02020025 CIOF DN
PEBTONO
BUILDING PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21695 NOONAN CT J K MASONRY 02020025
OWNER'S NAME: APPLI ATION SUB DATE
YAAKOV—ASIA MILSTAIN 521 S BASCOM AVE #A 02 06/2002
PHONE: (408) 287-2398 SANITARY NO, CONTROL NO.
z Z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
w BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
1 hereby frim that I am of he B sines n., t .and mmen<m Job Description
oz=o fiat vmviai°^.^ chapter g CHIMNEY REPAIR.
FHFw with Section 90W1o(Divisionlof the Business and Professions code.and mylicenu
a g� is inmBmrceand<eBB'en. T/O APPROX 10 FT.
d z V rise Clan l- Lir,k
cmaracYY ON REBUILD TO CITY BUILDING CODE .
F. .I-i HITECT'S DECLARATI
LL e g 1 understand my plans shall W used as public rte
Eo O Licensed Pmfes timid
HOWNER-BUILDER DECLARATION
, 1 hereby M.that 1 am exempt from the Contractor's License law for the
t K-a following mason.(Section 9031.5.Business and Professions Code:Any city or county,
Y cc a which minims a Permit to consuucr alter,improve,demolish,or repair any structure
al �..p to is koance.also requires LWUPPIXemf hpemiu flea signed statement. -.-.-.)__._
Ruth 's licensed punoanl to the proms; f theCormuctr'.License' Law(Chapter 9 Or ea..,p rS
(c m .B with Section,9000)of D ] f the Busi ess S Ftd Professions Code) L 1 5's,g f l:] Ft.P.Floor
Ar
$234p'0luation
man at tie is exempt therefrom and the basis for the alleged c$em,xma.Any violation t
-of Seetion 9031.5 by any applicant far a permit subjects the applic...m is civil Penalty
of not more than five hundred dollar,($500) 3571k#bIt§i��f ;'• . .... . Occupancy Type
°I,as owner of Ne property,or my employees with wages as their sale compensation,
will Eo theweak.Professions
due structure Th is not intended d orae eredLaw doe salt apply to
- ---__101 - FOUNDATIeAuired Inspections:
easiness and Professions Cade:The Connector's License law does not apply m an "
owner of property Who builds or improves thereon,and who does such work himself 312 — CHIMNEY REBAR & STRAPS
or through his own employers,provided that such improvements are not intended or
offered for sbleaf.however;die Wilding-- ... - t is w1d'within one �'o(. _..-. ..._-.... ...._ E,[3*
orimprovemtn n rem 514--'FINAL; '•
'completion,the ownerbuildu will have the burden of proving that he did not build or
improve for purpose of_ule.).
°1 s n< f theEmptily am exclusivelycontracting with licensed contractors to - - ----''-' '- -__ ... . ...........__.._. . ._. ..._._.
compact the project(Ser 9DL1 Business and Professions Code)The Contractor s FEB 2 2 20 U2
- - iccm law d«s not apply m ow r fpr 1 eny who builds or improves thereon.
ne
._ ..and.xho.c°nuac¢.for h In cta tui .a co mcm;I.liccnsed.p rs'a nt m she. ..._
Cnntm<mrs l,ittnx,I. . ._ ._..._._.—. .._p_
_ ❑Tum exempt under�Ce.' I ,B&PC for this reason .i t' I ICpuILD'NG
_ Ownei'- \\ fin '
WORKER'S OMPENSA ON DECLARATION
I herehy affirm under penalty of perjury udc nithe following declaratiam:
° 1 have and will maintain a Cmifate of Consent to ulf-insure for Worker's
Compensation, m provided for by Seetion 3900 of the Labor Code. for the
_ penRomme,of the work for which this permit is issued.,.
1 have ad will mmudiin Worker Compen5aiinn Insurance,as required by Section
f he labor Codefor tM1 aperfmar f ih m1k'mi which tris a: t
ee C m mat oIns c c rid Policy ram
- f
is,u<0 MyW rk n ('
ic
0.2
tCERTI PICAf10N.OF XEMPTION FROM WORK RS • ,V pf')yl 6 I ii 1 '�/k h 4^S r\ 1�r �.� ��✓�tv 1 1 l a -.
COMPENSATION INSURANLE�Li.i O.._.._�_..- _ ._._.. ....<_
' -fTh s union need not t<complc¢d if the permit is for one huiMmO dollars
IE 100) I .1
-
1 m fiat l the pastor nonce f the wnrk for ivh h th s
shall not employ
n
any person in any ma m to become object
a in to the Workers' '
Cpmivmtm ori. of California,Date
NOTICETU APPLICANT If,after making th C h t fEg pf 'y, h Id becomehle t t'th Worker'sComb sato P th M Cad y must
Q Q forth hh ply with h p this p f II d e ned rt ked.
F ti 1 1 - CONST N L NDI ENCY
' 1 h by ufr th t ih ." s J(S nJ n9 Ci"en
f thepc formun«
f th' k far wM1ich th psn t- _,i
W Q -Lender.Name'._ . . _ . ._. .. _ _. .._ ...... ._ _ _. _ .... ._ -... . .. .._. .... _..._. .__ .. - _ ... ._
�' Lnder.i Address
_.Z n n
V-C 1 certify that 1 have read this application and state that the above Informmion is
'clirieasl agree to comply with all city and county redinances and state laws relating
- Q.V In Wilding construnidn.and Wrehyamhmixe'iepresentatives ofthii citym enter upon
;s. ;4 he adeve-mendrincid pro peny for inspection purposes
[..r IY (We) g e t e d m 'dyad keep harml,s'he C ty of Cufm�rfi3o ilaim,
tq bIt s lYdgrens,costsd expenses which may in any y against said
- U:Z, C'ry yet hh<R t'gof th per t f Q v
' s('LICAN'r UNDERSIANDSAND WILL CO\IPI WITH ALLN V:PO hT' ! `
wRG.r"E LA 1 Ns y d Issued by: Date
` SigmmrctdApphcangCcurnmemr. . . ' ''` ate c, Re-roofs
HAZARDOUS M Ii ..-Type
DISCLOSURE
- wlitfi f p ., a al ..Type of.Roof--...- -..--. . .- _.- .;._. _.. . ........iwd, ._._. ..
ppl t e t t baud g p t i m ha dl h aN
CadefScd ec'iis ru5°I.sI MY pal Cod Ch t 9TR and It Health 1', ridSafety
1 .J-J \ '^ .'r^s ` aa•d.� Z i I<5^ it \ s .s
i All roofs shall be inspected prior to,any roof ng material being installed.,.
O
Will the applicant f mm ulla gocc pant use eq tpp w deme which If a roof is installed without first obtaining an inspection;Pagree to remove
I mosindims at,co t ara isasdef <d by he Bay Am.Air Quality Management
D t R� all new materials for inspection Applicant understands and will comply with
-
°Y '1 - "SNO - all non-point source regulations.__ I
.. 1 have read.the h dour n`utetials reqs ik neons under Chapter 6.95 of the
Calif..in
Health&Safety Code.Sections 25505.255]3 and 25531.1=undersmed that
:ifihe buildingdoes not cumentl have a temat.Nat it is Y y
y y mapnce oft m m��� she
a<upam of the rc 'ircmenis x�hich most be met prior m issuance of a Certificate of
' °cru 1e - __Signature o_f Applicant Date
T' ¢ Od o Si
Owner orauthon dagent- � � Date� All roof coverings to be Class "B"orbetter
OFFICE