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04070106 CITY OF CUPERTINO BUILDING DIVISION PERMIT E� A%R NP'6_ "' BUILDING ADDRESS: JONES MASONRY PERMITN'04070106 : 20199 PA OWNER'S NAME: - PERMIT ISSUE DAM LEO SMEYMAN 1049 DELL AVE NE: SANITARY NO. CONTROL NO. 4083777512 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB . MECH 0 Zeno LICENSED CONTRACTOR'S DECLARATION Job Description i 1 Waby atnrm Net I am Itenmd under provisions of Chapter 9(commencing n< with Section 70110)of Division 3 of the Business and Professions Code.and my hums is '"I'llI rod Me, CHIMNEY REPAIR Daunm Cl o ARCHITECTSIDECLA ATION 3 und.mtend my plans shall be used as;2S&,mmds �e, O/ 3 C 1 Licensed Pmfenional `® S OWNER-BUILDER DECLARATION JA, F0 0 1 mum affirm that 11. exempt from the Comment's C's License Lew for my F.pe D following mason.(Section IID LA Business and improve, dcro li Code:Any city or county se m which requires a permit m construct,eller,impmm,demolish,or repair any structure aw-O poor In its iuuam.also requires thpermit to applicant for such perto Ble a signed statement < that W is licensed pursuant tome provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation Wz C (commencing with Section]0D0)of Division 3 of the Business and Profnsstons Code)or Net he it exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects Ne applicant toe civil penalty of 3 WWAibilcrO 0 Occupancy Type root more than five hundred dollar(35110). Q 1,0 owurof Ne propeny,ormyemployces with wages as rhehmle compensation, willdo thework,and theswctum is not intended oroRemd(oracle(Sec.7044,Business and Professioru Code:The Contractors Lienee Law does not apply in an owner of Required Inspections propeny w ho Wilda or improvesthereon,and who does such work htmol f or through his own employees,provided that such improvements are notin ended orolfered forted.if. however.the building or improvament is mid within one yew of completion.lie owner- . builder will have the burden of proving that he did not Wild or Improve for purpose of sal..). Q 1,as owner of the property,am exclusively contracting with licensed contractors to c.nslrom the for su(Sec. Business end Pm(essions Code:)The the Coewes LI- �Ia f�� ams Law does not apply m an owner of propeny who Wilde or improves themon,and, pri®sem {■■'@,M�Hw. who contracts for such projeeu with a conumtar(s)licenxdpursuenl to the Convector's License Law. ❑I am exempt under Sec. ,B&P C for this noun Owner Dau WORKER'S COMPENSATION DECLARATION It R.siss Fe :; i'ui 41 I hereby elfirm under penalty of perjury one of the fallowing dmlatations: - Q I has and will for by ection 37W of donse to Labor Code, tfor WoheM1 ompon- ce of the �Ty uF CUPERTINO satian,n provided maintain by SeNon 3]00 of the Tabor Code,for the performance of the work for which this permit is isma p�y p�/1 ^ DA Q I ban and will maintain Worker's Compensation Insurance,as required by Station L;��l�_)IIVl� 1 7�r�aMENT 3700 of the Labor Code,for the performance of the work for which this permit Is issued. My Workers Continuation Insurance carrier and Policy number are: c�r�rrFer.ti.dZwnla�,0,Nn,:bt NIlig701 CERTIFICATE OF E�EM�TION FROM WORKERS' COMPENSATION INSUR NC Ohb section need not W completed if the permttis furore hundred dollars(31011) or less.) I unify that in due performance of the work for which this permit is iuued,l shall not employ any person in any manner so as In become subject to the Workers'Compensation Laws of California.Dau Applicant NOTICE TO APPLICANT.If,after making this CmI ficate of Exemption,you should become subject to the Worker's Compensation previsions of the labor Code,you must OZ forthwith comply with such provisions or this permit shall W deemed revoked. z O CONSTRUCTION LENDING AGENCY [—i I hereby alarm that thea is aconsluctlon lending agency(nrthe pmformum of ai 7 Om work for which this permit is iuued(Sec.3097,Civ.C.) {f]Q Lender's Name IY Lundeen Address - V 0 I cavity that 1 have read this application and sou that the above talented.is Is,H torten.I agree to comply with all city and county ordinances and utak laws mating to O(, building construction,and hereby autharine reprommadins ofthis city to enter upon the W above-mentioned properly for Inspection purposes (We)agree to ata,indemnify and keep Inco es,the City of Cupertino against wy raj/ liabilities,judgments.costs and expenses which may to any way accrue against mid City V Z in consequence of the granting of this permit. ^ APPLICANT UNDE ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date RC RIS LA g. 1 Re-roofs rSecOon pli t/Contrsewr Dealt HAZARDOUS MATERIALS DISCLOSURE Type of Roof applicant or future building occupant store or handle hazardous material e Culler Municipal Code.Chapter 9.12,and the Health and Safety 5532(x)+ All roofs shall be inspected prior to any roofing material being installed. ZNo applicant or boom Wilding occupant use equipmentor devices which If a roof is installed without first obtaining an inspection,I agree'to remove azaus air contaminants u dcBord by the Bay Aum Air Quality Managcmcnt all new materials for inspection. District] Q Yes I ham lead the hazardous materials royuiremenu under Chapter 6.95 of the Calirm, nix Health&Safety Couc,Sections 25505,25533 and 8534.1 understood Nulittle building Jon2ftnis unently haus a wnmL that It is my mapouibility w notify the meta t of the whichm Wmetpoortoiuumceof.Cmdricauof0ecuanySignature of Applicant Date AW 7 All roof coverings to be Class"B"or better amhoow gent etc Community Development f 10300 Torre Avenue i Cupertino CA 95014 Telephone(408)777-3228 PTYOF Fax(408)777-3333 �UPEkTINO n BuildingDepartment JOB ADDRESS-o2oi .79 Y e, , . PERMI # OWNER'S NAME:-/,eon me ma �-, PHONE #,666 - 0 9 5S- GENERAL SGENERAL CONTRACTOR: I FAX # I am not using any subcontractors: 7 0 Signature Da e Please check applicable subcontractors and complete the followin information: 60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting • Linoleum/ Wood E3Heat lass / Glazing ing sulation andscaping Lathing Masonry Ornamental Sheet Metal ` Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock • Tile `. ~7 0 /Contractor Signature Dat CITY OF CUPERTINO e CUPERTINO PERMIT APPLICATION FORM `v APN# 3 fa q 9 Ct O / / Date: 17-�? /_0// Building Address: � Mailing Address (if different from building address): "Pb/99 /'a � � 24. Owner's Name: �e n rn�n Phone#: 34 6 9 S 6 Contractor: License #: `77 Z�1�5390,569 Contact:,W . Phone: 377. 7S/�i Cupertino Business License#: ,�/L2 Fax: . -77. 75/3 021 a0 Building Perms Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Job Description: `7P.a,paZz n.u' C,—A Residential ® Commercial ❑ Sq.Ft. Floor Area: S/Sq.Ft.: Cost of Project: S e Occupancy Type of Con ruction: Please ch tis bo ' e project is a Aak second-story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERl Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M BtuMECHANICAL 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 I of CITY OF CUPERTINO CITY0 - PERMIT APPLICATION FORM CUPERTINO Quantity Fee 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 BUH.DING 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 Stonn/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING low BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BRENU URN 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 Ap Hance ELECTRICAL 2 of 3 ) 0 CITY OF CUPERTINO CUPEI� INT TINO PERMIT APPLICATION FOR uanti Fee ID Fee Description Fee Group 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 j BTEMPPERM Temporary BIPermit BUILDING BTEMPSVCSOMech em Dist Svcs ELECTRICAL , BUSLICusiness License BUILDING ELECTRIClectricals foot ELECTRICAL EPERMITFEEc Permit Issuance ELECTRICAL MPERMFEEechanicals . foot MECHANICAL MPERMITFEE Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3