02060172 CITY OF CUPERTINO - - '- -
BUILDING DIVISIONpE CONTRACTOR INFORM
a, _
BUILDING ADDRESS: PERMfp NO,
10471 STOKES AV JONES MASONRY 02060172
OWNER'S NAME:
APPLICATION SUB DATE
ROSA CROSBY 1058 DELL AVE 06/26/2002
PHONE:
4083777512 SANITARY NO, CONTROL NO,
{Pts O O ARC WTECf/ENGINEER: BINDING PERMIT INTO
BLDG ELECT PLUMB MECN
MFI-7 u 1' "I LJ
O y= LICENSED CONTRACTOR'S DECLARATION Job Descri tion
Z
I hereby aRrm thn I r m licensed under provisions of Chapter 9(commencing p
rn 1: with Section 7000)of Division 3 of the Busines d Professions Code,end my license BUILD OF BRICK CHIMNEY. FINALE®
<m y is in full tome rad If
Pr*-ae 6 License Z Lii,N" 3Ap s
�7c S mrncmr JUL 0 1 2002
g p ARCHITECT'S DECi-A9 ION
1 understand psy plays shin I)_be uhf x puMCormier
5 a o o ueenaee Pmreas BUILDING i o OWNER-BUILDER DECLARATION U G
I hereby notio .ffirrinsoo that I am exempt from the ConwcsCo e:Any
Law for the
t Z (allowing reran.permit
comm Business and Professions Code:Any city or county $6000
F 4 O which requires a permit so conswd,alter,impmve,demolish,or repass any swcut
3mPsior to its issuance.also oqu'vesahe opplicanifor such permit tofileasigedmommcnt _
shat he iSlicensbd pu[suml tq she provisions of the Conuactor'a License law(Chapmr 9
(commencing,Msenion]000)o(Division3of the Ropiness rRd Profusions Coda 'r 2 ;/�t1LO;�UV"`'1 ,: 1•, Valuation
or that he Is exam]thefefrom'and the basis or
the elle cal exam itOB.An )i`' 1'j° '
P B p Y violaion
of Section]031.5 by any applieam for a permit su elocu the o"hoant m e civil per el y
of not moi[than Eve bandied'ellars(S500). 101APN SAT ION I: - Occupancy Type
°1,m owner of the property,or my employees with wages as their sole compensation, -
will do she weak,and Ne swcam,is not intended or uffered'for to Ise.7044; - - -
Business and Professions Code:The Contractor's License Law does not apply to an 514 - FINAL Pi13�4tL@d W0ftMns
owner of property Who builds or improves thereon,and who does such work himself
or though his own employees.Provided that such improvements art not intended to
offered for sale.IL however,the building or improvement ii sold within one year of
completion,the owner-builder will have the burden of proving that he did not build or
improve(or purpose of cele.).
❑1,as owne of she P(Sm.7 Y g with licensed contracmra int
airs eCIYS1V[I CanlraClln ,.
Licconense
the project(Seel]044.Business and Property
who
CudoO iThemproves
ves Contractor,
Lice nu Law does nes apply to pm owner of property who Wilds or improve thereon,
t ._ contracts for.such projects with a contractors),licensed pursuant m the ..
an who
Contractors unIoW,
°1 am exempt Se.' ,B&P C for this reason
_ Owner' Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm archer Penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent so self-insure for Warker's
Compensation, u provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued,
°1 have anal will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Cade,for the performance of the work"for which this por mil is
issued.My worker's C opens lion Insurance c r and Policy number arc:
..._. ...
CERTIFlCATIOl40F IXE ON FROGS WQRKERS'1 t ? fa• i ry
COMPENSATION INSURANCfi ' r `
(This aeNon ivied nos be completed if the pemdt is for one hundred dollar -
(S10(Dor lean.)
1 certify than in the n in any ma n the work for which this awit a issued,'
. Com not employ Laws
person in any manner so m In become subject m the Worked' "
Compensation lava of California.Due
NOTICE TOAPo the Workers If.after Compensation
'his evisio sof of Labor od,youmuld
st -
z become subject to he Workers Comp nsmian provisions of the Labor Code,you must
forthwith comply wish such provisions or this permit shall be domed revoked.
"•' ,��, CONSTRUCTION LENDING AGENCY
' > I hereby affirm thin there is a conswclion lending agency for the performance
i
of the work for which this permit is issued(Sec.309],Civ,C.) ,
4.0 -'Lendch Nome. .. ....-... ..
"D z L nder's Address
I, I certify that I have read this application unit sate that the above information is
Lea:Fr correct.I agree 10 comply with all city and county ordinances and sate laws relating
to building construction.and hereby cathodic represenmdves of this city to enter upon
•y the obo(Wa)agree to saw,nd for inspection p hrawms. 9/5M/rix�0
r.Ln t es,j dgme to save,indemnify and keep hamay in the Ciry of Cupertino against
W Liabilities,judgments,cosm and operates which may in any way accrue against said
V Z Cit in co sequence of the graining of thin permit. t-v
PPLIG.TL'CDERSTANDS AND WILL COMPLY\PITH ALLNON� IpT
Issued by: Date
SipykaWpplicanduarmarlor ,Dam Re-roofs '
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm Wilding occupant store or handle hazardous material _-,Type Of ROOF . .._. ,. .
as defined by the Cuper iw Municipal Code,Chapter 9.13.and the Health and Safety
Cbde.Saction 25533(4). .. s , •,:, .• ....., -
oYe•' All roofs shall be.inspect' prior.to.any roofing material being.installed.
Will
ml hazadoihucs aappclontoodirnePomins tue Wdeifldiniendgbuyccthe Bitysc equipmentotdeviccawhich If a roof is installed without first obtaining an inspection, I agree to remove
Arom
°bye. a Air Quality Management
lat"`" V all new materials for inspection. Applicant understands,and will comply with
all non-point source regulations.
I have reed she hated...materials rtquiremenm under Chapter 6.95 of the
California Health&Safety Code.Sections 35505,25533 and 35534.1 understand that
if she building does not currently have a tenant.that it is my responsibility to notify the -
«u ens she r quiremen s which must he mel prior to issuance of a Ce 'lima,of
Signature of Applicant Date
woe o on d.,an, we All roof coverings to be Class "B" or better
.- .. . . . . - OFFICE _.
I 0 0
1SC�1CITY OF CUPERTINO d j Z
• CUP
CITY 0' O PERMIT APPLICATION FORM ' 2� /
APN# / ,/- O ,2g Date: z 0,9-
Building Address: `I
j0 Y7/ S Xy e,
Owner's Name: Phone#: 9
Contractor: License#: S
ne � 3y03�
Contact: Phone#:
r !�o-ru s- y0�37 7- y6i Z
Applicant/Co actor:
Building Permit Info:
]d 6,000•60 Elect PlumpMech
ob Description: 0
Residential: ¢s Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Val tion: G,poo•O D
ype of Construction: Occ
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MEC14ANICAL
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> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housin Mit. Fee BUILDING
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