06050138 CITF EATING
BUIL ISlor+ PERMIT COIRAG�_`yTURIM�OKMATIQ�
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BUILDING ADDRESS: JONES MASONRY PF"m""x'06050138
21979 OAKDELL PL
OWNER'S NAME: PERMIT ISSUE DATE
ROBERTSON ARTHUR D AND ANNE L1049 DELL AVE Oc;/17/9006
E: SANITARY NO. CONTROL NO.
� 4083777512
ARCHITEMENGINEER: BLDG BUILDING PERMIT INFO
O HLECI' PLUMB7 MECH
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LICENSED CONIMACTOR'S DECLARATION
U IObDescription
I hereby affirm that i am licensed under pmvidu oof Chapter 9 knormanelnl
1 with Sec0on 7000 of Division 3 of the Buda and Profession,Code.and my Hanson is
inmu(am amaffM� � a !{ REPAIR AND REBUILD 2 CHIMNEYS FROM THE THROAT U
'y�3 Liee"w WITH METAL PIPE.
Dale Can DELL
ARCHITECTS DECLARATION
f 1 unticssunJ my plans Nall be and as Public rtcords
yyU p�n1yT
i�z
Licensed Professional /l 11 fad r7�nn
y OWNER.B UII�ERDECLARATION RN
ry
I mmM1y aRm Nn I am emmpo from the Contractors Ucenm law for the 1r''JI�
O O following moan.(section 7031.5,Business and Professions Cade:My city or county
SO
I m e which requires a Permit a rnnarocL altar.Improve,dared W,m repair any atromure
prior to its issuance.a su requires theapplieanl far met permit m an a signed wement
E C thnheI.licensed purmmtmthe provisen,aftheConnector's U..Law(Chapter 9 Sq.Ft.Floor AreaUf! r L 2006 Valuati$15600
a� (cammmtcing with Sad.700(1)of Division 3 of the Budoenond Profession,Cook)ur
e g q E dual m Is exempt themfmm and the basis for IM alleged reception.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil panally of }e;py7,�,7 7}�7 tuber Occupancy Type
not mom than five hunlrod dollars(5500). 3Gb.I7 04 . 00
❑1.u owner of the pmpmty,err my wplaycu withwages u theb role campemdon,
will do that war4and thesbuctue is not ImandadaroBeud forsak(Sea.7W.Buda Raired In;
and Profession,Cade The Cantsmu's Liam e ec on law does not apply M se Owner of q p
property who buildurimprosNereon.md whodoessuchwmt himlfo through his
oweemplaym,provided that suet Improvemants art returmndm oronerd fosala If. -
however,the Wiidinlorimpmvemml is mid within oro year Ofconplation,the awrer-
buildar will Mw the burden of proving Nat m did an,build or improve for pupae of -
sale.).
0 I,as want of the property,am exclusively contracting with licensed contnnora to
construct the pmjcm(See.7044,Busla and Professions Code:)M Coamera U.
cam Saw does not apply in an Owner of property who Wilds or improves thepaan.ad,
who conn etsfar such Projects with a eanmclAdl)licensed Pursuant m use Ceneuters
Ltaem law.
❑I am exempt under See .B k PC for this won
Owner Data
WORKERS COMPENSATION DECLARATION
1 herchy affirm under pewty of perjury arc of the(allowing declara0mtz
I haw and will maintains CasdBmm o(Camnt in self-ilium for Wadwel Camper,
1C.,
Ion,u provided fm by Section 3700 of Ne labor Cade,for the performance of theork for which Nis permit is issued.
1 haw and will maintain Workers Compensation Insmmm,u required by Section
00 ofthe Labor Code,far Ne performance of Ne work far which this permitIa Intend.
y Warmgs,CompmOa. I"mm�rtl[e oMeranPolity num r .71?
rtier. K" rre.s•% Polity N".: I
CERTIFICATE OF EXEMPTION FROM WORKERS
EMPlweesCOMPENSATION same omcompleted frompettaiIs amhhundred d-flus(3100)
or leu)
I unify that In the parformance of the work far which this permit Is blued,I shall net
employ any persue in any mmnerm u in become,subject in the Worms'Compemdon
Laws of Califamia.Data
Applicant
NOTICE TO APPLICAKT:If.afwr making this Cenificate of Exemption,you should
become subject in the Workers compensation provisions of Be labor Code,you must
.J O foMwith comply with such provisions or this permit shall be deemed rawkcd.
?► CONSTRUCTION LENDING AGENCY
[••d I thereby affirm Nat deeuae"uvucdnn kmingagcnry,fmthe perfommmm
C
the work far which Nis Permit is issued(Sec.3097,Civ.C.7
0.Q Lendaes Name
]Z Lenders Addw
U0 I coley that 1 have mad this application and sem that the abew infa..IN.ts
V,F cortex.l gpae to comply with all city and county aMnances and sue laws palatial In
OU building construction,and hemby authorise mpmsenutives ofais city to enter upnntar
W shove-mentioned property for inspection purposes.
(We)agme to taw,indemnity and keep hatmless the City of Cuponi"o against
(.y W IiabilWu,judgments,eoau andexpenms which may In my waymeme against mid City
U,'Z in consequence of the gmndng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 'U G
s0 CEREG ATIO
Re-roofs
I tee ol'Appli muacer # DAW
AZARDOUS MATERIALS DISCLOSURE Type of Roof
WIN to applicant orfmum building asuptam ore Or handle hamedon,material
u declined by the Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
Cade,Section 255330)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Will the applicantar future building occupant use equipment o devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hoard"m air communmts a defined by the Bay A.Air Qwllty Management all new materials for inspection.
arict7
❑Yes ONO
I mw read the hsaadmu materials paqummems muter Chaptar 6.95 ofde Calilm-
-I.Haelthk Safety Cada,Seed.25505,25533 am 25534.1 understand that lfdta building
does an,cur¢nlly haw a Imuo.Wl it is my responsibility in notify de Occupant of de
mcmaauma which most tpdar missy fa Canipeak O adq. Signature of Applicant Date
ares d nth // te All roof coverings to be Class"B"or better
lie
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_ CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32639004 . 00
DATE ISSUED. . . . . . . : 05/17/2006
RECEIPT # . . . . . . . . . : 34432
REFERENCE ID # : 06050138
SITE ADDRESS . . . . . : 21979 OAKDELL PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : ROBERTSON ARTHUR D AND ANNE L
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : JONES MASONRY
CONTRACTOR . . . . . . . : JONES, GREG LIC # 21205
COMPANY . . . . . . . . . . : JONES MASONRY
ADDRESS . . . . . . . . . . : 1049 DELL AVE
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : 4083777512
*EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 126 . 36 60 . 65 0 . 00 60 . 65 0 . 00
BPERMFEE VALUATION 6, 000 . 00 126 . 36 0 . 00 126 . 36 0 . 00
BSEISMICRE VALUATION 6, 000 . 00 0 . 60 0 . 00 0 . 60 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 187 . 61 0 . 00 187 . 61 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 187 . 61 16783
TOTAL RECEIPT 187 . 61
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
-------- ---------------------------- -------- ----------------------------
101 FOUNDATION 312 CHIMNEY REBAR & STRAPS
514 FINAL PUBLIC WORKS
•
Community Development
N 10300 Torre
Cupertino CAB 014
Telephone(408)777-3228
Cl OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: I - PERMIT #
, • cUG A ce—
OWNER'S NAME: PHONE # 7 7 - -7 5 aZ
GENERAL CONTRACTOR: Jo ne 4 404r'4FAX#
I am not using any subcontractors: ? v
ignature Dat
Please check applicable subcontractors and complete the following information
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
• Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
6/111:1�ontractor Signature Dat
0(¢05b 138
CITY OF CUPERTINO
CUPERTINO PERMIT APPLICATION FORM
APN# 32(p_ — /
Building Address�/9 ? 9 ,`+lakr/El� Mailing Address (if different from building address)'
I
Owner's Name: (/ Phone#:
IL16 -
Contractor: FJ17I°s License#: 3 9D 365.7
Contact: • //_ Ph e:377-7571 Cupertino Business License)#:
Fax: z77-;U-,l 3
Building Perniff Info:
Bldg Elect ❑ Plumb ❑ ec ❑ j
Job Description: 2LPi S
Residential VL L J �`�ommercial E]
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: G�B p Occupancy Gro j
d i
Type of Construction: Please check this box if the project is a
• second-story addition: ❑
Project Size: Standard Large ❑ Major ❑
Quantity Fee.ID FeerDescri tion Fee Group
BAPPL-OTHER OtheiApoliAndes MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL 1
BBOILER2 Boiler> TOOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler IM to 1.75 M Btu MECHANICAL
BBOILER5 Boiler>1.75M Btu MECHANICAL 1
` BCONSTAX Construction Tax BUILDING I
BCONSTAX Ind/Off/Comin/ uasi BUILDING
BCONSTAXB Con. Tax for B .. Zone BUILDING I
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax-Regi/Mobile BUILDING I
BELEC1000 Elec 600V<=d000A ELECTRICAL I
BELEC1001 E16c.600V> 1000A ELECTRICAL j
BELEC200 Elec Sves:600V<=20.0A ELECTRICAL
$ENERGY Erier' BUILDING
BENERGYADD Ener Add'Multi BUILDING
BINVESTIGA Investi ation`fee BUILDING
I
1 oN
I
CITY OF CUPERTINO
CUPEf�F PERMIT APPLICATION FORM
11 N# Date:
Building Address: Mailing Address (if different from building address):
Owner's Name: Phone#:
Contractor: License#:
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
ro'ect Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> IOOK 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 hid/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V<= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF CUPERTINO
CUPEf�TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
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 rinkler/Backflo 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 cfrn 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 Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2 of 3
* �( CITY OF CUPERTINO
' PERMIT APPLICATION FORM
CUPEkTINO
uantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdi 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 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 Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
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