03040011 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT C®1VTRCR, xNFOOT.t AN
:a Bn n8ADDRESS:SSTELLING RD LEON MASONRY INC PEaMTNo.03040011
OWNER'S NAME: PERMIT ISSUE DATE
RICHARD HANSETT 240 MOSELLE CT 04/02/2003
NE: SANITARY NO. CONTROL NO.
(408) 365-1660
ARCHITECDENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l�
u0Z0 LICENSED CONIRACIOWSDECLARATION JobDescri tion
I hereby affirm Net 1 am licensed under provisions of CWpmt 9(eommenein{ p
�� with Section 7000)of Division of the Business and Pmfou1luns Code..aand my litems is
? In full force and ctt �� LIC.M xZ ) 3 g r
5'�b LlaeF - ,K CHIMNEY REPAIR FROM SHOULDER F1N/�LE®
z: Oats 1. Contractor /TSDECL
CHIlh,.d ECLA ATION
l anMrwnd my p" "'k"a`� ..p"bld, �^ti APR 1 0 2003
G Licensed Pmrculonal F
5 OWNER-BUILDER DECLARATION
f I hereby aMno that 1 am exempt from Na Contractors License Law for be
p0
Following mason.(Section 7031.5.Business and Professions Cade:Any city or county BUILDING
$Pi which requires a permit m...mutt,alar,Improve.demolish,ser nepalr any structure
prior m its Issuance.also onalres the applicant fortieth permit to file.signed testament
F that he is licensed pursuant to Ne provisions or the ContracmrsUccom Law(Chapter 9 Sq.Ft.Floor Area Valuation
y $ MconamcingwithSection7(1ofDivision3ofNeBusiesandProfousion,Code)or I $2000
Net he Is exempt therefrom and the but,for the alleged cumptlon.Any viDletion of pp��NI� hI,�f.
Secdon 7031.5 by any appticantfor a permit sub)ecu the applicant to a CIA]penalty of 3SzJ2'1 8T 00 Occupancy Type
ore N
not man Rve hundred doll.,({50D).
❑I,u owner of the properly,as my employees with wegtau their ole compensation,
wllld.ft.,k.andNeswcturet,notinmndedoroQemdfonalc(Sa,7044,Busineu
and Profevaions Code:The Conuacmrs License Law does not apply m an owner of 101 - FOUNbA;trT i*IBS pecdons
propertywho bullas orimprovea thereon,and whodoesauchworkhlmselfor through his 312 - CHIMNEY REBAR & STRAPS
own employees,provided thatsah Improvements am not tnmeded oroRered(mule.If.
however,the Wilding or improvement is sold within one year ofeompledon.the own.- 514 — FINAL PUBLIC WORKS
builder will have than burden or Proving than W did not build Or Improve Ire purpose of
rale,).
❑L,s, net of the property,am.elusively contracting with licensed anbaCmn to
constmct the project(Sec.7044,Business and Professions Code:)The Coalractor's LI-
acme Law data not apply to an owner of property who W1ms or Improves Former.and
who contracts for such projects with a comoschar(s)licensed pursuant b than Conuactort
Llcanse Law.
0 lamnemplunder See, ,Bk PCfurthiuwon
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby aBiam under penalty of perp ay tae of the fallowing declandons:
I have and will maintain•CoNfiau ofCamn.t to self-fins..fm WaftesCompen-
u0oa,u provided for by Section 7700 of the labor Code,Ire the performance of the
W
ork for which NI,permit Is Issued.
if"have and will maintain Worker's Compensation Insurance,u required by Section
of the labor Code.for the performance of the work for which this permit is Issued.
My Workers Compensation lnavama carrier and Policy number am:
Csnler. 5 -tP 'V- rt Policy Nwe5l'yFT 0�?_
CERT)FICAIE�PTION FROM WORKERg'
COMPENSATION INSURANCE
(Dissection need not W complemd If IW permit Is fornna hundred dollen($100)
ar ItasJ
L certify that In Ne performance of the work for which this permlt D issued.I shall not
employ any Peronin anyIP5 N be�me/ubkct to the Workers'Compensa0on
rawofny person y f]�,
NOTICE
NOTICE TD he Work f,afterpe ng thts CenNeam of Exemption.Ca,youumust
blame subject to the Worker',Compensation provisions of the labor Code,you moat
.JCL forthwith comply with such provisions.this Fermi[malt be deemed revoked.
„Zai O CONSTRUCTION LENDING AGENCY
l.r IWrwhichhy ithi thatft.t,aed(Sec.3M.leading a{tory for the performance of
the dark for which Nts permit 4 issued(Sac.709'1,Civ.CJ
0 Lender,Name
�z lantleri Address
U Q 1 certify that 1 have mad Obis application and tum Nat the above information Is
ly;'" correct.1 agree t0 comply with all city and county ordinance,and state law,totaling m
C VC building communion.and hereby authorise representatives of this city m enter upon the
{I.l .hove-mentioned pmperty for impaction purposes.
(Wan)apace to save,indemnify and kap harmless the City of Caperton against
Q. Eamlidea,judgmenu.cord and expense which may In any way accrue against said City
V 7 In consequence of the flooding of this permit.
a APPLICANT UN STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
S URCE RE ONgr) //
�/ Y Re-roofs
"' S possum ApplinnVConmcmr m
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will Nan epplltanlarfmure Wlldin as uTwt9aomhendlchusmous material
u dented by tho Cupertino M=Zci ode,Chapter 9.11,and the Health and Safety
Code,Section 13532(e)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yee No
Will the applicant or furore build ng Occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit h.amous air contaminants u cd by Ne Bay Am.Air Quality Management all new materials for inspection.
Di uin7
❑Yes u
I have mW Ne Nurdousmaterlabm iulm unu under Chapmt6.95 ofthe Celifor.
nit HcalNgr Safety CoM.sations T55115,1357I and]5534.1 undcntsnd Natirthe ilding
Jas not c Ser el h an4 oral 0Is 55 rcapomihi4.y m dryl D
mqutmmenu wh' m mctprionoluuuaofa CerdRce c Signature of Applicant Date
mired Z:: Dare All roof coverings to be Class"B"or better
aYor
CITY OF CUPERTINO
CUPEPERMIT APPLICATION FORMRTI
�# ' / ® 0 Q, Date:
Building Address: V V
r wJ
Owner's NPhone#:
am /
Contractor: 4by m�S r G License#(lj. ,2 3 3�9
Contact: n Cupertino Business License#:
� X21
Bldmg it Info:
Bld Elect ❑ Plumb ❑ Mech ❑
Job De tion: __ `` // /
esid ic
al _a x ., ' n airL o Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: D Occupancy Group:
Type of Co struction:
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 IM 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
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CITY OF CUPERTINO
CU CITY OF o PERMIT APPLICATION FORM
uanti Fee ID Fee Descri tion Fee Grou
BMITIGATR Res. Hou-in Mit Fee BUILDING
BMNEWMULTI New Multi-Familv Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bld s MECHANICAL
BNEWMULTI Multifamil Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamil Res PLUMBING
BNUSFD New Single Famil Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric VacuumPLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINPERCEP Ind Waste Interce for PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Re eat Fee BUILDING
BPREPIPE Repine Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING .
BPTgAP Kitchen Tra PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pi e PLUMBING
BPWHEATER . Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER I A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL
BREMAPPLI A liance Install MECHANICAL"
BREMBUSWAY Remodel Buswa ELECTRICAL
BREMFINT Li htin 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 A liance 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 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
BSPECIAL Special Insection BUILDING
BSWIM Swimn-dng 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
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