08110023 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �,C�„NRAQI2 `' ATzO� _
BUILDING ADDRESS: PERMIT N0,
7430 WILDFLOWER WAY MP3MA
OWNER'S NAME: PERMfr LSUE DATE
CONTROL NO.
Tn r nrnnc
(831) 637-6663
7AIC,H]TECT(ENGINEER: BUILDING PERMIT INFOBLDG MECHLICENSED CONRtACf00.'S DECLARATION1 h meby affirm that I w IismN uner pmvidvof Chapter 9(...lot Job Description
Section 7=)ofDivision 3 ofdm Business and Profession,Code.and my tccnse is
_ nrarmandan- �Gt s �i CHIMNEY -REPAIR (E) MASONARY FRM SHOULDERS
,ulse 1 L-9:2 Lk.0
t F• Dao: L� Conuxoor
` ARCHr1ECT'S DECLARATION
I undersand my play shall W used as public meords
Dyu
k 40 Licensed Professional
5 OWNER-BUILDER DECLARATION
<� 1 hereby affirm that I am acmpt from the Contractor's lueve Law for the '
2- following mason.(Section 70313.Business and Profession,Code:Any city or county
E m which requires a pamit to construct aper,improve.demolish,or repair try stmemm
Lzi prim to is amauce.ahr require the appliesnt for such Permit to file a signed comment
xx< that he is licensed forecast In the provision of the Consumes L3seom Law(Chapv9 Sq.Ft.Floor Area Valuation
YFct (commencing with section 7”)or Division 3 of the Business W Professions Code)or
y $ that b is exempt therefrom and the basis for tW alleged exemption.Any violation of 83975
Section 7031.5 by any applim,for a permit ubjects the applicant in a civil penalty of APN Number Occupancy T
net more thus BK hundred dell.(gear). 36618033 . 00
P y ype
E]I.u owner of tW propmy,or my wploym with wags u the'vsele crmpemtion,
will do drawers,and the structure is an,intended or offered forsale(Sec.70th,Business
and Professions Code:The Contracm/1 Liam Law does nt apply m N many of Required Inspections
property who Wildsorimpraws Ovcon.and whodoesauch workhinnaelfor though his
awn employees.provided that such improvements art not intended oroRcted forsalu If.
however.dre Wilding or improvement is old wnthin one year of emepletiov.da owusr-
Wilda will have,the Mndeo of proving Wt K did rot laid or improve for purposs of .
sale.).
❑1,u owner of the property w amluiwly contracting with licensed mWach rs m
construct dse project(Sec.7060.Business and pofestiov Code:)Tie Canuacmr's Li-
muse raw dos not apply to an owner of prepeny who Wilds or improves thereon.and.
who contracts for such pmjects with a contractor(s)licensed pursuant to the Contracter's
Lican ,Taw. .
❑I an exempt under See .B A P C for this users
Owner Data
WORKER'S COMPENSATION DECLARATION
I bereby affirm under pevlty,of perjury arc of dm following dmlantionx
I lues and will maintain a CuhiOmm of Covent to self-imus,far Workses Compcm
an.u provided for by Section 3700 of tW Labor Code,for the perfomanm of the '
work for which this permit is issued. '
I haw ad will maintain Workeh ns
Compeation Irtsm'ance,u required by Section
3 of NC Labor Code,for the perfrmaece of the work for which this permit is issued. '
My Worker's Compwstion Insurance whim sed Policy number am:
Cartier_/77797c!5h
j47 D Policy No.:lobel3;3 U
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nus suction used setheeanplemd lithe permit Is foram hundeddr0an($100)
or lest)
I certify that in the performance of the work per which this permit is issued.I shall not
employ any person in say manneru as m become subject to the Woken'ComperesaWn
Laws of Califtrus.Dam
Applicant
NOTICE TO APPLICANT.If.after making this ce ormam of Baemption.you should
bceome subject to the Worker's Compensation provisions of she lake Code,you used
.J O forthwith comply with such provisions m this permit shall W deemed rcwked.
CONSTRUCTION LENDING AGENCY
(.v.�. I baby affirm that Vert is a construction lending agency for the perfurman¢of
Cthe work fm which this permit u ec issued(S 3097,Civ.Q
Ian
1 Q der's Name
7 Z lender's Address
U J Q 1 certify Nat I have mad this application sod sate Nn,the aEOw information Is
Uy comm I agree to comply with all city and county ordinarmci and sere laws missing b
p Wilding construction.and hereby oNonee reptesenauvts ofthis city to enter upon the
W &lave-mentioned impart,for inspection purpues.
�"gy (We)ague to sew,indemnify sed keep hamlets she City of Cupertino against
rat liabilities,judgments,costs sed..parses which may in any way accrue agairteL aid City f
()Z tAnPPLLlgA nceo�RSTANDS Ats punch.
ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
so S. Re-roofs
Signause of ApplimttlCon v7acWsDam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appliant or future Wilding arupant score orlandk haummus material
as deRned by ter Cubans.Municipal Code.Chapter 9,13.and the Hollis and Safety
Code.SOy.35532(x)? All roofs shall be inspected prior to any roofing material being installed.
Will the almWant m um bWhile,oempaal ue equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It harudnw air cum
uminants as dcOned by the Bay Area Air Quality Management all new materials for inspection.
strict?
C]Yea 19Nu
1 have mad the hasartlmrs`-maenab requimmcnu m der Chapter 6.95ofde Calilm.
na Halth k SafetyCode.Sees=ss505,25533 and 25530.1 uMvs oul Natif the building
deer co aY he a ter it u my mspoviNlity m mtify the meuput or the
mu� `�^r'aiarumhm or ar�l of6mp�yr Signature of Applicant Date
All roof coverings to be Class'1W'or better
0 ncr or authorised agcm Dam' '
CITY OF CUPERTINO
• 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36618033 . 00
DATE ISSUED. . . . . . . : 11/06/2008
RECEIPT # . . . . . . . . . : BS000006559
REFERENCE ID # . . . : 08110023
SITE ADDRESS . . . . . : 7430 WILDFLOWER WAY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : RODGERS JOSEPH T JR AND JOANNE
ADDRESS . . . . . . . . . . : 7430 WILDFLOWER WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : MP3 ENTERPRISES
CONTRACTOR . . . . . . . : PATRICIA GERE LIC # 27197
COMPANY . . . . . . . . . . : MP3 MASONRY
ADDRESS . . . . . . . . . . : 4530 FAIRVIEW RD
CITY/STATE/ZIP . . . : HOLLISTER, CA 95023
TELEPHONE . . . . . . . . : (831) 637-6663
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
------- ----------- --- - ---------- ---------- - --- ----------
1BSEISMICR VALUATION 3 , 975 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1BUSLIC FLAT RATE 1 . 00 110 . 00 0 . 00 110 . 00 0 . 00
1CHIMNEYRE EACH 1 . 00 490 . 00 0 . 00 490 . 00 0 . 00
---- ---------- ---------- ----------
TOTAL PERMIT 600 . 50 0 . 00 600 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 600 . 50 #3972
---------------
TOTAL RECEIPT 600 . 50
•
ohl00"2-3
= 1 CITY OF CUPERTINO
CITY OF
CUPER INO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # u 3 3 v c) Date:
Building Address:
7' ,30
Mailing Address (if different from building address):
Owner's Name: Phone#:
k/v/S od
Contractor: Phone: 7—
�3 h2Sd Fax: �3/— joj7
Contractor License#: BSBS�
Cupertino Business License#:
Contact: Phone:
• �� ��/� Fax:
Residential Commercial
Job Description: �v�7��_ (Nf /�tl/✓OX/t—� 4c c y � n2_
Building Permit Info:
Bldg Ej-� Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B ❑� 3
Valuation: 60 Square Footage:
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
• For help, contact Build it Green at www.builditgreen.org
Revised 10/20/08
CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
IGENCOM
1 BBOILERI For the installation or relocation of ea M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw
1 BBOILER2 Installation/relocation of ea M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
1 BBOILER3 Installation/relocation of ea M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
I BBOILER4 Installation/relocation of ea M •
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1 BBOILER5 Installation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
I BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
1 ELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
1PLMBINSP Other Plumbing & Gas Inspections P
(per hour)
1MEETINGIHR Application Meeting B •