03020024 CITY OF CUPERTINO ,y,r„� -* • •a, .t. wi�a,,:"
BUILDING DIVISION PERMIT �CONTRACT9R,:I FORMATION:
to
BUILDING ADDRESS: BOB GERE MASONRY PERMITNO.
19781 BIXBY DR 01020024
OWNER'S NAME: 480 CROSSLEES DR APPLICATION SUB DATE
BIERMAN RONALD E AND KATHERINE 02/07/2003
ZONE: (408) 972-1285 SANITARY NO. CONTROL.NO,
ARCHITEC 7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
0 0 0 0
00 LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby affirm shat 1 em licensed under provisions of Chapter 9(commencing o
with section 711!X1 Divisi n 3ofthe Business and Professions Code,and mylicenscis
G „ in fullfnwaan �. REPLACE CHIMNEY
zOfaZ Licmnaa s AhALED
ARCI117BCI'S DP A FINjlar
<?ZQ—_ Date Contracto
z C&< I undersand my plans shall he used as public records
'
a �O License)Pmlessinnal FEB 18 2003
OWNERrIexempt IR DECLARATION
cop�yNyp I hereby mason.(Sect that 11. exempt Iran We Cssions o License Law far the
u°4+P O� whichinguiesa (Seri..7031.5.Business and improve.
or:Any city or county BUILDING
which its requires a permit m.i.,,n,stmt,improve.demolish or repair any structure
�Y}+
that he
incensed pursuant
to the proviionsof for mchpatoiunicese Law(Casemem
�< thmhc is licensed PSectiouothe provisions of the Contractor's Proflaw(CbodwrH Sq. Ft. Floor Area y5`2WQIgt1O❑
iti F S (cat he 11 acingWithha Section 74XXB of basis
r the
the egad ess xempt on.Any
vi Code)ion of
that he is exempt themfmm end the hssis for she alleged exemption.Any violation of
Sued.7031.5 by any applicant for a permit subjects the applicant o a civil penalty of or 0 Occupancy Type
nos more than Eve hundred della.($SIIB.
❑1,as owner of the property,or my employees with wages as Weir sole compenadon,
will do the web,and the structure is not intended or offered for sale(Soe.7040,Business tot — py's��.ys p$PT
ppb,
and Professions Code:The Communities License law does not apply to an owner of 312 — CH I MNE 'ANAPCp Oct".7 1 RAP S
proporty who buildsor improve themon,and who doessuch work himselforthrough his
own employees,provided that such improwmenu am not unarmed oroRemd for a*,It, 514 — FINAL PUBLIC WORKS
however,We building or improvement is said within one year of completion,We owner-
Wilder will have tha burden of proving Was he did not build or improve for purpose of
ale.).
❑1,as owner of the property,am exclusively contracting with licemed contractors m
cunswet the project(Sec.704,1.Business and Professions Code:)The Contractor's Li.
cense law doe not apply to an owner of property who builds or improves thncon,and
who contacts for such projects with a contractor(s)licensed pu.vanno the Comsutoh
License Law.
❑ I an exempt under sec. B&P C far this..no
Owner Date
WORKER'S COMPENSATION DECLARATION
"hereby affirm under Penalty of perjury one of the following declisations:
J ch.as and will for
Section 3700 of Oc Labnt toCod inaurefer Worker's Combed-
Mich.
ompete
amen,n provided for by Stenion 3).1 of the IaMu Code,for the performance of she
fm which Nis permit is issucm.
01 have and will maintain Worker's Compensation Insumna,a required by Section
7 of the labor Code,for the Performance of the work for which he, .it is issued.
My Worker's Com coxa iar Insure a carriennd Policy number are:
f Carrier. olicy No.: S� 9
CE TIFICAT OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section neem not W completed if be permit is for one hundred dollars(SIM)
nr less.)
I coni fy that in the performance of thm work for which this permit is issued,I shall not
employ any Person in any manner as as to become subject o the Workers'Compeoxation
"awsof Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions Of the Lelan Cale,you most
OZ forthwith comply with such Provisions Of this Permit shall W dimmed mvokmd.
z CONSTRUCTION LENDING AGENCY
f+� Ihereby affirm Oat Were is a construction lending agency On the Performance of
{� 7 the work for which this Permit is issued(Sec.3V97,Civ.C.)
0.i Lenders Name
Under.
nders Address
U 0 1 certify that I have read his application end sum that We above information is
U. F Correct.l agree to comply with all city and county ordinances and state laws relating to
0 building construction.and hereby amhori m representatives of this city to enter upon the
I31 above-mentioned poPmrcy for inspection purposes.
G (We)agree to save,indemnify and keep harmless the City of Cupertino against
1,y L,) liabilities.judgments,costs and expenses which may in any way accrue against said City
in U APPLPA4 TOUNDF.RSTAng lfthis
D WILL COMPLY WITHAL NPN POINT Issued by: Date
so e H d^�
�� 7 Re-roofs
Signature o(ApplicantiCcantrissaffi, I Date
HA2MlDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant some or handle haardous mown.]
az dcfined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
IMa,geclinn 3ss331a)1 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Wi11 the aPPlicam future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
Tit beaNnus eircunta nano JefincJ by the Bay Area Air Quality Management all new materials for inspection.
uiet]
❑Yes No
Ihawmad Wch a wsmmawrialsr uimmentsundcr ,CMpwr6.95ofthaCalifor-
niaHelth&Safety Cr4c, tioru3550S,25533 aJ 355}4.1 undersand thvitthc building
docs n ncmly have wn 4 Net it is my respnnsihility so redly IM mcupant of the
m m ma in cmof.Cenlfwomo, Occu �ySy. Signature of Applicant Date
wrier or sums nt paw All roof coverings to be Class"B" or better