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03100088 (2) CITY OF CUPER'1'INO am,�Er >t .; '^ �' > :;'' BUILDING DIVISION PERMIT CONT„RAGTR�INF(7ItMAT10N, BUILDING ADDRESS: BOB GERE MASONRY PERMIT No.03100088 OWNER'S NAME: 480 CROSSLE,ES DR PERMIT ISSUE DATE INC: SANITARY N0. CONTROL NO. (408) 972-1285 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH ;Oo LICENSED CONTRACTOR'S DECLARATION JobDescri hon 1 1 ion? affum that I am licensed under and Professions of Chapter 9(commencing p wish ScI hereby o that I am of the Business and Pmfcssiof Chapter e9(com eenciis i ziin m mRO,rce+ t. f force Lie,N CHIMNEY REPAIR Llccn t„p Da¢ CumrEs /O/ Q� qq7W ARCHITECTS DECENRATION//�!i"' p W U I understand my gl....hall be used u rt public cnNr�' Licensed Professional OWNER-BUILDER DECLARATION <I 1 hereby affirm that I em exempt from the Contractor's License Law for the 0 O following reason.(Section 7031.5,Business and Profesainm Code:Any city or county $ which requires a permit to construct,aper,improve,demolish,or repair any structore iy Poor it)its issuance,also mquires the applicant for such permit to file a signed statement s�� that he is licensed pursuannn the proa vieloof the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation z� (commencing with Section 70DO)of Division 3 of the Business and Professions Code)or 3 $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of 3263 qo36 . on Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not marc Nan five hundred onion($500). 1,u owner of the pmpeny,or my employees with wage u tMinole compensation, will do the work.and the wnure is not intended or offered for sale(Sec.7044.Business 101 - FOUNDP{e�P;gd Inspections and Professions Code:The Contactor License Law does not apply to in owner of property who builds or improves thereon,and who doesauch work himselfor through his 312 CHIMNEY REBAR & STRAPS own employees,provided that such improvements An,not intended or offered formic.It. 514 — FINAL PUBLIC WORKS however,Ne building or improvement Is sold within one year of completion,Ne owner builder will have the burden of proving that he did not Wild or improve for purpose of uleJ. ❑I,as owner of the progeny,em exclusively contracting with licensed contactors to compuct the pmjen(Sec.7044,Business and Professions CodeU The Contractor's Li. ce=law does not pply to an owner of property who Wilde or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to on C^^Mactor'e License Law. ❑I am exempt under Sec. B&P C for this reason Owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury am of the following declarations: I hoe and will maintain•Ccuifun of Consent to self-insure for Walkers Compere .tion,as provided for by Section 3700 of the Labor Code.for the performance of the wa forwhichthpc isrmttisissucd. I ban and will maintain Worker's Compensation Insurance,As required by Section 700 of the Labor Code,for the peffmmmee of the work for which this permit is issued. My Wnrkere Cnmpe in muranceurtiennd Policy*WR um W^ e i Co. l✓ Policy NaJ CERTIF CATEO SATIONIINFROMW RKERS' COMPENSATION INSURANCE (This%smart need not uncompleted if the Permit is for one hundred dollars($lfq) or less.) I certify Nat in due performance of the work for which this permit is issued,I shall not employ any person in any manner an As to become subject to tbe Workers''Compensation Laws of Celifomia.Data Applicant NOTICE TO APPLICANT:IL after making this Ccnifrcam of Exemption,you should become subject to the Workers Compensation provisions of the labor Cank,you must Z forthwith comply with such provisions or this permit shall W dreamed revoked. OCONSTRUCTION LENDING AGENCY 1 beEhy affirm that there is conswctinn lending agency bar On performance or Y ti the work for which this permit b issued(Sec.3097.Civ.C.) JJ Q Lenders Name 2 lender's Addmtss 0 1 cenify that 1 have read this application and soon that the above information is y F cortex.1 agree 10 comply with all city and county ordinances and state laws reining m DU hulldi ng convection,and hereby autioriE representatives Of this city In enter upon the C 'l ova-mentip oned property for inseed m purposes. Wo)agree to save,indemnify and keep harmless the City of Cupertino against J h coni wncc ethcgmnindexpcnuawhicbmayinanywayecerveagainstsaidCity / S .�z APonuquenccAm� UNDEgranung oS IAND WILL COMPLY WITH ALL NO Issued by: Date S _ /21D 03 Re-roofs oateof Appl/do'It DOUS MATERIALS DISCLOSURE Data Type of Roof Will the applicant ser future building Occupant store or handle haardous material a defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety cade.sotYa,zssu(a)7 No All roofs shall be inspected prior to any roofing material being installed. Will the epplicantor fuwrc building occupant sex equipment ordevicu which If a roof is installed without first obtaining an inspection,I agree to remove p hvaMous air srmu mi ants u defined by the Bay Area Air Quality Management all new materials for inspection. ntricR ' ❑Yes u have mad the haamduus materials requirements under Chapter 6.95 of the Califon nixHealth&Safety Code,Sectmes 25N15,25533 and 25534.1 understand that if Ne Wilding does n tly have a tenant that it is my responsibility m unity do Occupant of the req ' w ' kxi ear.cenifica Ocap Signature of Applicant Date A raranthamcd n Date - All roof coverings to be Class"B" or better CITY OF CUPERTINO b v CITY OF PERMIT APPLICATION FORM CUPEkTINO PN# )1,. C) Date:, ,/) 0 o3 Building Address: Mailing Address (if different from building address): Al �a Owner's Name: Phone#: Contractor: License#: Contact: G� Phone: Cupertino Business License#: G Fax: Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Job escription: Residential ❑ /``�' Commercial `❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: i Type of Construction: Please check this box if the project is a second-story addition: ❑ 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 I of CITY OF CUPERTINO 1 CUP ATY F O PERMIT APPLICATION FORM QuantityFee 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 BNUCOMIvIE New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUC0MIv1P New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING 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 Repipe Of Fixtures PLUMBING 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 Heater/Vent 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 Ligbfing 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 BREMPOWER Power Device/Apparatus ELECTRICAL 2 of 3 Sam& CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMRECEPT Rc tl Switch & Outlets ELECTRICAL BRENU ELOCA 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 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