06060288 CITY OF CUPERTINO 4 :f
BUIDDING DIVISION PERMIT CONTRACTOR INFORMATION
•BUILDING ADDRESS: JO MASONRY PERMITN0.06060188
1128 STAFFORD DR
0 W NER'S NAME: PERMIT ISSUE DATE
DON FERRIS 1049 DELL AVE 2006
ONE: SANITARY NO. CONTROL NO.
4083777512
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
opoLICENSED CONTRACTOR'S DECLARATION
.-'5 1 hereby affirm Nat 1 am limed under Pmv�ensorehapter v anmmersina lob Description
"C' a
with Section 70(10)of Divivon3ofW Buoess
nand Professium Code.W mylicenses
��$(-� p /q .a
in "'am
l ro lean 9� REBUILD CHIMNEY SHOULDERF1
l[gy114
j v�x License lass Lle.X
=F0 Dam COntracmr
1Js A C.ITECTS DECLARATIOf
-s 1 understand my plans shall he used to public resort
T LiccmeJ Professional
2006
OWNER-BUILDER DECLARATION
if 1 herehy affirm Nat I am exempt from the Contractors License Law for W
O O following reamn.(Section 703 1.5,Business and Pmfecdons Code:Any city ar mumy /jX�a`,'
K m f which requires a Permit to consumer.almn improve.ticmblish.nr reput,my suunme N :�/}00
Y9En prior w its issuance.also requires the applicant for such permit to file a signed statement
< mat he s licensed pursuant td W provisionsdf dm mr
Comisc 's U..Law(Chapter 9 Sq.Ft.Floor Area Va113 aI10n`
YFG (commencing it Second 7000)of Division 3 of the Business and Professions Code)or
y tat M is exempt Wrefrom and W basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects to Applicant o A civil penalty of er Occupancy Type
not more Nan!rte h rted dollars($SDa
Las Donor of the property,or is employees sur offered
wages r Wv sole 7ampens inns
will do mewons add W 9roC ontr dots Licerd,Law
cls s set apply us a4.BusOwner of Required Inspections
and Profession Code:The Contractors I d tm Law Jar oat apply lf an rough or q P
...,propenywyO builds Oded tat sunproves Wreo eEncom as are
Bursa a mallf orNr We his
own employees.provided or i mat such improvements are not intended OrPRead for Asle.H.
however,Ne building or improvement is costo within ane year or completion,W oca
builder wild bare W burden of proving Wt he did rot hill or improve for Pwmm of
of
sale.).
0 1,As owner of W property,Am exclutivclY Cont acting with Iicensod ansrxmrs As
comtrua W project.(sec Hiss,Business and Professions Code:)The Contrumrs Li-
come Law does not apply At an Owner or property who builds or improves W mon.and
who contracts for such projects with a contractor(s)licensed pursuant w W Contractors
Liccnsn Law.
❑ m laexempt under Sm ,B A P C for tis season
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury One of W following El"Imatiom:
1 As
and will for by
o a C M 3700 of Comers r self-insure for erfammsCompcn-
workf for
for mi Ssissu 3700 of the Labor Cade,(Or W perfdnnana Of W
work for which Nis permit is issued.
1 have and will maintain Workers COmpemaoon Insurance,As required by section
3700 of W Labor Code,for to poforreara ofW work for which this permit is issued. '
My Worlyr's Com swoon lm c artiv and Polity nugtbe,
Cartie Policy
FICAM OFEXIMPTION FROM WORKERS'
COMPENSATION INSURANCE
flus session need not be completed ifft permit is fordnc hundred dollass($100)
at less.)
I cenify Wt in W performance of W work for which tis permit is issued.I tell nm
employ any person in any manner sO As As become subject nos the WorkersCompensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this CcO ifinm of Eaempodn.You should
becpme subject m Ne Wmkcr]COmpemation provistom of W Labor Code.you most
.J O f otwith comply with such provisions Or this permit shall be deemed revoked.
Zy CONSTRUCf10N LENDING AGENCY
(--t Ihemhy AM.Wt there iso eonstrnetinn lending agency for to pedoorrome of
ai>
to work for which Ns permit s issued(Sec.3097,Civ.C.)
0 tenders Name
:) z Lenders Add.
V Q 1 Certify Nat 1 have read this application and sate Net to above informed.is
U. Correa I agree m comply with all city and county ordinances and sone laws relating to
QU building conswnion.and hereby authorise representatives of tis city to enter upon the
rpr
�a ahuvc-ms,judgdpropcny fond expenses which ms
(We)Agra m Asst,indemnify and kap harmless the City of Cupertino against
o-F-t In IiabiliomucncC ents,emuand expenses which they in any wyacmue agaimtsaid City
V z A consequence of the gmnong of this Permit. /'
^ APPLICANT ERSTANDS AND WILL COMP Y W TH ALL ON-POIM Issued by: Date 61-
Signature
sOURCE RE O
649
sigmmroornpPHeanCon�rof ��% Data
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicam ter f Me buildin acupa "nom
or handle havardaus material
As dented by to Cupertino MunieiPa Ode.Chapter 11.11,and dte Heat and Safety
Cook,c on 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
Yu
mon If a roof is installed without first obtainingan inspection,I agree to remove
WillWappCIAMAor furore building arupam use equipment or Jevicas which P g
0.1,halyd airconumimn�Bned by me Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yes Nu
I have read W harasdons materials requiremonu unt uChapmr6.95 ofthe Califor-
niaH.Il &Safsty Code.Sceoom25505,25533and25534.1tmdcrsundmmiftc building
MgUE. ."a,annot y atenaf),tat it �o m
reyuirtmcnuw m Fv7X'//�"spri tau nncen; r!x Signature of Applicant Dale
owner orautori.<�cnt Dare All roof coverings to be Class "B"or better
,,,a., Community Development
10300 Tone Avenue
f." '/ Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
*UPEkTINO
Building Department
JOB ADD R�,SS: PERMIT#
l�'g' ,2 0 X060 /
OWNER'S NAME: U PHONE # 6 Z3
GENERAL CONTRACTOR: FAX # 6 3 77 7.$
I am not using any subcontractors: /&Q4
Signature ate
Please check applicable subcontractors and complete the following information:
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
•
Owner/Contractor Signature Date
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36207013 . 00
DATE ISSUED. . . . . . . : 06/21/2006
RECEIPT 4 . . . . . . . . . : 34968
REFERENCE ID # . . . : 06060188
SITE ADDRESS . . . . . : 1128 STAFFORD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : DON FERRIS
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 115 . 56 55 . 47 0 . 00 55 . 47 0 . 00
BPERMFEE VALUATION 5, 000 . 00 115 . 56 0 . 00 115 . 56 0 . 00
BSEISMICRE VALUATION 4 , 400 . 00 0 . 50 0 . 00 0 . 50 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 171 . 53 0 . 00 171 . 53 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ -- ----------------
CHECK 171 . 53 16821
TOTAL RECEIPT 171 . 53
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
101 FOUNDATION 312 CHIMNEY REBAR & STRAPS
514 FINAL PUBLIC WORKS
•
CITY OF CUPERTINO
Ulf OF PERMIT APPLICATION FORM
CUPEkTINO
APN # V�� J Date: / �l Ui /
Building /rel ailing Ad ess (if different from building address):
Owner's e: Phone#: Z 3
Contractor License#�i G� ?�
Contact: Phone: Cupertino Business License#:
�� Fax: t6�37? 373 Q �'
Building Permit Info:
Bldg VrmElect ❑ Plumb ❑ Mech ❑
Job Description: /- I
Residential 5 / / 41Cf1/G� omme cial El
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: IZ Occupancy GrQup:
Type of Const tion: Please check this box if the project is a
4'di 1 � second-story addition: ❑
'11Project Size: Standard M- Lar e ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
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 Ener y Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
1 of
al- CITY OF CUPERTINO
blw F 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 BUILDING
BPFIXTURE PbIg 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 Instalt/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent 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 Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Ap liance ELECTRICAL
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` (0,- CITY OF CUPERTINO
CITYOF PERMIT APPLICATION FORM
CUPERTINO
Quantity 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 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 Mechanical sq. 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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