The URL can be used to link to this page

03020066CI TY OFCUPERTINO''�-- BUILDING DIVISION PERMIT CONTRACTOR`INFORMATION - ,UILDING'ADDRESS: PERMITNO. I—A J K MASONRY llpsl,,Xqc� MAR BR APPLICAn 521 S BASCOM AVE #A ;NF:: (408)28,7-2398 SANITARY OL NO. ARCHITECTENGINEER: BUILDING PERMIT INFO ' BLDG ELECTPLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under Provisions of Charm, 9 (commencing p with Secti n70g0.f Divisi.n3of NC Businose�P,j6fcsygns Ccbc, dm lice sc is an lot �6 y a� T V% LIc.X CHIMNY RSR-ROOFLINE Dam m SV R� '�C� " rJ� �� luihk and my Plansahsall he uudapuhlic cnOl FEB 2 5 2003 Licensed Professional OWNER-BUILDECLARATION I hereby affirm exempt License Law fur the 11, acmpt Rum the Contractor's Code; Any tiny or county following mosna (Section T(13L5. Business and Co on tie, thoindi sig any structure which requires a permit to conNuct, eller. Improve, demnllsh, or ANG e& theapplicant tar Nemneral'IO flats Lae(ahapter1 prior Inslcense 70tH pre vision of theeBusinesa License Law(C that Sq. Ft. Floor Area i�l� tion palsolequhea (commeccenscd Punuaw the Code) or (commencingwith Section 78(�d Divisions Professions Calc)or that the exemnd ption, that he Is exempt therefrom and the buil for tiro alleged cxemptl.n, Any violation of he is alleged 3 Ml� OeGUparaCy Type Section 7871.5 by any applicant for a petmll subjects Ne applicant to a civil penally of not mom Nen five hundred dollars ($50)). 0 0 UVT� ❑ I.uownerofthepropeny,mmyempl.yeeswiNwagesathch Nle compensation, 101 - FOUNDI>I� 4t�d Inspections will do the work, and the swcwm is not intended or offered rot sale (Sec. 7041. Business and Prnfessi0n Code: The COnbacmrs License Law docs not apply to in owner of' property who builds., improves themon,ind who dmasuch wo,khimselforNmugh his 312 - CHIMNEY REBAR & STRAPS own employ=, previded that such improvements art not Interned oroffertd for sale, If, however, the building or improvement lss.ld would.. e....fc.mpleu.n, the owner. 514 —; FINAL PUBLIC WORKS builder will have the burden of proving that he did not build or Improve for purpose or sale.). . ❑ I, as owner of the property, am exclusively contracting with licensed conmacmn to comwct Ne pmjeci (Sec. 7044, Business and Professions Code:) The Contractors Li. cane Law docs not apply to an owner of property who unions or improves Neeson, and ' who contacts for such projects with a conlnctor(a) licensed pursuant to the Contractors - Licene law. ❑ 1 am exempt under Sec. . B & P C for this reason r Dam WORKER'S COMPENSATIONDECLARATION 1 hereby arrum under penalty of perjury oro of the following declaration: 1 have and will malnu n a Certificate of Consent 1. aelfdnsure for WorkerL' , .mpen' area, as provided for by Section 2700 of the Labor code, for the performance of the work for which this permit is issued. ❑ I have rad will maintain Workers Compensation Insurance, as required by Section , 27 of Labor Code, for the performance or the work for which Nb Permit is Issued. MY art Cn@penSenion h�y,ana,.,Sarticr o t y Na; Pool numhenrt: Carrier. S /•h F i CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE �?AiQ3 (Thissection need not bccomplemd if the permit is for one hundred dolWs(g IM) or It..) I cenify Thai in the performance of the wort for which this permit is issued, l shall not employ any Person in any manner N n to hecume subject o the Workers' Comfunsalum - Law, of California. Data Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provision of the Labor Code, you must forthwith comply with such previsions or this permlt shall he deemed revoked, CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for Ne perfmmmce of . the work for which this permit is issued (See. 3097, Civ. C.) Lender's Name Lenders Address 1 cenify that 1 have read this application and sum that the shout information is _ correct, l agree to comply with all city and county ordinances and sore laws relating to. building conswction, and hereby authorrxe represenmives of this city to error upon the " ab.vemenummil property for inspection purposes. (We) agree to ave, indemnify end keep hsrmleas the City of Cupertino against ' liabilities, judgments. costs and expenses which may in any way accrue against aid City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH L NON -POINT Issued by: Date ' SOURCE 2E LATIONS. ^f(bo3 Re -roofs - of Roof wrc of Applic n(CimmemrData HAZARDOUS MATERIALS DISCLOSURE/Type Will the applicant W future building occupant store or handle hazardous mamrial as defined by the Copeman Municipal Code. Chapter 9.12, and the Health and Safety . Sectionzssu(°)7 All roofs shall be inspected prior to any roofing material being installed. 0y. �Nu If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building =upon, use equipment at devices which nit hazardous air conmsnin oars as defined by the Bay Arca Air Quality Management all new materials for inspection. - oilet? ❑Ycs Nu I It 'wreulthchasa twamauri.istcquimmcnuun&rChapwr6.95ofihc Calitor, .is Health&Safely Coda Sections 25505,25533 and25534. I makmmnd- tifthc building does not currently have a mnnh Nal it is my responsibility to nouly the P turns, reqa me ichmuRbeme1 'onui a anecorace,uoeamnroc'eanatt Signature of Applicant Date 2. /Dam All roof coverings to be Class "B" or better ONO or auihori'cd agent f 1 of 1 CITY OF CUPERTINO OPERATOR: suem COPY # : 3 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36910036.00 DATE ISSUED.......: 02/18/2003 RECEIPT #.........: 21139 REFERENCE ID # ...: 03020066 SITE ADDRESS .....: 19913 LA MAR DR SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: JERDE TERRY H AND LOIS G ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-3310 METHOD OF PAYMENT AMOUNT _________________ ____________ CHECK 166.05 TOTAL RECEIPT 166.05 VOICE ID DESCRIPTION 101 FOUNDATION 514 FINAL PUBLIC WORKS r NUMBER ------------------ 1330 VOICE ID DESCRIPTION 312 CHIMNEY REBAR 6 STRAPS RECEIVED FROM ....: JK MASONRY CONTRACTOR .......: KELLEY, JAMES M LIC # 11823 COMPANY ..........: J K MASONRY ADDRESS ..........: 521 S BASCOM AVE #A CITY/STATE/ZIP ...: SAN JOSE, CA .95128 TELEPHONE ........: (408)287-2398 its ID _____ UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW SAL BENERGY _____________ __________ PERMIT FEE 77.00 __________ __________ 23.10 0.00 __________ 23.10 __________ 0.00 BPERMFEE VALUATION 2,000.00 77.00 0.00 77.00 0.00 BSEISMICRE VALUATION 1,965.00 0.50 0.00 0.50 0.00 BPLANCHK PERMIT FEE 77.00 65.45 0.00 65.45 0.00 TOTAL PERMIT __________ __________ 166.05 0.00 __________ 166.05 ---------- 0.00 METHOD OF PAYMENT AMOUNT _________________ ____________ CHECK 166.05 TOTAL RECEIPT 166.05 VOICE ID DESCRIPTION 101 FOUNDATION 514 FINAL PUBLIC WORKS r NUMBER ------------------ 1330 VOICE ID DESCRIPTION 312 CHIMNEY REBAR 6 STRAPS