01030125CITY OF CUPERTINO
CONTRACTOR INFORMATION:'
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
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PERMITNO.
10445 BREWER AV
JONES MASONRY'
:'01'0304.25
OWNER'S NAME: --
APPLICATION SUB DAT E: u' .
MIKE SEEVER,
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"'1058 DEL AVE`
03122/2001.,"''
PHONF,:-
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SANITARY NO. CONTROL NO.•
4083777512 '
ARCHITECT/ENGINEER: - -
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BUILDINGPERMIT INFO,•
BLDG ELECT PLUMB_ MECH
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- LICENSED CONTRACTORS DECLARATION4
- Job Description
1 hcrehy arum ❑ " f I n I" 's I anden f chapter 9 6°nmeac ng
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will, Section 7000)or D 3ofthu9u nesn tad P ,feeyta Code ,dmylee,ec
Lic'mccir's °�°L. ue.a, ��
REBUILD CHIMNEY FROM'.SHOULOERS' RFL"
Dane r_ 7 Cnnlmca°r-
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�, — T'SDEC.A TI
- I undersmad my plans shall be used as public reeoli
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Licensed Phofexdofit l -
OWNER -BUILDER DECLARATION
ARATION
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I hams, aluval II ( l .,it -waahEThmn the Contractor', LicenseL for lire
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loll , ma . (Scml' a 701 .5, [business d Professions C J : Any city or county
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which rcyuiru a peril to command. after, improve, demolish, or repair any In arum
priori n ssu L 9 t "pplle t f I p i f filera'abl'tureareal
Sq. Ft. Floor Area
Valuation. '
but he is licensed P . II 'he powileall 'Ifd Clannor1lats, License I" (Chapter 1)
(c ort
f the
kino
ss
lirbmU°n 7nand fDbasiso
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he is ex
or that he is theaeg ewladln.AnonaCNa)
Any viobction
Iherefntm and the basis for ubj alleged amntma
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31.5 b to
of Section 7031.5 by aoo applicanl fm' a permit subjects the applicum In n civil penW(y
a not dtnm maiih Eve lhanarad ammr> rSSOn>.
A'PN Number
- Occupancy Type • - J
❑fth P pelt Y ply d g: a. lir I p ielan
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.illl d are weak," 1 the thatthaturic is nor intended or elLeal 1 (S 7M4
Business and Profe,fores Ct de: The Co,t t a s License Laws does not apply 1° air
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Required Inspections
htp 'ally "...... :d h de, work trial
tg1 hwremployee,.
e l Yee p d d clan 1 net a1 led or'
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i01.—FOUNDATION
soa ed r c If lowest, thente p ea(td w mn nae year o1
corridor erlwill have burden rptnngmatnedid ,mndlenr
312 CHIMNEY REBARI'd.;STr RAFS,='•r
improvefpurpose ofsae
exclusively
' 51'4F:I•NAL :PUBLIC
°i, a, owner of the properry. all, contracting with licensed contractors fit
.WORKS
construct the project (Sec. 7044, Business and Proessin e, Code:) The Contractors
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License Law does not apply to no owner ofr eopeny who hands or impales thereon,
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aad who contrncls for such projects with a cmdmjnj(�) licensed pur,vant to the
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C:a1m, m's License Law.
❑Iain exempt muter Su:. ,B& P C for this reason
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'Owner DNi.
WORKER'S COMPENSAI ION DECLARATION
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h) 0 J b n'ItY 1P 1 Y if the fll in, J 1'
I base hall will hernbuir a Canificbm if C r m lolf-in,onefor K rke
Compensation, l . IF ided f by Section 3700 of the Labor Gale, Ru the`
pert ,voflh, work fin which lis pe nr is issued.
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DIf dill 'IllWk Clap ]it c41i JhyS 'n
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17110 f Int 1 6 Cal r O p r m o f int }f ���yyyjjj b IM1n }}}}I
issued My k k C lI�. f I ry am ar tp Jm far%nt� Y,;TAr,
Cainer �U—PoIi yN : �/
Nb
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C . IFI A LUN OF E%F.iby
C 1 N FROM WORKERS
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COMPENSATION INSURANCE
(Thisvediai need nor be completed i1'the permit is for one hunched dollars
($100) on leas.) -
,1 terrify that in the pert air ce of the work for which (his permit is urd, I
shall nor employ any per,( in airy manner ,, as nt bemin, -subject tothe Workers'
. a
Comreasm'mn Laws of Culilorma. Dare
Applicant'
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NOTICLrOAPPLICANTIf. afterearkingth'C ltcatenl Exnnpfnnlotstculd
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lar .ubjcettorheW k C pmml p M1
s of Labor Cods, you mum
forthwith comply with such provisions or this permit shall be de owned invoked.
CONSTRUCTION LENDING AGENCY
I nerchy art! rnt Wm (hare is ,,urs huaim Iending ngency fill the perfonnnnee'
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of till, work for which fhi, peril Iv issued, (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
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I tardily lhill have mailth'. ppb" t and state that the hove informati"
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ire , I y e to comply is hit inIcity and county 1 I rat ling
to hailding construction, andhu.by nflum representatives f this sty to user urbanr
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the above-ascrecnu1 property for inspection purposes.
(W)ageIn role, orderanifyinalkeplxml. the City of Cupertino against
liabilities, judgments. cost. and expIuclb may in any way accrue uga ns( sad
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City in cm,c,.cmc,,oftire yr, ngdthhp rot.
APPLIC UNDERSTANDSAN WILL COMPLY WITH ALLNO �PO
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c LA%�
Issued by:, �l.G Date
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Ignamma ApphtantiCommemr Date
'Re -roofs.'' . • .
HAZARDOUS MATERIALS DISCLOSURE
Will flude,fionl nr mmrabaldr, sa"set sero or handle hlnardonenmmddTypeofRoof
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al, defined Oy (he Cupertino Municipal Calc, Chapter 9, 12, E I the Ilcullh and Sli my
Code, Section 25532ed?
°Ye Cl No
All roofs shall be inspected prior to any roofing material being installed.
I Will the applicant a;• future inodingnecapantmergtdpnemmdevire,whleh
hazardous
If a roof is installed ..without'first obtaining . an inspection,'I-agreetoremove
mint air b ersamnuno as dunned by the Bay Amu Air Qualify Management
Distad^ -I . 5'
" all, new materials for inspection. Applicant understands and will comply With
°Yes - 11 No W
all non -point source regulations.
1 1, vu end the ba,colon, froulliall ne,mr, ents hade,'Chaph,' fi 95 of the
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Coldiarent Health &Safety C d Sernamr,25505,25533 and 25534 1 understand that
If the hadd"tgdoesant tly have a locart, that it".myric,pro,dTifin, to norfy the
s' n
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decorator of the rabblement, hi,h a f be ,air poll, to issuance ,f a Card', .Is of
p
ff�� yy,�,
SignatureofApplicant '" Date
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��/q lbd
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p All roof coverings to be Class B" or better,
G al Data
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- OFFICE