrier and Policy number art:(�
Carrier:. Ft
,JI tF�- )YI 1) Policy No.:
C RTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
(This section eced nm kcomplecd if the Permit is for one hundred dollars($100)
lir less)
1 cenify that in the performance of the work for which this Permit is issued.1 shall net
employ any persen in any manner so a in become subject o the Workers Campeaxtion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exam prion,you should
become subject to the Worker's Com Penation provisions of the Labor Code,you must
DQ forthwith comply with such pmvisinm or this Permit shall be deemed revoked.
Z rte`. CONSTRUCTION LENDING AGENCY
1 hereby aRrm that there is a construction lending agency for the Performance of
1a dte work for which this permit is issued(Sec.3097.Civ,C.)
QLender's Name
2 Lender's Address
C 1 minify dot 1 have read this application and sum that the above informaiun is
y f-
' correct.I agree to comply with all city and county ordinances and state laws relating to
V buildingconsnctianert hembyauthoriurposes. tiv of this city to center upon the
4t1 ahovn(We)tmdare 1.save for canniftion kePmus.
pw (We)agree to cave,Ind expenses
and kith harmless the City ro Cupertino against
Ji,iZ incoises.quene Or the granting of
f this Permit. may inany way eccmc against said City
..)z in consequence ohbe granting af3hia Permit.
APPLI NC3-ACOMPLY WITH N-POT Issued by: Date
SOU RE
/O as3 Re-roofs
Signatureof Applictu tlCo Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ar future building occupant store or handle hazardous material
as delincd by the Cupertino Municipal,Code,Chapter 9.13,end the Health and Safety
otic.Section 255320)? f.�N. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or matte beilaing occupant e4pipment ar de.ie a whim 'If a roof is installed without first obtaining an inspection,I agree to remove
it haturdous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
-
uia7
❑Ya
1 have mad the hiramous materials requirements under Chapter 6.95 of the Califor-
nix Health&Safcry CWe.Section.25505,35577 sod 35534.1 understand thea tithe Wilding
does not dy ha a¢n a t i soy oet*a Certs m notify tM occupant tk
rtyvi ns aCcrdfean Occup Signature Applicant Date
l l/ /e J ��d g PP
Owner or agent Dam
All roof coverings to be Class"B"or better
authnrimd
i114
CITY OF CUPERTINOCU ERT
0 o PERMIT APPLICATION FORM 3
APN # � Date:
i 6 D
Building Address:
� ed
Owner's Name: Phone #:
Contractor: License#: t�
Contact: Cupertino Business License#:
Building Permit Info:
Bld Elect ❑ Plumb ❑ Mech ❑
Job/Description* /
Residential Y� Commercial ❑
Sq.Ft. Floor Ar $/Sq.Ft.:
Cost of Proj ct: , _ Occupancy Group r
Type of Const coon:
Quantity Fee 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 > IOOOA ELECTRICAL
BEL C200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC I Comm. Housing Mit. Fee BUILDING
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CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO .
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
BNUSFD New Single Family Res BUILDING
BOVERTWE Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
if 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 S rinklerBackflo PLUMBING
BPSTORM Stonn/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 I Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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�amm
CITY OF CUPERTINO v
CUPEYOf PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Apphance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, 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 Insection 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
PPERNHTFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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