05090040 (2) CITY OF CUPERTINO �r +.; , , '^��yf"t��'r 'y�+'7� x" t(a�75
BUILDING DIVISION PERMIT �4oLnl�juoll/R�1\I'�AviYx1�'. iyl�
BUILDING ADDRESS: BLOOMFIELD CUSTOM MASONRY PRE""NO05090040
OWNER'S NAME: PERMIT ISSUE DATE
5
ONE: SANITARY NO. CONTROL NO.
4083231111
ARCHITECT/ GINEER: BUILDING PERMIT INFO
BLDG O ELECT O PLO O
A 0ij LICENSED CONfRACR]R'SDECLARATION lob Description
�Z+ 1 Mseby affirm Net 1 em licensed under ryavislam of CMper 9(rommeneing
< withSecamilf0U)Of Dlviaian Sof NCBu9neV Profe,slllm Code.sndmylicenseis
6666 m full forte and effect
g_ p�a,aclate C.29 , ( rTQ6I4 _ REBUILD FIREPLACE TO FOUNDtA�{t{t{ggq�TIfy�1N1
ms seem ECrS DECLs aT ON trS'a-U)n ��! A ij Iyf�,:D
undenCenJ my phm Watt be used u public rteard, U.'.-e � (J VVV fi 4"^a"'"'
Gia Licensed Professional.
`ran OWNER-BUILDERDECLARA71ON OCT as, 2005
I hereby affirmNat I me exempt from tae Cantractars License law far Inc
i A O following mann.(Section 7051.5.Business and Profeasmas Cork:Any city or County
$(< which require,a Permit ro convect.alw.improve,demolim,lir repair any arucomen as as t9-TA.{1�t , v v1 �5 0 0 0
_Zs prior b its Womac,also exports the applicant for such Permit un Me a signed statement rl
s€o Chat W is licensed pursuant to the provisions of the Contractors license Law(Chapter 9 Sq.Ft.Floor Area LU Up lfe
90 (commendngwith SeN..70DO)of Dlvlslon5aftho Busiva ftf.iou Code)or u
le that he"exempt therefrom tad the basis for On alleged exempdon.My violation of
Section 7051.5 by any applicant for a permit subjects the aPPfiant m s civil Penalty of Occas
set mom than five hundred dollen ane(ISM , Occupancy Type
❑L asomme of Ne property,Or my etoployom with magest,their sole campenation,
wi0 do the work and the stramum ls not intended woRemd forsaie(Sec.]ON,Business
and Professions Code:The Cortrxetor,License law don ant apply m in owner of Required Inspections
property who Wilds orimprovns Nerco ,and who duessuch workhimselfseruuough his
own employees,provided thatsah improvements tae net intended maffered forale.If.
however.the building or improvement it told within ane year of eompkdon,the Owner.
builder will have Ne burden of proving Nn he did not build or Improve for purpose of
ale.)•
❑1,as Owner of us,Property,am exclusively contracting with][earned cenuassen to
construct the project(Sec.7044,Business aM Professions Code:)The Conuamars U.
came law does not apply In an Owner of property,who builds or improves themon.and
who contracts for such projects with a eommetar(s)licensed pursuant to Ne Contractor's
Liana law.
❑I ser exempt undo Seo .B R P C far this moan
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby Affirm under penalty of pedury ane of the fallowing dG motions:
1 have and will maintain a Cenifiwm of Conant on self-more for Wmkch Compen.
1031.,00
on,as provided fm by Section 5700 of the labor Code,fm the performance of the
rk for which this permit Is issued.
1 have and will maintain Worker's Compensation Insuance,u required by Section
of Ne labor Code,for the performance of the work for which thin permit ls laved.
Workers Compensation Insurance carrier and Policy number sm:
ttier:(nrhteJ-\CW Po11ryNo.: 14- CC
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectionrecd notnecompleted irthe permit is fm one hundred dollars(SIM)
or lea.)
1 arify that in Na performance of the work for which this Permit is issued.I shall not
employ any person in any manner to as to become subject to the Workkri Compensation
Lowe of California.Data
APPlkant
NOTICE TO APPLICANT:If,after making this CeniOeate of Exemption.you should
become subject m the Worker's Comrcnmdon provisions of the Lahr Calk,you must
J O forthwith with comply with such provlslnor this permit shell bu deemro
ed oked.
'ZC 7)w
CONSTRUCTION LENDING AGENCY
I hereby Nat Nem is a c inpgeey
for Lia Performance of
tiro work rte which this perrnn to issued(Sao..5097,cis.
c.)
W�Ca Undos Name
Z)z Lendere,Address
U0 1 artily that I haw mad this application and stain that the above information is
ly F contact.I agree to comply with all city and county ordinances and thou law totaling to
p C.7 building convection.and hereby aulhodm mpreemadves of this city Co enter upon Ne
W above-mentioned pmpcay for impeetion purposes.
g), (We)agree to ave.Indemnify and kap MMIM the City of Cupertino agaWt
y liabilities judgments.casts and expenses which may in any my ecoe again,,said City .y
C)z incOmequenceof he Ing of Nhpc Issued by: Date �— /^✓� f
APPLICANT RSTANDS LLC PLY WITH ALL NON-POINT
SOUR LATION
S 9��ar Re-roofs S u
gnnammof AppApplicaugCon for s Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building navpantstore or hulk haudom material
as defined by the Cuperim Municipal Cade.Chapter 9.11,and the Health and Safety
Code.Section 255324)? All roofs shall be inspected prior to any roofing material being
Installed.rlYet -Ba-
Wll
the applicant or future Wilding occupant Lia equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
It hwardow air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
svicR ry�Nu
Oyu r\
I have mW the h sial. els ire ms Cook,CWpen 6.95 of the Olifo.
matkxlthk SafclyCade. 25 25534.I undcmW Nat If the building
does not C=dy ve a ant m min' ty m mtiry tae oceupant of tae
myvirt nts m Ycau, Signature of Applicant Date
caner Cr auhhomrA ager Dam All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
1 Cupertino CA 95014
I It
Telephone(408) 777-3228
�
CITY OF Fax(408)777-3333 UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
0S-2 0 tl r,- S''D � Do ` ( a
OWNER'S NAME: IPHONE #
GENERAL CONTRACTOR %e(cY FAX # / — I I I
euSrorv-
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following ' 0 tiom
ba SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry 6J r Sd
Ornamental Sheet Metal J
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile `
Owner/ actor ignature Date
CITY OF CUPERTINO
CUPEkTINO PERMIT APPLICATION FORM
N# 3-5. 0/ O 3 Date:
Building Add ess: 1 Mailing Address if different from building address):
/,S e 0
Owner's Name: Phone#:
Y`f� Is dct
Contrac 6: �„ (1 C � �d� License#: e�(,S—
Contact: ,.(� one% Cupertino Business License#:
op �� elm Fax: / r�
Building Permit Info:
Bld Elect ❑ Plumb ❑ Mech ❑
Job Description: pp / n
Residential A--r��rJ(,c,c (cX r-e u���'UIrQ ❑
Sq.Ft. Floor Area: q.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: \ Please check this box if the project is a
f 1\ /,r second-storyaddition:
ro'ect Size: Standard ❑ Laze ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
13APPLOTHER Other Appliances MECHANICAL
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
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CITY OF CUPERTINO
PER
CUPERTINO MIT APPLICATION FORM
joiL-Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMNM New Comm Electric ELECTRICAL
BNUCONDAM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb 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 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 InstalVAlter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfln MECHANICAL
BRENLAIRHAN A/C Units<= 10,000 clm 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
BRENRvHSC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
IMF BREMRESAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUPER,TINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, 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
BSPECUL Special Inection BUILDING
BSWINI 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 Mecb Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Commet Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUII,DING
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