05040028 CITY OF CUPERTINO '^R"��'"` '""�`
BUILDING DIVISION PERMIT 7CQ � Q� � a.�'�IQ
BUILDINGADDRESS: LEON MASONRY INC PERMIT NO 05040028
OWNER'S NAME: PERMITISSUEDATE
NE: SANITARY OL NO,
ARC HITECT/ENGINEER: BUILDING PERMIT INFO
BO ELECT' PLO MECH
O
+adz LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby.(tion Nal 1 am liceucd under p.wwI.of Chpter 9 woomomwi;
wMSadon]OM)of Division5eftha BusinmwdPmfcuinvC my license4
in ren Class 56 (p?1 3 5 % CHIMNEY REPAIR
z LkenIf ave seen g / .
Dak RCHDE(_rn DECr ATION A/
YI cramostand my plane elWl be used as public records
33 Licensed Pmfcuieral
OWNER-BUILDER DECLARATION
I Wntynaso .(Enn Nn I I.S.eBumpt from me Conuct,Co License law for the (�
O O
which
meson.(Section]f15 LBusiness sed ".de ass Code:My city or county V
$ which mquiry.permit to construct.im eller.Improve,demolish,or repair m.sig any nruclum
F-�t^ prior wtat INItsiensedpaltantto ma thovisios of for suchpermitmfiense Low(Cha ned Ment ,
GNobelact.&wheSeenn7Mthe M.fviviaion3.f cOninContrachraLk.'cnwlaw(Cede).1 Sq.FL Floor Area Valuators
4t s (core a is exempt
Saefrout nd the
West IN of me egad ca pt Prefcu vi GMc)ter
Wt he la..crept therefrom and des bu4 for the alleged ewmption.Any violeGon of
secdon 7031.5 by my applicant for a permit subjects me appileant In a civil penalty Of 3 SWB1 4r0 0 Occupancy Type
not more man Bw hundred dollars(5500),
❑I,u Owner of the properly,or my cmployeu with wages,u metr sole compev.don.
will do ow work,and de aWdum is not intended of Offered for sale(Sec.71144.Biomass Required Inspections
and Profession Code:The Conmerefs vane e Law dean not apply to an Owner of q p
property who builds c r Im prow.desmon.and who does such work hlmsel f or through his
Own employee,provided that such Impmsenvents one Out intended oro@red formle.If.
however,the building N Improvement Is sold within ON year of compkdon,Ne owner-
builder wig thaw the burden of proving that k did Not Mid or improve for purpose of
❑1,u owner of the property.am exclusively contracting wit licensed mnu scums in
eownwl the pmjen(See.7044,Business and Profusions Code:)The Contromoh LI•
rlw law does not apply in an Owner of property who builds or improve.Nelson,and,
who contracts for such pwjecu with a contractors)licensed pursuant to the Conweeme.
Lkeve law..
❑Iamuemptunder Sce ,B&PCforchismuan
Owner Dow
WORKER'S COMPENSATION DECLARATION
1 hmby affirm under penalty or perjury NO of the following declammos,
1 he. ad will maintain a Certificate of Covent to self-hone for WorkersCompen-
ution,u provided for by S.U.n 77011 of the Lobar Cade.for the perfannmce of me
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Ivmauncece,u required by Section
5700 of the labor Code,for the performance of W work IN which than permit 4luved.
My Worker's CompertsmNinjuntace carrier and Policy number ave:
Cakr�n (/t2j_Policy No.:UCXJ7 J 'J
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This vection Ned tint Mcampleted if the permit is forovhundred dollar(5100)
N Ina)
1 certify that in the performance of the work for which this Permit is Issued,1 shall not
employ any person in my owner an u to become subject m the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making Ohio Cenifica4 of Eaempdon,you should
become subject in me Worker's Compensation provision of des LAW Code,you man
OZ forthwith comply wit such provisions;or this permll shall be deemed evoked.
z[r~ CONSrRUC ION LENDING AGENCY
NI hereby inn
chat dere 4a mvuuctwo lending.Bev,for the Ndmorma of
K> me work for which m4 permit I.blued(Sec.5(19).Civ.C.)
QLender.Nurse
7 z Lender'.Addrran
U Q 1 anify mer 1 dew mW This application sed state that tle above Information 4
comem I agave to comply with all city and county ordinances and sure laws relating in
p aS.-J: buildin{canavuctian,and herebyauthodm representatives,orthis city to enter upon me
{17 above-mendarlod propeny for inspection Purposes.
LL (We)agree to save,indemnify and keep haeme the City of Cupertino gaivt
rant in III Hitiea,I dgman LL0`1 capenava which may in my way wrnw agrtnll said Cty
in canseqNoce 0n6 of .pcnnik
�+ APPLICA RSTAN ND WILL COMPLY WIT ALLpON-POINT Issued by:91toDate
SOURC ATI S. G//,
VV Re-roofs
S' li on m Dam
AZARDOUS MA DISCLOSU0.E Type of Roof
Will the appliantorf��um 031 BaauP�go_or handle hanlous material
u de0ned by the Cupemi.Muer' I Code,Chpser 9.12.and the Health and Safety
We.Section 25552(a)7 All roofs shall be inspected prior to any roofing material being installed.
Oyu No
Will IN applicant or tumrc building occupant sew equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It huaNnue air conluninmts u nW by the Bay Area Air Quality Management all new m s for inspe 100.
It hue
t]Yes
No
e—,I—,
Ihwreedmeh,Soc n=awdaLLequimmanta 4.lundcmwd 95ofthaCtlifao-nos not cc Safety...ansm.thjt4,jF5J5morabil.lin notify Oirft cupntif ft
dao not cwm ave a wnant. Y reepovlhilily a notify mo acupmt of me
supine. wmuatbcccrulmawf Qjd7I atureo Ap IcanL Date
orawhor./ G Dam All roof coverings to be Class °Bw Or better
Community Development
' 10300 Torre Avenue
j Cupertino CA 95014
Telephone(408)777-3228
C OF Fax(408)777-3333
#UPEkj1N0-
Building Department
JOB -7q ? S� 5 �I PERMIT#0S b K �-p
OWNER'S NAME: G PHONE # T
GENERAL CONTRACTOR: FAX # /
I am not using any subcontractors-
/ /G
ignature Date
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
l
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
T'
�/ Gloms
Owner/ tractor Signature Date
�7 CITY OF CUPERTINO a S C , o o L�
CUPEf�TINO PERMIT APPLICATION FORM
APN# Date:
S 3z `� �
Buildin Address: Mailing Address (if different from building address):
� S S fQr✓ �v� �-
Owner's
(! rl v ' -( Phone#:s& �j � / Z
x/77 Vic d
Contractor: _ te2 License #: 3 3 F
Contact: Phone: 365- -1(' 60 Cupertino Business License#:
/7 cWe orL lzi Fax: Cos=/
Building Permit Info:
Bld -Er--� Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential ❑ r�Air G`la�.e Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Proj Occupancy Group:
Zoac�
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard ❑ Laze ❑ 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
BBOILERS 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
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,�. CITY OF CUPERTINO
CUPEIo PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
ON 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 Ins ection 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 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
BREWMAT Heater Installation MECHANICAL
BREMINHOOD Installatibn 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
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CITY OF CUPERTINO
CUPER,TINO PERMIT APPLICATION FORM
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 Mechanicals . foot 'MECHANICAL
MPERMITFEE Mech Pernut 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 Chane BUILDING
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