03030031 CITY OF CUPER7'INO TRAC$'TORTIVORMATION' .
BUILDING DIVISION PERMIT CONg .,, , •..��: ...'.'; •
PERMIT NO.
BUILDINGADDRC55: .... LEON MASONRY INC
21416 HOL FERMIT ISSUE
0
'S NAME 240 MOSELLE CT
COLE JERRY R AND
SANITARY NO. edaUCL N0.
(408) 365-1660
BUILDING PERMIT INFO
ARCNITECT(ENGINEER: BLDG ELECT PLUMB MBCH
LICENSED CONTRACTOR'S DECLARATION Job Description
e� 1 Mmby e(firm Net l am licensed under Previsions or Chapmr 9(commencing
ith Satlon 9gM3)of Dlvidon 3 of the Busineused Professions Code.and mY licanse is
mrvilrone-nREPAIR CHIMNEY
qZ Lieenw ass Lie.A g OP: N1 Yl<GW ]✓
❑ Dam Co temor
7W ARCHITECTS DECLARATION
< 1 understand my plans shell be used u Public records
e. Liccrued Professional
O OWNER-BUILDER DECLARATION
<2 1 hereby air,.that I am exempt from ted Contractor's License law for the
p O following mown.(Section 70111.5 ns Business and ptnressloCode:Any city or county
$
0!. which mquins a Permit Io cnnstmc6 erre,.improve,demolish.m repair any structure
i—� Pa.U,its issuance.elw rcquiresthe mpliunt for such permit o file a signed statement Sq.Ft.Floor Area Valuation
Zs a the,W is licensed pursuant to the previsions of the Connector's Leon.Law(ChaPtel9
$1800
(commencing with Section 70OX)of Division 3 of the Business and Professions Code)ar $18 0 0
i Nu he B exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by my appiicantfor a Permit subjects an,applicant to a civil Penalty of -AA.yvT.Nvravaty� 00 Occupancy Type
root mon dun live hundred dollars($5W). 3 OO��ll!!Z�'"'CC//::77"" .
I,aownerofthep,opwy,mmYcmploycnwithwg asftkwk—Penudon,
will do the work.end the structure u not intended or offered for We(Sax.TOW,Business 101 - FOUNDRE iE dd Inspections
and Profusions Cade:The Convenor's Limsee Law dins not apply to an owner of 312 - CHIMNEY REBAR & STRAPS
preparty who builds or improves thereon,andwho doessuch work Idmsetf orthemZ1,his
however,
nHarcne ouOfdmoffcreddo,Ownir. 514 — FINAL PUBLIC WORKS
halide, the building or improvementahat withinooe)earofcomewfeermenwmr-
Wildm NB Tuve Ne burden of proving that he did not build m Impmvm fm Purpose of
sale.).
❑I,a owner of the properly,w exclusively convecting with licensed contrecmn to
construct toe project(Sec.90",Business and Professions Code:)The CommelOrs Lt'
cense law,does not apply to en owner of property who Wilds or improv thereon,and
who convects for such pmjec0 with aconvmur(s)rimmed punuam to the Convector's
License Lew.
❑lamuemplunder Sec. ,B&PCferthbmxmm
or Dam
WORKER'S COMPENSATION DECLARATION
1 hereby a11im under recoody of perjury One of the following da hma'a:
I Itave end will mtlntain eCmal"C n of Consenuoulfdnsece fm WmkcesComper-
utiun,a provided for by section 39W of she labor Code.fm the Performance of dm
work for which Nis permit Is issued.
❑1 hese and will maintain Worker's Compensation Imunnce.as required by Section
37W of the labor Cade,for dm pufommna of the work for which this Permit is Issued.
My Worker's I Componealfo—n Insurance canis and Policy number am:
,mm,.Sl44-< /—NuiY Policy No.:6 V610 —
CERTIFICATE OF EXEMPTON FROM WORKERS'
COMPENSATION INSURANCE
rials sembn,ecd not W cmnpleted ifft Permit Is foromhundmd dollar(SIM)
or lou.)
1 ceNfy that in me pefformence of the work fm which this Permit is issad.I met not
employ any pe.n many meaner so as m become subject to the Workcrs'Compemnion
Lows of Cslifmnis.Dow
Applicant
NOTICE TO APPLICANT:IL after making this Ccnirm to or Exemption,you should
bocce eabjw to the Workers CompclW,lon provisions of the IdWr Code.you mum
O forthwith comply with such provisions or this Permit shall be deemed invoked.
Z r CONSTRUCTION LENDING AGENCY
F IWmby affirm that them iso construction lending agency for the Performance of
tYi 7 the work for which this permit is issued(Sec.3097,Civ.C.) .. )
fL1 Q larder's Name
z Lender's Address .
V(] I certify that I have read No application and sum ren the above inrorma6on is
Iy F comeel.I agree to comply with all city and county ordinances and state laws relating to
0 U Wilding construction.and hereby authodm representatives or this city to cow upon the
mned
purporac
W aMvcmenudgmproperty forinspection
which ret V A+s�
L}�
(We)agree to save,indemnify and kap harmless the City of Cupwino against
it res/] incoseque consequence
of thecmuend expenses which may In any way accrue against aid City
V 2 A APPLICANT
of the granting of this Permit. Q
•` APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature of ApplicantrCmame er Dam .
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding oavPent Bon or handle haaacdom material
as defirmd by the Cupertino Municipal Code.Chapter 9.11.and the Health and Safety
ode.Seetier 15531(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yet �No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hawrinus air contaminants ae defined by the Bay Area Air Quality Management all new materials for inspection.
Could? 1
❑Yes III Na
I have tewl the haysrdoua mamruls mq.im..0 under Chapter 6.95 of tho Califo>
ria Halm&Sefmy Cook.Sauom155U5,15573 eru135534.1 understand mulfthc Wilding
don not c tly ba enrol Ne,i,is my rupomiMlity m notify de occupant of me
rylmtFment which tOc poor toissawaof&CcNrmaeoroaw.racy. Signature of Applicant Date
All roof coverings to be Class"B" or better
Owner or wthonved agent Da¢