01120067 CITY
ofcDPESIONO
SINPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19682 AMHERST DR MIRACON CONST 01120067
OWNER'S NAME: APPLICATION SUB DATE.
BEAN ROBIN C AND KINNEAR RAYMO 5171 RAFTON DR 12/17/2001
]•PHONE 4082642059 SANITARY NO. CONTROL NO.
0 C ARCHITF.CT/ENGINEER: BUILDING PERMIT INFO
c uL ELECT PLUMB MECH
v a ou L, 1-_. L_I L�
. y= LICENSED CONTRACTOR'S DECLARATION Job Description
i z=7 I hertby aRrm that 1 ton licenmen
sed under provisions of Chapter 9(comcing p
;,tet- with Section]000)of Division 3 oft he Business and Professions Code,and my license REBUILD CHIMNEY FROM SHOULDER UP.
is'n full force and elfec 5 'S
c ¢ aDn,
O w U Date S DEC
t & ARCHITECI" DECLARA ION
1 1 undersand my plans shall be used as public records
iEMdoe
/mac /ii
I ` Licensed Professional O A,(—/l � /
u 1 y OWNER-BUILDER atom DECLARATION J
I hereby affirm that
I n exempt from the Contmnor's,License An,a Law fm the
?< following reason.(Soden]0315.,,,Aness.nd Processions Cud,:Any city m county $1550
to C which itquiet a pemso to construe,aper.improve.h Permit t filo
«pair any strveture
i3 oO'goon t c also q 'es the isioux of for such Permit tofk 'fined set cm
0mourthat I dpb:un froth v sol the Cc B., rsL la (Chapter,) a - valuation
orth ngz rosato 7000).fhe ns oofe311i meas aiProfession,eotlo S.'4P'': t .�3 $_ g6.IP: :�, 711"L:i,t'���'';.
or that io s 2 b therefrom and the buns for the alleged p lmpuoo Any violation
of Section 7031.5 by any applicant for a pcmot subjaa Nc applicant to a civil Penalty
of not mom than five hundred dollars lsxal. 10�'PN DATION 11 7'vl i ",,, Occupancy Type
❑I,as owner ofthe propcny,or my employees with wages as their sole compensation.
will do the work:and the'structim is not intended or offered for sale(Sec.7M4,'
Business and Professions Code:The Contractor's License Law does not apply to an 514 - FINAL P1ilk4LtT(0 S lWPR -
owner of progeny Who builds or improves thereon,and who does such work himself
or 1lvaugh his own employer,provided lost such improvements are not intended or ,
`offered for sale.If,howner.the buildn ----- t is sold within ane -
-'- - --"- —"" ' -"-"" -- '-' -- ----------- --- -
1 ompletion,the owner-builder will have the burden ofproving that he did not build or r
improve for purpose of sale J.
O 1.as owner ofin,._ --_ withl .-.-_-_.. . ... _. .....--_ __ aIW Ag C ._.
• pmpcny,am exclusively contracting with IicensW contractors to �
c License
t the lass n Sec.
appl 7041,owners and ProPoshob Code:)The sm tract.,I
thereon, 1
License Law does not apply to an owner of progeny who builds or improves thereon,
.and who commea.for such projces.with.a contmetoro)licensed pursuant to toe. _
o1 am axe License See.
-- -JAN- 1--5 2002
_ ❑lam exempt under Seca � �,B&PCfar this reason
' own; Date BUILDING
'r WORKER'S COMPENSATION DECLARATION
nn- I hertby affirm under penalty of perjury one of the following eeclarations:
-c7 I base and will maintain a Ce .fimte of Conant to self-insure for Worker's
Compensation, a.. provided for by Section 3700 or Ne Isbor Case. for the
performance of the work for which this permit is issued.
❑1 have and will maintain Worker s Compensation Insurentt,as rtquirW by Semon
3700 of the Labor Code.for Ne performance of the work for which this permit is
issuW.My W.,lo, Compensation insurance cava and Policy ndmber are
Cart 5 t
Is i, }a 1 r.,;2 Pobc No.
„- }' t.ICERTIFlCATION OF EXEMPTION FROM WORKERSI S`l�i:.e r� �� .. i+ b j ;'`'sa tY t n 1; •.y': . .... ,)
' COMPENSATION INSURANCE:';,,;
' (Ties secti6n need not be romplemd mit if the peris for one hundred dollars
I5100)orlessJ,1
0..r ..r _-..v..-..- ...._.._.. ..- ,
1 nfy th(mth pert a fNc okfor whichN pemit '.uW 1 ,,1 ' •- •�- _„_...-
shall not pl y any yc y r t Come subject to the workers '
Compos a f C bli mma.Dam rte Sqy ,fie-ry/
NOTICT:TUA1RLrCA Jif: f,after making this Ccndaate of Exemption.youshould '-
tiecomc subject to the Worker's Com -
Z ) ns or this peorah shall the ee ed Code e . must
00 forthwith comply with such provisions or this pertnir shell be revoked.
'ti " 's 'CONSTRULTIoNLENDING AGENCY
1 hcrehy Dorm the there ii a connronion lending agency fur the performance -
�,� sof the kfo hichN pe 't'.'isxuee(S J09] Civ.CJ ` -
y-G ..Levee N _
� Z ICCnlf Nat Ih have Wsa lieinformation - - - - - .-
Lender's Adertss
I
V'0 y comply
city application acme Nm Ne above awfoms '
tz Es c'orten.1 agree to comply wnh allut and county ordinances and sate laws relating /Z
�.V to move-meng nsvucdpropsehcrtbyaection parmentativcs of Nms city mrntcr upon
W the above-mentioned aQ m properly for fy and keep
purposes.
} 0. Iwo)agreew.save in demnifyand keeph.;a.the Cetyof Cupemm�oagamnat
Z Eabdin cs,judgmcros,cosy and expenses which may in any way accrue against said
C.7 Z City inco film gtooting of this pens t. - .. "',- . - 1.
APPLICANT UNDEFSTANUS'AND WILL COMPLY WITHAL NON-POINT'•
SOURCE REGU>�noNS. r'• : •• Issued by: Date /
Sr nature f ��.. t /)�/
g _o pllcanJ ntractor
Date 'y
HAZARDOUS MATERIALS DISCLOSURE Re-roofs
Wdl h
pial cant or future build ng occupant a handle haled s material _Type Of Roof
as defined by theCupertino M n ipal Code Chapter 9.12 and theHealth and Safety
Code•Section 25532(.), t - .
I]Yes, �ti ' 5�4a 7.w '.;tri Yet'
' .AIL roofs shall be.mspected.pnor to.any roofing.materlal being installed.
W ll duiirapplicant
future building occupant equipment r - poswhich' If a roof Ls Installed without first obtaining an inspection,I'agree to remove
�c murk d In t.crier dbSN Bay Arm A Quality Nen met
°tine all new materials for inspection,_Applicant understands and will comply with
OYe - - f�N
all non-point source regulations.
1 M1 ve reaJ the h.za boos materials y remenB'under Chept 695 orihe-
CaliM sea HealN&Safety Code.Sections 2550525573 and 255341uad.*mad that
if the building does not currently have a nnam.that it is my inxpoasibility to notify the
nccupA - - -- -
at 6 the
Occupancy.lrcquiremm
es which moss be met prior to Issuance of a Cenificate of
Signature of Applicant
_ Date
f
owner or nothorred agent D t Al] roof coverings to be Class "B”or better
OFFICE '