03090244 (2) 'CITY OF CUPERTINO r.4 " 5- .^&f `-
BUILurvcDrvlsloN PERMIT } F_
PE1.. Pk
BUaomc ADDalsss: BOB GERE MASONRY PERMITNO.03090244
607 NORMA-NM34 W34
OWNERS NAME: 480 CROSSLEES DR PERMIT ISSUE DATE
NE: f - SANITARY N0. ii� CONTROL NO.
(408) 972-1285
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
;00 LICENSED CONTRACTOR'S DECLARATION Job Description
4 1 hereby affirm Thal 1 am licensed under provisions of Chapter 9(commencing p
zz wish Sccu.,7000).f Div '.n of the Buamessm of tions Code en licenxis
DA. in full forte on
,qz oast Lie.« CHIMNEY REPAIR . /0 /
Vis, Da¢ Camncn maia !Sj
qq ARCHITECTS DE 0
I 2 undersand my plans shall he used es P I lie records r -D
)6 V
°0 Licensed Professional
OWNER-BUILDER DECLARATION
�A I I hereby affirm that I am ucmpt from the Contomoh License Law for the
-p o following mason.(Sectiun 703 1.5,Business and Professions Cods:Any city or county
I$ which inquires a Permit to consumer.eller,improve,demolish,or repair any structure
-Ztprior to its issuance.also requires the applicant for such permit to rile a signed statement
(hal he is licensed pursuant[it the provisions of the Commamr's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
2 $ (commencing with Section 7000)of Division 3 of the Business and Professions Coon)or
that he is exempt therefrom and the basis for dm alleged exemption.Any violation Of 36611159 . 0
Section 7031.5 by any applicant for a permit objects fie applicant to a civil Penalty of APN Number Occupancy Type
not mom than fiw hundred dollars WOB.
❑I,as owner of the property,or my employees with wage&as their sole compensation,
will do Ne work,end 0.amorous is nor Intended or offired fonele(So..7044,Business 101 - FOUNDP. �(>�d Inspections
and Professions Cade:The Contractor's License Law does not apply to en owner of
property who but Ids or imposes thereon,and who does such work himself or through his 312 - CHIMNEY REBAR & STRAPS
own employees,provided Nat such Improvements are not intended or offered for mle.If, 514 — FINAL PUBLIC WORKS
however,Ne building or improvement is old within one Sear of completion,the owner-
builder will have the burden of proving Nal he did nm build or impove for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct me project(Sec.7044.Business and Professions Code:)The Contractor's Li.
cense Law docs not apply to an owner of property who Wilda or improves Barman,and,
who contracts for such projects with a contractor(s)licensed pursuant to dre Contractor's
Lic rose Law.
l am exempt under SAO. ,B&P C los this moon
Owner Data
WORKER'S COMPBNSATION DECLARATION
1 hereby affirm under penalty of perjury one of Ne following declarations:
I haw and will maintain a Cenificote of Camara m saffAmun for Workers Compere
Bion,as provided for by Saban 3700 of the ISWr Code,for the performance of the
w
for which Nis Permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Code,for Ne performance office work for which this permit is issued.
My Worker'.Cnmpemation l tt rier end Policy
Cartier. Paliry No 'D _
E TIFI ATEOFEXEMP IONFROM WORKERS'
COMPENSATION INSURANCE
(Thaseaion need not be completed if the permit Is for one hundred dollars(Sla))
ar los.)
1 cattily that in the performance of the work for which this Permit is issued,l shall not
employ any person in any m roe erso As to become subject o the Worker'Compensation
Laws of GIif.m m Da¢
Applicant
NOTICE TO APPLICANT:IL after making this CeniOcete of Exemption,you should
become subject to the Worker's ComPenution provisions of the Labor Code,you must
7Z forthwith comply with such provisions or this Permit shall be deemed mvoked.
z O CONSTRUCTION LENDING AGENCY
1 herby aRrm Nn Neff is s i o tswninn lending agency for N:pe rismar tax of
Si the work for which this Permit is issued(So,,3097,CO.C.)
4A Under's Name
3.3. z Lender's Address t
Q I codify Our I have mad this application And stsm that me above information is
S.F corer.l&&rte to comply with all city and county ordinances and state laws relating 10
DU Wilding construction,and hereby audorim represenms iveof this city to enter upon Ne
�L57 atom-nontioned Popcny for iespcerion purlvm4
(We)agree to on,indemnify and keep harmless the City of Cupcnino against
y liabilities,judgment,costs and expeaes which may in any way accrue against said City
J 7 in con fthe gnntin of this crmil.
L7 APP ICANr U ID• D .- MPLY WITH LL NO POINT Issued by: Date
S R ERE D
Re-roofs
Sin rt a Applicaro Co r Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupmtsl.n or handle heaari us mnerial -
as de0aed by the Contemn. nicipal Code.Chapter 9.13,and the Health and Safety
.de.seeti.n:ss3z(an
Yes No All roofs shall be inspected prior to any roofing material being installed.
❑
WWII the applicant r future building Occupant equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It harardnus air c.nnm�AmaJA me by the Bay Ana Air Quality Management all new materials for inspection.
Or'
❑Yes(havertaJthelia ¢riah nyuirtmcnts under Chaptcrb.95 of the Glifor
ria Halm&Safety Cato,Sccdura25505,25533amd25534.1undenmM iftM Wilding
does remedy hew as that it is my mspons, , I,Wool,the pmt or the '
sty m a v, eFprier.w�xAm of g/2q SI ature I Ap [ aI0
Gwnm-Or atnn.d] I _ll � Dare All roof coverings to be Class "B" or better
CITY OF CUPERTINO
CUPS OF PERMIT APPLICATION FORM
N # Date: �3Q 0
3
Building Address: lZ�
Owner's Name: r #: -62, - s33
Contractor: vLi ense :
Contact: ��- �a ✓/��y�� Cupertino Buns is se#:
��'
Building Permit Info:AJ ooCC J
Bldg Elect ❑ Plumb ❑ Mech ❑
Job escription: .
Res dentia] ❑ Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Proje400 cu
Ocpancy Gro
�-
Type of Cons cion:
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> IM 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
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CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
13MITIGATR 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
BNUCONR M New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BP13ACKFLOW Atmospheric Vacuum PLUMBING
` 13PCESSPOOL Cesspool PLUMBING
J BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g 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
Alk BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo 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
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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