03030092 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .CONPReCTORINFOAIO.N "
BUILDING ADDRESS: PERMITNO.
J K MASONRY -
OWNER'S NAME: 521 S BASCOM AVE .#A PERMIT Lis A
NE: - SANITARY O4iOL NO. �-
(408) 287-2398
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION O O O
I hereby affirm that l am licensed under provisions or Chapter 9(commencing Job Description
9di. with Section 70fl(Onf Division Sof die Business and PrmfessioM Code,and my lice..is ' " FINALE®
mom fottto.e erc`er_�� Lie. EOlaCHIMNEY REPAIR
Licence Clw ( .
Dau 1 TO
/�z TS DE Or
'r��r- AaG—�Gr-to"m R IGN MAR 1 8 2003
1 understand my plans Nall be used at public records.
o Licensed Professional, BUILDING
OWNER-BUILDER DECLARATION
1 hereby nrcirm that 1 am exempt from the Commodes Licence Law for the
D O following reason.(Section 7(31.5,Business and Profetaores Code:My city or county
'S$ which requires a permit to construct.shot.Improve,demolish,Or mitair any structure
ZS^ prior m its issuance,&Is.requires the applicant for such Permit to Bin signed.nemenl ]
g1 BfI
g < that he is licenced pursuant the pmvislnu of the Contractor's Limn.Iaw(Chapmr9 Sq.Ft.Floor Area `J/ on
(commencing with Section 7000)of Didslon Sof the Businessand Professions Cudc)or $2
-
that he is exempt therefrom and the basis for W alleged exemption.Any vinladon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of 3$�$SIB19�[ 0 0 Occupancy Type '
not more than Rve hundred dollars(5006
❑I,uowneraflhepmputy,mmyemplorc withwgesuNebwlecompewtiw,
will do the work and theswcture is notinundedaroaened foruk(Sec.7044,Busircsa
an101 - FOUND 4d'y d Inspections
And Professions Code:The Convase eo ector,LimLaw d .1 apply m an owner of
property who builds or Improves Mercer,and who does such work hlmselfor through his 312 - CHIMNEY REBAR, & "STRAPS
own employees.provided Nat such Improvements tee not Intended or offered fm sale.If. S14 - FINAL PUBLIC WORK$
however.the building or lmprovemant is sold within one year of completion.the owner- ,
builder will have the burden of proving that W did not build or improve for purpose of .
sated. _ ..
❑1.as owner of the propeny,am exclusively contracting with licensed conuenora to -
construct the project(Sec.70".Business and Professions Code:)The Contractor's I.I. -
come law does not apply to an owner of property who Wilds or Improves;themon,and, -
whoconvacufor such projects with a eonvac.r(s)licensed pursuant to the Counselor's - t
Lice.Law, -
❑1 am exempt under Sec" ,B&P C for this mason
er Dau
WORKER'S COMPENSATION DECLARATION
I hereby Aram under penalty of perjury one of the following declarations: -
Ihave and will maintain aCenificaeofCoruenttosel6lnsure fur Workeri Compen- , -
sation,As provided for by Section 3700 of the Labor Code,for Ne performance of the ' -
workforwhichthispermllisissued. , -
❑1 haw and will maintain Workers Compensation Insurame,as required by Section -
37M of Ne labor Code,for the performance of the work for which this permit is issued.
My Workces C1oompensation insurance carrier and Policy number am: -
abler. 510.'1-[ Fu et-)' ' Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .. '
(This mcilon reed not heeompleted if the permit is foram hundred dollars(SIM)
Or len.) w
1 cenlfy that In the Perin ml ce of the work for which this Permit Is Issued.I shall not
employ any person In any manna mbecomesubjal to Workers'Compcnsatlon
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making N4 Cam f Exemption,you absurd
become subjal m the Worker's ComPenuti.n pmvisi..a of N hat Cube,you most
z forthwith comply with such proviainm or this permit shall be doe. rooked.
,z�., CONSTRUCDON LENDING AGENCY -
• I-, Ihereby affirm that them in construction lending ali for the performance of -
gG> the work for which this permit is Issued(Sea 309'1.Civ,C.)
Q lender's Name
z LeAc$2 Address -
U 0 1 certify that I haw mad this pplication and Aute That the @how information is
U. !-t correct.l agree m comply with ell city and county ordinances and state laws relating to -
0 rU building wnswctlon,and hereby authorise representative,of this city to enter upon the
above-mentioned properly for inspection purposes.
�-t y (We)agree to gave.indemnify and kap harmless the City of Cupertino against
y Ilatelitia.judgmcros,costs andespeau which may in Any way meroe ag.l=Wd city
V 7 in consequence of the granting of this permit
'7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCERE ULATIONs.
7 Re-roofs
sl{ um of Appli a ontnc au
HAZARD MATERIALS DISCLOSURE Type of Roof -
WIIINca linin or Tutu. Ilding eecupanamre nr hancic harallou material
u dcrioe0 by Ne Cupertino Municipal Cock.Chapter 9.12,and the Health and Safety
de,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed. •
❑Yrs
Will the applicant of(mum Wilding occupant u.equipment or devices which If a roof is installed without fiist obtaining an inspection,I agree to remove
I haurdom stir conteminanu As deOncd by the Bay Arte Air Quality Management all new materials for inspection.
st ia1
❑Yes
I have real the beraMnusmaurials requirements under Chapter 6.95 of the Celifor.
ria Health&Safety Code,Sations25505.25533 and 25534.1 understand their Nc WiWing '
dans not currently haw a temm.Net It Is my responsibility an notify the occupant of Ne
mmthe nu soh mustbemet prior toissuanceofaccrvlica¢ofOccupany. Signature of Applicant - Date
J < 3 IS o
Owne auNrroma {e#11 All roof coverings to be Class"B" or better