00090052 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMITNO.
j8NES MASONRY cam.
OWNER'S NAM.. l\lUVt=VIbt�H DR APPLICATION SUB DA[h
PHONE: D BE'—!— AVE SANITARY NO.
O p O CT
ARCHITE '/ENGINEER: �. BUILDING PERMIT INFO
c m_ BLDG ELECT PLUMB MINCH
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LICENSED CONTRACTOR'S DECLARATION Job Description
. �' 1 hereby amrm Ina,I Pact,Im.mt, under provL,i,m,,r Chrism,v aml,nnuneing
�_ with fall force ad e f Divi,inn 3 or the ltusincsx unJ Prul'sssion,Cndc,and any license
x s is in run file'ane effect.
License Claus Lic.M
ygodu Date SDECL,f REPAIR CHIMNEY
lu 3,a,vl—i ARCHITECT he a DRCublic peord
t:`°5 I uneer,wio any plans Ic wed a parol.me.,t,
' Y
y�o O Licensed Pndcosional /
a n—LL OWNER-exempt ifr m the ontr10N
'—^ I hereby rffirm that 1 am exempt from the Contractor C License c Law for the ^
CZ6 followingairs,..(Sectio,"constr, t,tire, mprve.dsnions Cndc:s, Gary,rumnry Vv
i 2 p whirM1 rcquiren a pe.it,
so re construct,pian improve demoli,h,nr rtpaig any samcture
i3= _pnonohsimntnm,aHo requires mua...I I for sucnnermi,mFile a,aaw, ase stammem
den bel,cegwith aaamm3,nic 00)ofDamna3ol beBowine,l-oaacaooLv,,ar,Ilier 9ode) Sq. Ft. Floor Area Valuation
(commencing exempt Sermon ont anofhe halon 3 0l the Ito etre x art io nfA ny ou Cade)
or than he is31.5 btherefrom and,he nail for the alleged exemption.Any violation
m Sedi,n]03 L5'v atry dyed dun bn a pvm,ir,uhimu for npPliaaml m u civil penary
or mar marc man(Ne hna,arcd dollm.(y51ro), AP[V Number Occupan m .
❑I,its owner of the propeny,(or my employees with wages as their,nle csnvpensation,
will do the work.:,,d the so....am is Bol intended nr Noted 6n sale(Scc.7044, r sGf
Buvlma and Professions Cade:The Contmcmrs License Use has all apply to an f""'V�"R410ired Inspections
owner of pmpeny Who hailer or improve,themon,and who does.such work himself
or luongh his own employees,provided That such Improvumenx are rot imemlN nr
,Bend lot sal..If.however,me thankful,or intm„vctocan i<,td Ilton Ione year of 101 — FOUNDATION
completion,11.o s ion,bu,le er will hoc the buten of proving that he did not build or
otgnosc nmPosen 31.2 — CHIMNEY REBAR & STRAPS
01,as ranerofthe pro,vny,am socluvivdy contracting with licensed contractors to 514. — FINAL PUBLIC WORKS
ansWet the project(Sec.744,Baines and Pmfessions Code:)The Contractor's
Lir'ense Law Joe%nor apply it un owner of erry who hrild,or'unpmvsn Inemon,
and who contracts liar.such prnje"%with a emmmrinfls)licensed pursuant it,the
Contractor's Liccnsc Law.
❑T rot exengv under Sec. ,B&P CI'or this reason
Owner Doc
WORKER'S COMPENSATION DECLARATION
T heathy affirm trader Penalty of perjury one trr the following declarations:
O I have and Will ormmmn to Cenircau:of Consam u,iclf-hu'um for Workers
Co.n,mra on. as p.rvlded Ila by Seedon 3701 ,f he ball Coale, fnr me
performance of the walk for which this .it is issued. -
❑I have ani will maintain Worker',Cbmpenet o In.wrunce,ax required by Seem
3700 of the Labor Code,for the perliammnm or the work for which this plana,I%
rued.My Worker'.%Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.:
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
frhis section need not he completed it the permit I%for one hundred dollar
Ib uxp or ms.)
1 rectify that in the perfmmaas,of the work for which this permit is issued.1
shall not employ any Formalin any manner so as to he .
crme subject ,the Workers'
Cuan,ra,aa on Lews of Celd.....n.Doc
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifieate of Exemption,you should -
become ewhi ,,the Worker's Cnan,rvao m pro ,,ion,of th,Labor Cods,you most
Q O hmhwah cannily with such pmvi,i.n, a this permiT shall be domed revoked.
Z y CONS'1'RUCTION LENDING AGENCY '
I hereby aff! than them.,a cmgmdio I Tarim,i9mey for tho pcAanunme
or the work for which thin permit is issued(Sec.3097.Civ.C.)
6. Q Lender's Name
D Z headers Addrer,
U I vi that 1 have mad this application and slate that the throve information I%
co nee.1:agree m annply wan,all city not worry ordinance,and,tate laws remring
Q V ,hoileil,g conalrvcllnn.mad hcachy nnlhnnw r'prcacnarivo of lhn day r,enter open
} the(hove-merti.ned progeny for inspection pofposev.
(We)agree msrve,indemnify and keep harmless the City of Cnnenmo against
fA Iixbilille,.jodgmonks,ons and Cvpcnse%whmh may in ally way accmm against said
U Z City in mamequenct,of the gmntingof this W....il. ,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT . Issued by: Date
SOURCE REGULATIONS.
Signature of ApplimnOContruaor Date Re-roofs -
HAZARDOUS MATERIALS DISCLOSURE
Will be apphcatn of f num molding axi apart store or barono hamtiro nnational Type of Roof
as defined by the Cupetnm Matim,d Cade Chapter 9.12,sad the Health sad safety .
Cod.,Section 25532(x)?
❑Ye, El No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or furore building ncmpat use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
r h:vanloa,air...Barin:mu nsdefined by me Bay Amo Air Quality Manngnnem
irndct? all new materials for inspection. Applicant understands and will comply with
o Yes ❑No all non-point source regulations.
I hate read the haurdor materials rnlui cols ondor Chapter 6.05 of the -
CNifomie Ileum&.Surety Cote.Section,255115.25533 rod 25534.1 under,mod that
ifthe building does not currently have a tenant,that it is Illy re,an ility u,notify the
ea.....,I'the rtge!....enln whielI anas,I be ane, or In mroanse,I'a Cenrlerle of
Ocer.'try' Signature ol'Applicant Date
owner of aum,daed ages, Dat, All roof coverings to be Class "B'- or better
OFFICE