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04030205 (2) CITY OFCUPERTINO BUILDING DIVISION CON N PERMITTRACT�QRL.NFORMATIOriN h. BUILDING ADDRESS: PERMIT NO. BOB GERE MASONRY 04030205 NVANN12PORT DR.0ARC EWS NAME: PERMIT ISSUE DATA NE: SANITARY NEWS NO. HRECUENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 y O o LICENSED CONTRACTOR'S DECLARATION Job Description YmF 1 hereby apron that I am licensed under previsions of ChapLer 9(commencing <Z, with Secdom7")o(Division3ofdm8uercssand fioxdopxCm1c.epgmylic.ma" �a ��® nrmlma. ,d� !�lp s32) / REPAIR CHIMNEY FROM SHOULD mea j�Z License Lic,g =pp Da¢ ARCNR pp ECTSContractD RA I - APR 1�, 2004 '�tl 1 ndersunJ my plans&hall be used as public recon l 72U ;o Lkcnttd Professional BUILDING OWNER-BUILDER DECLARATION +� 1 Wool from that 1 am exempt from the Cro racmrs Lianas,Law for the ip o following mason.(Section 7031.5,Buenas and Professions Cade:Any city of county $ which requires a Permit to construct,alter,improve,demolish.Or repair any swemm tb< prior to its lament,also requires Ne applicant for such permit m rile a signed statement Sq. F[. FlA dnheisliamWpursuant pursuanothcprovisionsofth ConuacmriLiancLaw(chapter9 Floor Area Valuaton $ (commencing with Section?000)of Division 3 of the Business and Professions Csrde)or that he Is exempt therefrom and the barb for th alleged exemption.Any violation of Section 7031.5 by any applicant for.permit sabjau the appliramn0•civil Peodly of 3 1D114er0 0 Occupancy Type nut moa Nan Ron hundred dollars(5500). - I,ssawncr of tie propmY.mmY voPloyces with wagesssthc'v axle compensstian, will do she wank,and on,structure b oo0nlandeamonered mraale(Sax.70M.Bash Required Inspections and Professiosu Cade:The Corms cmr's License Law does not apply m an owner of 9 P property who buildsorirepow Hereon,and whodoessueh work himsedf ortmou d,his own employers,provided that such improwmenta rte not inlenhd moRernd(m sok.IL howew,the building or improvement is said within one yen of completion,the owner. builder will haw tW hard.of proving that M did not build or improve fa purpose of sale.). [:)1,as Owner of the property,am exclusively contracting wish Ilcataed contractors Is comuuct she project(See.7044,Business and Professes Cade:)The Contractors U- cause Law docs not apply to an owner of property who builds or improves disease.and, who contracts for such projects with a co ossemr(s)licensed pursuant to the ComractoYs Liceve law. ❑1 un exempt under Sec. ,B&P C fm this reason OwMr Data WORKER'S COMPENSATION DECLARATION I hereby affirm under peedty of perjury one of the following declandioa e 1 have and will maintain.CeniOuk of Conant to self-iruum forworkees Compen- sation,ss provided fes by Section 3700 of the Labor Code.for the performance of the work for which this Permit is issued. I haw and will maintain Workers Compensation Bsamora,as,required by Section of the labor Cudc,for the performance of the work for which this Permit is Issued. My Workers n pemni n//I/n��y�/yna/�nniv and Policy nu—myb'era¢1 Carrier: CAPolicy No.: ERTIFl ATE OF EKEMPI IUN FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed ifthe passed.Is fm one hundred dollvs(5100) or less.) I certify that In the perfn rnmr.of the work for which this permit is issued,I shell not employ any lxnan in any manner so as to become subject to the Workers'Compensation Laws of California.Dalc Applicant NOTICE TO APPLICANT.If,after making this CeniRcare of Exemption,you should become subject,he the Wmker's Compensation provisions of the Lahr Csdc,you most Z forthwith comply with such provisions or this Permitshall be deemed revoked. ZO CONSTRUCTION LENDING AGENCY [r (hereby airrm Nat ft.iso construction lendimgagcncy far the performance of (5:> the work fur which this Permit is issmd(Sec.W.Civ.C.) fgd Q Landers Name a LaMar'sAddress CJ Q1 certify that 1 have mad this appliesdom and state that the abew Information is (•" comet.l agree to comply with all city and county ordinances and state law relating m V building construction,and hereby eushorim mpmxnutiws of this cirymcmmrupon the U above-mentioned pmpcny fon impaction keep ho / gyr (Ws,)agree to saw,indemnify and keel hamdess Um City of Cupertino agaiest FVy Iiabilides.judgmcnta,costa and,aN.which may in any wayaccme ag.insist id City U Z in WA u f IMO it. Date K qND WILL COMPLY WITH A L NON POINT Issued by: i ��1� "l Re-roofs Si naroreofApplicmOCanuacmr Date T�� of Roof HAZARDOUS MATERIALS DISCLOSURE Type Will she applicant or future building Oaupant Was or handle haca dons malarial n deeded by the Cupenimo Ma-wIPel Code.Chapter 9.13,end the Health and Safety adilliliCode.Sccuon 15533(.)? ,' All roofs shall be inspected prior to any roofing material being installed. ❑Yes Will the applicant of a um building occupant are equipment or devim which If a roof is installed without first obtaining an inspection,I agree[o remove 70wncr n hamdous air com mat is u defined by the Bay Amo Air Quality Management all new In for inspection. District? ❑Yes Nu /JJJ l have mad the havardous materialsfequiremenu under Chapkr6.95 ofthe Califor- li aSafmyCodc.Salimu255)5.255JJ anJ2533d.lwdcrslarWthuifthc building s n lady haw a that it b my rexpomihiliiY m wutj Ns, upani of the rem t mvpniormi eea(aCeniBwm Oca/' Signature ofAppi t Date ll All roof coverings to be Class"B"or better or authonmd age ate 1 _ a Community Development a 10300 Torre Avenue k Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 cl>Y DF PERTINO Building De artment JOB ADDR PERM ��a9 s mer 003 OWNER'S N 7yg -IN PHONE # S - GENERAL CO ACTOR: FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followin information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry y e�G Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile r/ ntractor Signature Date r CITY OF CUPERTINO p 2- CITY CITY OF PERMIT APPLICATION FORM CUPEPTINO APN # J�� (/ O� Date: Building Address: Owner's Name: Phone#: Contractor: License #: Contact: 1 Cupertino Business License#: Building Pen-nit In o: Bldg Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential J Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: �1 i7 Occupancy Gro p;' Type of Co truction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL 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. Housing Mit. Fee BUILDING Iof3 CITY OF CUPERTINO CITY° PERMIT APPLICATION FORM CUPEI,TINO Quantity Fee ID Fee Description Fee Group 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 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 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 BREMFM Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> 10K 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 2 of 3 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 Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Ligbting 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 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 Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3