10030099 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10862 WILKINSON AVE CONTRACTOR:JONES MASONRY PERMIT NO: 10030099
OWNER'S NAME: LISA L FRIES
1396 WESTMONT AVE DATE ISSUED:03/17/2010
PER'S PHONE: 5598015539
CAMPBELL,CA 95008 PHONE NO:4083777512
❑ LICENSED CONTRACTOR'S DECLARGATION BUILDING PERMIT INFO: BLDG ELECT[— PLUMB r
License Class i� 9 Lic.# 3 / MECH F- RESIDENTIAL r- COMMERCIAL
Contractor 'S- Date 17
JOB DESCRIPTION:REPAIR OF CHIMNEY TO THE FOUNDATION,&REBUILD
I hereby affirm t t m licensed under the provisions of Chapter 9 INTERIOR FACE STAYS;HEARTH STAYS
(commencing with Section 7000)of Division 3 of the Business&Professions
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.
1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$7300
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:35613033.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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-poi ource regulations per the Cupertino Municipal Code,Section Date:
9.18. / Issued by:
Signature
Date
RE-ROOFS:
V OWNER-BUILDER DECLARATION
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.
1,as owner of the property,or my employees with wages as their sole compensation,
Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
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
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this 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 Owne.-A authorized agent: Date: 3-17-10
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm 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 for which 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
mnify and keep harmless the City of Cupertino against liabilities,judgments,
s,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-poi t ource regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature t SLP Date ��
CITY OF
is CITY OF CUPERTINO
GENERAL BUILDING
CUPERTINO PERMIT APPLICATION FORM
APN # �� `, 7Date:
Building Address:
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No Pfl
HOA: Exterior work only) Yes Y No ❑ If Yes,provide letter from HOA
Owner's Name: Phone#: ..
FA,/t S- L ! -- �t�r 573/
Contractor: Phone: jf7� �Si �-
Fax: J - 7<1 3
Contractor License
Cupertino Business License
Contact: %' ) e• Phone: 3'7?-7!!;/--4-
6Z �� S.f�N Fax: - 7- 75; 3
Residential Commercial ❑
Job Description: _)
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ I]/Ill/V-A ❑ II/III B, IV-HT, V-B [i]�
Valuation: Square Footage:
7�3�C�.c�cr
Project Size: Express Standard ❑ Lar e ❑ 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 07/14/09
�SU
CITY OF CUPERTINO
CITY
'�F GENERAL BUILDING APPLICATION
CUPE TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
ACOUSTICAL
REVIEW
IACOUSFDW SFDWL/Duplex New B
IACOUSRESAD SFDWL/Duplex-Addition/Alteration B
I ACOUSCOM Multi-Family/Commercial B
CHIMNEY'S
1 CHIMNEY Chimney B
I CHIMNEYR Chimney Repair B
FENCES
1 FENCE>6FT Non-masonry, over 6 ft in height B
1 FENCEMAS>6 Masonry, over 6 ft in height B
FIREPLACES
1FIREPLMAS Fireplace Masonry B
1 FIREPLFAB Fireplace Pre-Fabricated/Metal B
1 FLAGPOL>20 Flag pole(over 20 ft in height) B
1 MODUSTRU Modular Structures B
FOUNDATIONS
I FOUNDREP Foundation Repair B
IPILECAST Pile Foundation Cast in place concrete B
1 PILEDRIV Pile Foundation Driven (steel, pre- B
stressed concrete)
3 of 5
M.Indoor Air Ouality and irnshes
1'use LOW'b'VOC Patti 1 IAQ/Health pts y=yes p
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes p
3.Use Low*VOCAdheSivss 3 IAQ/Health pts y=yes p
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes p
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes p
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes p
7.,Seal 4 IAQ/Health. pts y=yes p
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes p
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes p
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes p
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y_yes p
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes p
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes p
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes p
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes p
1 1 1
Total Points Available: 1 1401 130r----5-71
Total Points Project Received: �- Y� T— 0 0
G:data/progs/greenbuildingguidelines/remodelers/greenpointsfina12.I2.D4protected.xis
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: j ��;, PERMIT# 4
OWNER'S NAME: PHONE# 377-75/-Q—
GENERAL CONTRACTOR: BUSINESS LICENSE# Sq03q9
ADDRESS: f ej(Q CITY/ZIPCODE: �// � . 9�"�1��
*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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: ��
Signature Date
Please check applicable subcontractors and complete 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