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11030143 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10319 MARY AVE CONTRACTOR:JON R CRASE PERMIT NO: 11030143 CONSTRUCTION INC OWNER'S NAME: DUSTIN MANNIA 164 GILMAN AVE STE A DATE ISSUED:03/30/2011 C ,R'S PHONE: 5105995281 CAMPBELL,CA 95008 PHONE NO:(408)370-1485 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT PLUMB r License Class Lic.# r n MECH RESIDENTIAL COMMERCIAL Contractor 9 CZASL 70 Date ,9 tI I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPAIR I STUD BAY AND RE-STUCCO AT SIDE OF (commencing with Section 7000)of Division 3 of the Business&Professions EXISTING SINGLE FAMILY DWELLING(60SQFT) Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$4092 Section 3700 of the Labor Code,for the performance of the work for w6infotion ich this permit is issued. APN Number:32652003.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the abois correct.I agree to comply with all city and county ordinancesws relating to building construction,and hereby authorize representatives o enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regu,ations per the Cupertino Municipal Code,Section _ 9.18. Issued by: ` Date: Signature Date 30 L O -BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I Owner or au ized agent: become subject to the Worker's Compensation provisions of the Labor Code,I must Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I ereby firm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is w ' this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION g._.sing of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date I_J GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333•building Mcupertino.org MISC CUPERTINO ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL MISCELLANEOUS PROJECT ADDRESS APN# OWNER NAME PHONE lU -, q�' S Z ! E-MAIL STREET ADDRESS CITY.STATE.ZIP �S7�c1� FAX CONTACT NAME PHONEE-MAIL f ° ' C v'4' e c o z s�r✓c vrl. �^^- STREET ADDRESS r y CTCY, TATE ZIP FAX e" �t7,L, d 3 40. OZ 3B ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT A CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LIC SE NUMBE LICENSE E BUS.LIC# COMPANY NAME E-MAIl FAX STREET ADDRESSCITY STATE ZIP � A PHO 16- Aj,t 520- ARCHITECT/ENGINEER NAME n LICENSE NUIvMER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes Cl No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK 12— TOTAL VALUATION: By my signature below,[certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. ive read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building constructio I thorize representatives of Cupertino to enter the above i dntified roperty for inspection purposes. Signature of Applicant/Agent: / Date: 3 l SUPPLEMENT TION REQL`II2ED '� '�� „a�i ��• a a� LL�B � i { G � y MEPMiscApp_2Ol Ldoc revised 03/16/11 CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32652003 . 00 DATE ISSUED. . . . . . . : 03/30/2011 RECEIPT #. . . . . . . . . BS000013035 REFERENCE ID # . . . : 11030143 SITE ADDRESS . . . . . : 10319 MARY AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER DUSTIN MANNIA ADDRESS 10319 MARY AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JON R CRASE CONSTRU CONTRACTOR . . . . . . . : JON R CRASE LIC # 22250 COMPANY . . . . . . . . . . : JON R CRASE CONSTRUCTION INC ADDRESS 164 GILMAN AVE STE A CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 370-1485 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4, 092 .00 1. 00 0 . 00 1.00 0. 00 1BSEISMICR VALUATION 4, 092 . 00 0. 50 0. 00 0.50 0. 00 1STUCOAPP SQ FEET 1. 00 443 . 00 0. 00 443 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 444 .50 0. 00 444 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 444 . 50 #58685 --------------- TOTAL RECEIPT 444 .50 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: �'p, ry , mac= PERMIT# l -f 3 OWNER'S NAME: pvfrJ.v .*?ffi�/rV/y4 PHONE# %� — 'D' 1 GENERAL CONTRACTOR: e"-SC Ce u, BUSINESS LICENSE# ADDRESS: /,^ V L^lC-itila CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRA RS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. X/ I am not using any subcontractors: Sig ature D to Please check applicable subcontractors and c plete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date