03100050 CITY OF CUPEWFINO srh9 ,�;-y,-rte+ '%r+ ' lft,
BUILDING DIVISION PERMIT �>CONTRACTORUNFORMATION
BUILDING ADDRESS: _ BOB� GERE MASONRY PERMIT ND03100050
OWNER'S NAME: 480 CROSSLEES DR PERMIT ISSUE DATE
NE: (408) 972-1285 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
0
Op LICENSED CONTRACTOR'S DECLARATION IOb Description
{U C 1 hereby M.last I am Iiamed under provisions or Charter 9(commencing p
.zwU with Section]I1M))nfDivision Jo(the Businc send Pmfcssiom Cock.And myliccnm is
la< in tall fame an at. REPAIR CHIMNEY FROM PLATE LINE /
Lice�a (/�use� _ Lic.p O
Dole Cunt u _
��`' ARCHITECTS D
a l under¢sand my plana shall t¢seed as public ncmds
eau
LL Licensed Pmfcmiond
st OWNER-BUILDER DECLARATION
I<l 1 hereby affirm that 1 am exempt from Ne Conuactois License Law far the
-po following reason.Section 7031.5,Business and Pmfcasiata Code:Any city or county
5$ which repinny a permit m consumer,arm,improve,dcmnlixA or rapid, by structure
prior to its issuana.alsu rtquims the applicant forsuch permit to file a signednacirmat
< that he is licensed pursuant Sq. Ft. Floor Area Valuation
t1
1 (commencing with Section 7010)or Division 3 of the Business and Professions Calc)or
that he is exempt therefrom and the baso for the alleged exemption.Any violation of 35911036 . 00
Section 7031.5 by any applicant for•permit subjects the applicant to a civil penalty of APN Number Occupancy Type
Mm more than five hundred dollars($500).
❑I,as awncr of the t mp rl y,or my employees with wage.u their sale ttmpoloodba,
will do the work,and Ne structure is not intended or offered for salc(Sec.7014,Business IU1 — FOUNDd Inspections
and Professions Code:The Comment's License Law does not apply to in owner of p
property who builds orharrows thereon,and who das such work himselfor through his 312 - CHIMNEY RE AR & STRAPS
awn employees,provided that such improvements see not intended oroffered for Aide.If, 514 — FINAL PUBLIC WORKS
however,the building or improvement is wild within Marc you of oomplelion,the owner
builder will have the burden of proving that he did not build or improve for purpose of
sale I
❑I,as owner of the property,am exclusively contracting with licensed contractors to
convect the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law docs not apply to an owner of property who builds or improses theeon,and
who contracts for such projects with a con a ctor(s)licensed pursuant to the Conuactois
License Law.
❑l am exempt under Sec. B A P C far this reason
net Data
WORKER'S COMPENSATION DECLARATION
1 hereby afro,under pemhy of perjury am of Ne following declarations:
1 have and will maintain a Cenifream of Consent to self-insum for Worker's Camper.
sation,As provided for by Section 3700 of the Labor Cade,for the perfomtaoa of she
or which this permit is issued.
I Mve and will maintain Wurke(s Compensation Insunna,As required by Section
f the lobo,Code,for the performance of Ne work for which this permit is issued.
y Worker's nm ensai ttcaaiereadPolicynumberam-
Cartier. /�,r Policy No.::
C IFICA OF" MITION MOM WORKERS'
COMPENSATION INSURANCE
m da section need not lecompleted[fine permit is foronc hundred dollen($101)
or less.)
I certify that in the performance of the work for which this permit is issued,I.hell not
employ any pcnan in any manner art Asia become subject to the Wmmk Compammtmn
Laws of California.Due
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions o(lhc Ichor Code,ynu most
7z forthwith comply with such provisions or this Permit idiall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a convection lending agency for the Performance of
Ya a7 do,work for which this Permit Is issued(Sec.3097,Civ.C.)
ALender's Name
z Lcndu's Addrem
Q 1 cenify that I Moe read this application and state Nat Ne above infmmuiim is
F correct.I agree to comply with all city and county on inanas and ante laws relating to
DU building consuuclion,and hereby eutherim representatives of this city to enter upon the
a shove-mentioned property for inspection purposes.
y (We)agree to save,indemnify and keep hum less the City of Cupertino against
N liabilitics.judgments,costs and expenses which may in any way name against said City
JZ in cons."' ,the gra ' guF{h,Permit.
~
APPLI
E NT U 6. wOSAND WILL COMPLY WITH ALL ON-POINT Issued by: Da
a /O/ il
7�-t. Re-roofs
Sig to Applica o cmr Date
RDOUSMTERIALS DISCLOSURE Type of Roof
cantor
Will theapplifumra Mingoucupmtemm or M1andlc hsrsrdous motcriJ
As defined by the Cupertino Marm
al Lode,C pier 9.11,and the Health and Safety
code,seaYea 25532(.)1 1, roofs shall be inspected prior to any roofing material being installed.
Year
WBI the Applicant Towns 'Jing occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
havmdnus air contaminants .fined by the Bay Area Air Quality Management all new materials for inspection.
Dinrin?
❑Yes
I have mad the Maardous mawrials mquimmnts under Chapter 6.95 of the Califo,-
niaHealthg:SafetyCa .Sadom25505.25533md25534.lund n=dthuiftM Wilding
dors n ndy have a t t' ism rcsponsihiliry m m dly the a pont of the
m u menu hr h I nor to issu afaCc cafe Ocgu cy� Signature of Applicant Date
q �P�-- 7 VAll roof coverings to be Class"B" or better
Owner the ad Jul �atc
0 2( CITY OF CUPERTINO 00
CRY
CITY OF PERMIT APPLICATION FORM ( �
CUPEkTINO
APN # �7-�(n Date: D r D
Building Address: Mailing Address (if different from building address):
Owner's Name: Phone#:
Contractor: License#:
AVG �o
Contact: Pho Cupertino Business License#:
Fax:
Building Permit Info:
Bldg Elect ❑ JPlumb ❑ j� 'M"e`chh ❑
Job gescriptio ` j)
Residential h
Sq.Ft. Floo Area: $/S .Ft.: -
Cost of Project: n Occupancy Group:
eU
Type of Construch Please check this ox if the ect is a
second-story addition-
.—
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 1M 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<= 1000A ELECTRICAL
BELEC1001 Elec 600V> IOOOA ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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