06050021 CITY OF'CUPERTINO * ^M&3 7�b& 1g*LeLe—W*NPc 4
BUILDING DIVISION PERMIT CONrTR:AC. TOoR�I ,rear'(}ItMATtI1Q :
BUILDING ADDRESS: J K MASONRY, A PARTNERSHI PERMIT NO.06050021
10842 LEAVESLEY PL
NET'S NAME: PERMIT SELTE DATIS
GRAHAM DONALD E AND CLARIN J521 S BASCOM AVE 4A 05/02/9006
HONE: SANITARY NO. CONTROL NO.
(408) 287-2398
ARCHITELTIENGINEER: -
BO BUILDING PERMIT INFO
OPLO NEOCH
Zow LICENSED CONTRACTOR'S DECLARATION IOb DOSCTI n0T
i 1 hereby affirm Nat 1 ma licensed under provisions mm
of Chapter 9(coencing
with Satires lIXNB of DiviaonJof Ne Basin and Profcamua Code.and mylicaaea4 �, Q q ��
'1 m nnmame rs �n rI Q 9fj CHIMNEY REPAIR �1*\Y®q/��/tt�
n � K-s'--r --��—c Iraanr TEAR DOWN REBUILD TO PLA E
7 - -AKC I ECTS DECLARATION
I 1 uMeraund my plana shall W dead as public records �1dp,/1
e�� Licensed Professional pl(�I 10 6
s1w� OWNER exempt RDECLARATION
7 O I I hereby Maso alum Nm 1 1. exempt ,an Po Cmu.cmrm License law for me
p O which re won.(Section 7031.3,Basin and w.de oli Code:Any city stousny
ZOO
9 g which requires a remit to anaeuct,almc hnrmw,dem014h,or eapolr any strtewro
z P„' prior to its sentence.dwrequires the applicant for such permit to Ne a signed suument
Na be is licensed rommunt In to promises Of the Contractor's lJcxns law(Chaptm9 Sq.Ft.Floor Area ati$ig 125
(commencing with Section 7000)nf Dlv41o0 Jef dea Builnea and Prefaalnm Cade)or ''•
Na he 4 exu min members and One ba4 fee No Limited eaarlWon.Any vmhtim Of
Seinen 7031.3 by airy applicant for a permit subjema that applicant o a civil Pendry of APN Number Occupancy Type
Mn mom than nw bumdmd dollars(SSO(a. 35615034 . 00
0 1.as owner of de property,or my employees with wags as their ou cnonintervention,
will con thowark.and mass and Proftealoa Code The Commences Limt¢Las does Out dcalm (applyiy too aie'o errO Required Inspections
property he builds mlmpro mthereon•and whodaamshwork himselfor through his
own mrtPleyea,provided that much lmprmemanta ants trot intended V ORLsed roe sale.lf•
however.the building or Impnwmem ismld within one yea ormmpledon,site owner-
builder will have Ne burden Of Moving that M did rot build or Improve for purpose of
sam.).
0 1,as Owner of Ne Property sm aclwively cOnua6ng with licensed cormamm t0
coatmn the majora(Sec TOAs,Bain and Rofauoa Code:)M Contractors U,
create,Law does not apply man owner Of property who builds or Wpom Hereon,and
who conuau for such projects with A coninctor(s)licensed perm uct M the Conuacto's
Licenae Law.
0Is..amp,under Sea .B&P C for this won
ea
Data
WORKER'S COMPENSATION DECLARATION
I hereby arum under penalty of perjury me of the following declsoment
0 I haw and wnl far by
n•Cmnf31M ofConsery r Code.fur the
Wotoom a,of ft
adon,r provided fm Mouth
Ss lam J700 of Ne tabor Code,far Ne perfomma of tiro
work for which thin remit is lamed.
0 1 have and will maintain Workers Compensation Insumno,as required by Semon
3700.1'me Labor Coda In,Ne Md...of the work for which Nis pmork is Wold
My Workers Co�mo}ntumim In/ve's'ts¢ std Policynum /
Cartier. �// ysyVm' Policy No.: a -0O�� 6c�
CERTIFICATEOFIX MON FROM WORKERS'
COMPENSA ONINSURANCE ,
rods scWm tend rotWrompMed ifft mmII4fmonehundreddouses(Sim)
or less) t
I century Not In the pafmoneinca Of me work far which this remit 4 issued I shall rot
employ any person in any manrrse as in become subject to the Workers'Compenadon
Laws of California.Dau
Applicant
NOTICE TO APPLICANT.If.afar making this Ceel0cam of Exemption•you should
become,subject to Ne WOhers Carnpruation pro wed Of the lahm Codc.you ort
,J zit forthwith comply wish such provision or this permit mall be damed revoked.
,zy4CONSTRUCTION LENDING AGENCY
[-+ I hereby slam Nat there is acoMtrucdan lending agency forma perfomma or
g1.> the work for which Nis permit 4 Woed(Sec.7097.Civ.C.)
dQ Landers Nam
z Landers Address
U O 1 eenify Na 1 haw mad silo application and Mau Na the above Information 4
V. Fcomet.1 agree W comply with all city and county ordinances and mud laws misting W
U building construction•sons hereby auNrire repesenuuva of Nis city to enter upon the
W shove-memionsd property far Msacuen purposes
(We)agree to saw,indemnify and kap hamlea the City or Cup-m-O ageiat
liabilities.judgmenu.costs and expenses which may in my way acrus against said Gry
U Z in consequence of the aroMng Of this remit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CE REC AT3ONS.
tf I�� – r Re-roofs
Signature al'ApplicarlComonects, Dam Of Roof
HAZARDOUS MATERI LS DISCLOSURE Type
Will the applicant or future building aampamttme m handle emammus material
as defined by the Cupertino Municipal Code,Coupon 9.13,and the Health and Safety
Ode,Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Oyu ON.
Will the applicant o,(more building mzupant Me equil nent or devices which If a roof is installed without first obtaining an inspection,I agree to remove
coil bavanius air conuminants as defend by the Bay Area Air Quality Management all new materials for inspection.
District
OYes ®Nu
I ban mat the hesadmu mamr44 mquimmenu under ChMtcr 6.95 or Ne C.lifor.
MA Health&SafctyCode,Secuor25505,25533 and 25534.1 undersand thatlf die building
dma rot cumntl hew•tenant.that it 4 my responsibility W notify the Occupant of the
wquieamenuw ha mbemetpnor iamueeofacruncauoreccvprmy. Signature of Applicant Date
f-62 -,9
owne,ern .. . est Dam. All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
I ! Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
SUPEI,TINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: PHONE # ?-a3J
GENERAL CONTRACTOR e. FAX # t{o _06YV 0
I am not using any subcontractors: j--O 1 -o Z
Signa a Date
Please check applicable subcontractors and complete the followin information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
. Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry )•( W S,)vl �0 1-
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
. Tile
S' - o /- oma
Owner/Contract r Signature Date
C -
CITY OF CUPERTINO
cc OF
. CUPI Y Of O PERMIT APPLICATION FORM
pbo50001
APN # 355V
o/
Building Address: Mailing Address (if different from building address):
8 a,.e,,vesLe PLA-C-e
Owner'sme: Phone#:
QotiP-LiD &RAI R-Al (t/o0 a8�-a3q�
Contractor: -✓/�'J/�SOA/le License#:
/1 9
Contact: hone votl a-0-a34e Cupertino Business icense#:
Tul) lem L-e- Fax:( -Pa' qa -u8yo 5�3
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Job Description: 7-4,4�D&-v-nN.e
Residential CtilmNe (i'fPA/ Re LD o ��Te Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupant Group:
3 ► as". av _ 3
Type of Construction: Please check this box if the project is a
�—
second-story addition: ❑
Pro'ect Size: Standard1] Lar e ❑ Ma'or ❑
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<= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<= 200A ELECTRICAL
BENERGY — Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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aClITNyo
CITY OF CUPERTINO
PERMIT APPLICATION FORM
CUPE TINO
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rh*ler/Backflo PLUMBING
BPSTORM Stomi/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reins ection Fee BUILDING
BREMACOVER A/C Unit> 10,000 c&n MECHANICAL
BREMAIRHAN A/C Units<= 10,000 c&n MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Furnace> I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter H ating MECHANICAL
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ciao CITY OF CUPERTINO
CUPEI�TINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BREMRESAPP Remodel Res Apphance 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 ; Swimming 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
EPERNHTFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPER vHTFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING •
ZADDCHG Address Chane T` BUILDING
•
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