08110076 CITY OF CUPERTINO * •'� a
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BUILDING DIVIS JON PERMIT �XcllNTRAC`0Kj_N'�QRMA TI0 'R'
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BUILDING ADDRESS: PERMrr NO.
10914 DRYDEN AVE LEON MAS Y
OW NER'S NAME: PERMIT ISSUE DATE
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SMITH 2TR12WRN 9 AND BARBARA–A— 24G G`13
ONE: A O. CONTROL NO.
(408) 365-1660
ARCHI'ECDENGINEER: BUILDING PERM.'INFO
BLDG ELECT PLUMB MECH
uoii LICENSED CON`.ACTOWS DECLARATION�U5 - Job DCSCiIptlOn
1 herby dlirm tNt I am licensed under pmvivons of Chapmr 9(cemmeneing
wide S.ction 7")of DiNdon Sof Ne Resiaessud Professions Code.and my Iicenoc is
+�„ inrullfartealNceam2.7 �23 .q fo/ CHIMNEY REPAIR BELOW SHOULDER
j n z License Class L. P
n H Da¢ i f / ['i Comraclar /1 aN Al Aa`wr_L
e —f 7� ARCHHECI'S DE l-ARATIU de -v
U 1 understand my piano shall be used u Public meoNs
`o�, Licensed Professional
5 OWNER-BUILDER DECLARATION
1 ,mby off.dear I am smerpt from doe C..&.License Law far to
0 o following mason.(Section]0313,Bmiress and Pmfccmons Cade:MY city m county
which rcquims a permit in cotmamn.alter,hnpro m.dcmelisb,Or M*f any suucare
4;- ptlm m its issuance.aWI mqui.dm aPplicasuchnl far such permit m Bk satiated statement
-ii dent W is licensed parsout W der previsimu of the Comractues Li¢ns Law(Chapar 9 Sq.Ft.Floor Area Valuation
YFC feemmencing wit Section 700y)of Division 3 of do Business and Profcsieru Cade)of
y 5 3 mu be is emmpt tsercfmm and me basis fm dee alleged exemption.My violation o, $2800
Season 7031.5 by any,applicant fm a permit aabjav the applicant as a civil penalty of APN Number Occupancy Type
en more mu fiw hundred dollars(5500). 35615016 00
1,as owner of to property or my employees wits wages as their sole compenssd.n,
will do the..it and mcetmcmm is not amended...ffered forisle(See.70aa.Bus am s
and Proressi.ns Code:The Contractors License Law docs tit apply m an.vane of Required Inspections
properly who builds or improves themon,and who does amh work himself or trough his
Own employees.provided Nat such improvemerm m not inlondod oroffered for We.if.
however,the Wilding or improvement is sold within am year of camp eami.me ewmr-
W ildm win haw the Wrece of proving mat ho did not Mid or improve for puNoae of
tile,).
0 1,as oww of to properly..m cialmively Som aging who licensed mnuacmn to
wnstmct to project(Sec.7044.Bnsiness and Professions Code:)The Cmtrecmrs Li-
cense low dma at apply to an owner,of properly,who Wilda,or improves theme.,and
who comracis for such gajeeu with atonuanorts)Iieenad pursuant in she Convacmfs
License Low.
❑lameaemprundersec .BkPCrmmih..
Owner Da¢
W ORKERS COMPENSATION DECLARATION
1 hereby affirm mbar family.,Perjury ane of dee rnllowing declarations
1 have and will maintain a Certiansent m
Bm of Coself-insure for woheh Compere
en,u Provided for by Section 3700 of doe Labor Code.fm me performance of dee
wart for which ibis permit is issued.
❑1 have and will maintain Workers Comperuation Insurance,as re uirod by Seedon
3700 of the Labm Code,fm the performanceof one work for which No permit is Issmd.
My Workers C/ompeymado I/munum:cartler and Policy number am:
cattle: '5 a ; -EJA.rA . Policy Na.:� 7 3 °
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ro sscerlon need not W completed if the permit is franc hundred dollen(Stop)
or Ws)
I comfy that in to puformanu of the work for which thia Permit is issued.l shall nm
employ any person in any msoncr an as to become subject m to Wofivra'Campemadon -
Laws of Califomia Dam
Applicant
NOTICE TO APPLICANT:If,ager making this CcNRcalo of Exemption,you ahouhl
became subjm as she Wmkers Cmnpensstien provisom of de labor Code you muss
w,O forthwith comply wit such providmts m this permit shall W dammno
ed mlrd.
?7) CONSTRUCnON LENDING AGENCY
1 thealarm me den u a conumNen lending agency for t o performance of
!�
to work for which this permit is issued(Sec.3097.Civ.C)
[f] 0 Lenders Name
z lenders Address
U O 1 ecsufy mat I luw nod this application and suis to to aWve information is
is, comm.1 agree to comply with all city and county oNimnca and sou Ins relating to
o building construction,and hereby•umodn ropresenmivm of mu city to color upon the
aWve-mentioned pmpcat,rib inspection purposes
F1 (Wa)agae m mnify and keep harmless the City of Cupertino against
r/I Habilidns.judgm .cmuu eapemca which may in any way....,east said City
U z in cones the game o,this it.
�-' APPLIC UNDER NDS WILL COMPLY WITH ALL NON-POINT Issued by: DateiZO--!/�
SOUR REGULA 5.
i I X o-, Re-roofs
S' u o pelican r Dan
RDOUS MATERIALS DISCLOSURE Type of Roof
Will lW ap,licut or future Wilding oceupent core or handle b ccomepns mucrlol
or dunned by the Caperton Municipal Code.Chapter 9.12.and the Halm and Safety
Code.Sectie.25532(a)7All roofs shall be inspected prior to any roofing material being installed.
1-3y. a
Will me spphesat or future Wilde occupant doe component or m.iama whirs If a roof is installed without first obtaining an inspection,I agree to remove
It ha'rsmnw car cmuminsnu mrd by me Bry Arta Air Quality Management all new materials for inspection.
mic,7
❑Yes C]No
I have mol to hvamam maetials requirements under Chapter 6.95 of the Califor.
nia Hcalth@Safct Sections 505,25533am12S5M.luncommndmuifmc Wilding
a
dnnot comm h a ten a it is my mopansihiliry m notify dmc necupant of me
mquiOman2 CarcillignatureofApplicant Date
Incf 0y�/O
ow. .aam.ri dagent Date All roof coverings to be Class'1W'or better
CITY OF CUPERTINO
• 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35615016 . 00
DATE ISSUED. . . . . . . : 11/20/2008
RECEIPT # . . . . . . . . . : BS000006662
REFERENCE ID # . . . : 08110076
SITE ADDRESS . . . . . : 10914 DRYDEN AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SMITH STEPHEN G AND BARBARA A
ADDRESS . . . . . . . . . . : 10914 DRYDEN AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4746
RECEIVED FROM . . . . : RICHARD LEON
CONTRACTOR . . . . . . . : DAVE LEON LIC # 17323
COMPANY . . . . . . . . . . : LEON MASONRY INC
ADDRESS . . . . . . . . . . : 240 MOSELLE CT
CITY/STATE/ZIP . . . : SAN JOSE, CA 95119
TELEPHONE . . . . . . . . : (408) 365-1660
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ------- ----
1BSEISMICR VALUATION 2, 800 . 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
----------------- --------------- --------------------
CREDIT CARD 600 . 50 VISA
---------------
TOTAL RECEIPT 600 . 50
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''�'J CITY OF CUPERTINO
CITY OF
CUPEQ INO Y GENERAL BUILDING
PERMIT APPLICATION FORM
APN# I 50 1 Y 1 00 Date:
Building Address:
10C1141 DAydo-I
Mailing Address (if different from building address):
Owner's Name:
*eV� SM 14A Phone#: !93
3 � � /6 �
Contracto -"hson/ �� Zn i y Phone: 36 S — /& to a
Fax: 365 — /66'Gj
Contractor License#: 6 y 3 3 8-%'
Cupertino Business License #:
Contact: Phone: 3 6 S"—1 b !o r7
Fax: 365- - 16 6�1
• Residential Commercial
Job Description: /7,2571e4J
In r
Building Permit Info:
Bldg-El' Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ 11/I11 B, IV-HT, V-B -p- —'�
Valuation:a. go a Square Footage:
Project Size: Express Standard ❑ Large ❑ Ma or ❑
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.buildit reen.or
Revised 10/20/08
alF
CITY OF CUPERTINO
CUPEI,TINO GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1 GENCOM
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
1BBOILER3 Installation/relocation ofea 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
1BBOILER4 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
1 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)
iPLMBINSP Other Plumbing & Gas Inspections P
(per hour)
1MEETINGIHR Application Meeting B •