03050066 CITY OFCUPERTINO �I�� 3av, 4,-�a 'z '� xmnn
BUILDING DIVISION PERMIT £CONTRA.CTORINFOI.tMATIO�N��.,',;
BUILDING ADDRESS: BLOOMFIELD CUSTOM MASONRY PERMITND03050066
7518 WATERFORD nR
OWNER'S NAME: 6471 LITTLE FALLS DR . SSR' gn5/2003
INER JOEL H AND MARGARET
PONE: 4083231111 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
40c LICENSED COmRACTOR'S DECLARATION
0 I Wm N
reby affirm that am II«ued under provision of Chapter 9(cem ncrcing Job Description
with Section 70110)of Division 3 of use Business and Prafestioro Code,and my license is
License n. Class
Clue Lk.N anderrem REBUILD FIREPLACE FROM FOUNDATION
jVI Z Lf r n (o u A
Deck A CHIECTS DE LAR01I N _US�pFI®@Aw•—ED
Ins rmand ney pkroshall he used as public mtemmus
joLkenxdPmfur.nal MAY 1 5 Z003
y
OWNER-BUILDER DECLARATION
I Wrchy sifters that 1 am exempt fmm the Contractor's License Lew for the
D o following reason.(Section 7101.5,Business and Profenuu Cole:Any city or county
9 which".I.a permit to comtron.eller.Improve,dem.lkb,or repair any awcium
=�� prior an it,issuance.also mquires the applicant fonuch permit to fie a signed statement
than he is licensed punuanUo the pmvisimm.f the Commovier9 lJcenae Low(Chapkr 9 Sq. Ft, Floor Area
(commencing with Section 7000)of Division 3 of the Business,and Fontenot Code)or
9 that he is exempt therefrom and the btu for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit ubjects the applicant to a civil penalty of 3 6) NICAnlier0 0 Occupancy Type
not mom than frve hundred defiant($500).
❑1,uawoer of the property,or my employees,with wages u their role compensation.
will do the work and the suucmm is not intended or offered for .]a(Sec.IDN,Busioesa — IO�$$ Q�$
and Pmfeulons Cade:The Contractor's License Law dors not apply k an owner of '3 12 — CH I MNE AKp 1cu 9'tRAP.S
property who Wilds.r impr.vu thereon,and who does,such work himself or through his
ownemployrca,provided than such improvement,one not intended moResW foraak.If. 514 — FINAL PUBLIC WORKS
however,the building or improvement is sold within on year of wmpletion,lie owner.
builder will have the burden of proving that Ile did nmt Wild or improve for purpose of
sale.).
❑1.as owner of the propeny,am exclusively contracting with licensed contractors to
construct rte project(Sec.7014,Bu most and Professions Cade:)The Corso mme,LL
cense law does not apply to an owner of property who Wilda or impro es thereon,and
who convects for such project win a contracmr(s)licensed pursue to the Contractoes
License law.
❑I am exempt under Sea ,B k P C for this resa.n
Owner Dow
WORKER'S COMPENSATION DECLARATION
I hereby affnrm under penalty of perjury arc of the following declantiona:
I have and will maintain a CertlReate.f Consent to self4mum for WorkefeCompen-
.me u provided for by Section 3700 of the IaWr Code,for the performance of the
work for which this permit is luted.
1 have and will maintain Worker's Compensation Insmance,u required by Season
3]00 of the Labor Cole,for rte performance of the wort for which this permit is issued.
My,
y Worke�r's+,C�.a.Am�pemmio�n�ybero1mm,e c cr and Policy number are:
Cartier.. Polity Nos,[,w.].�4)1g'S
CERTIFICATE OF EXEMPTION FROM INGRKFAS' 1J�3
COMPENSATION INSURANCE
(This sent..reed not becompleted if the permit is for one hundred dollen($100) _
m kis)
I certify that In the performance or rte wart for which this Permit is ivied,I shall nut
employ any person in any manner se as b become object o the Workers'Compensation
Laws of Califomia.Date
Affluent
NOTICE TO APPLICANT:If,efkr,meting this Certificate of Exemption.you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.JO forthwith comply with such provisions or nice Permit shall W deemed revoked.
Z^ CONSTRUCTION LENDING AGENCY
'E1hereby.rr..that nen I..construction houdingagency for the perfmmancefu> the work for which this permit is issued(Sec.3097.Civ.C.)
IQQ Undch Name -
D Z lender's Address
U O 1 eenify that I have rtad this application and state thane move infmmmiun us
BTI FCG=L 1 agree to comply with ill city and county ordinances and some laws misting to
V Wilding convection,and hereby authorise representatives.fthis city to enter upon the
a above-mentioned property for impection purposes.
(We)agree In move,Indemnify and keep hamless the City or Cupertino against
tilt liabilities,judgments,cask and expenses which may in any way acme against mid City
fJ z In consequenec of the'nohng of
APPLICANT UyDER N AN L OMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RAE/OyLA S
57 Re-roofs
Sig smuof Applicanr/C tractor D m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will rte applicant or future Wilding occupant mom or handle haandous material
u defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Idoes
ode, 0 .nzss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu �.
s' rut `
Will nc applicant or future WilJin'cecupent tax equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
mit ha'sardnus air contaminants u dcfned by the Bay Amo Aur Quality Management all new materials for inspection.
istrict?
❑Yes �$bu
IhoerealrtehaaN.ons255 5.25ls 33andl maunder Chapter 95 dotifthe Callan'
e ,I Safdy Code,Sectians25N15.25533 and 25534.1 understand Nazi!de Wilding ��
not cuncnrlyy,heve•tenant dot it u my reeponsihility k ratify nc cecupant of Ne
quimme�tygafrCh mum (prior uanm.fa Cetircakor Occupancy, Signature of Applicant Date
f'/ All roof coverings to be Class"B"or better
ver er or authorized agent Dam
' bD
,� :C�' • " CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
IF.PN # 1,6 - Date:
Building Address: a
-�- S"/F
Owner's Name: Phone #:
6S-v-3,ys-- of
Contractor: n License #:
Contact: Cupertino Business License#:
AdR U' . 4 . 04.
Building Permit Info:
Bldg p- Elect ❑ Plumb ❑ Mech ❑
Job Descriptiono-�ti.1 A1
Residential ��pG�c �cvt Gcd �rv�� CDescription:
❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Pr oj t: Occupancy G p:
Type of Con ruction: �
t'
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER OtherAppliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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 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<= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1 OOOA ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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CITY OF CUPERTINO
CITY PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
mr BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
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 cfm MECHANICAL
BREMARUiAN 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
BREMMHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM '
CUPERTINO
Quantity Fee ID Fee Description Fee Group
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
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips,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 Inection 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 Issuance PLUMBING
PPLBG Plumbing Feesq foot PLUMBING
ZADDCHG Address Chane BUILDING
'I
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