010600931
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
22635 SALEM AV
01060093
OWNER'S NAME:
APPLICATION SUB DATE
VAN ZEE GARY AND CAROL
06/15/2001
1 PHONE:
SANITARY N0. CONTROL NO.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
F
BLDG ELECT PLUMB MECH
a LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
SectionvBB)nBert. n�jmeBusinessandemresion.Cwe.andmyuanse
INSTALL EXCELL CHIMNEY IN EXISTING
Jwith
is In full furtt a fPon'
CEJ S� I 1 9
Lic<ntt Class — Li<.x
Dae Contractor
ARCHITECT'S DECLARATION
I understand my plans .shall be used as public recows
O Licensed Pmkssimod
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
afollowing moor. (Section 7031.5, Business and Professions Code: Any city or county
$6000
which requires a permit m construct, alter, improve, demolish, or repair any structure
. prior to its i.s..nana,also reynnet meahhrcami(Ir.nehnrrmit to neasigoedataetncnt.
that heialiwnpdpm.uhhe todinw,ro`•iaons.film Commmors License l-aw(Clr..pmr9
mommcncing Section 7")of Division 3 the Business Profusions Cask)
t a-;
Iii0 3°.,f�ff„t"'."t %
Va]nation
with of and
or that he is escmpt thcmfrom and the basis for the alleged nemption. Any violation
(34 _
r
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not mom than rive hundred dollars ls500).
101APNPMftATIONOccupancy
Type
peation.
01. as owner of the progeny. or my employees with wages as their sole comns
—
514 - FINAL PUJMTj&LdNGft%J3)ns .
will dothework, and the .structure Is notintendedor offered for sale (Sec. 7Uta.
Business and Professions Code: The Contmctora License Law does not apply in an
owner of property who builds or impmves thereon, and who does such work himself
ro
or through his own employees. provided that such improvcmems arc not intended or
offered for visic. If howevc,he building or improvement issold will t one year of
'
completion, the b Td '11 have the burden of pricing that he did not hurW or
'nno,owe f tor p . )so I I.I.
01 f the p pshy I IYcontracting with licensed contractors m
on in t thep J t (S 7w.t B d Pmf . ons Code) Ths,improve,
L ce . L d t f t f p pent no halide or p ve, clacmr's
- _ ._ _ .... .._—. _... .. .._.. ..
1
such
and who contracts f h p jens.w th t ands) licensed pursuant m the
sed rsua t to the
-. .. ... ._.. .. _.._ .. .
O l tm(exeemmpptt/un�d&Sc. .B&PC far this
O
ovsh
/`/ WORKEk'S COMf'F,NSATI A I N
'Ihereby 0lfirm under penalty of perjuryormaf thefollowing declarations:
❑ I have' end will monarin a Csdirmule of Consent <o self- mure for Wmker's
Compermona. as provided for by Section 3700 of the Labor Crile. for the
Performance of the work for which this permit is issued.
❑ 1 ha:m and will maintain Worker's Compensation Insurance, as required bi Section
3700 of the Labor Code, for the performance of the work for which this permit is
,,sued M warkcisC ,c t Imurance currier and Policy ten r 'e'.'
Cent ,C Policy No % / "Z-
', CERTIFICATION O'EXEMPTION FROM WORKERS'' -
f `-
. ... .. _COMPENSATION INSURANCE .', ....
_. .._...._.._ _._.... ..—.-_.__ ___._..__._._...__. .�._:_...._..__. ..._. .. ... __ __. _. _.. _.. _.... _.. ..
(This scclion'need not be cinnplcted if the permit is for one hundred dollars
1 coolly that in the performance of the work for which ihh permit is issued. I
in became m the Worker,
shall not employ any penin any name, so as rd subject
Compensation Laws of California. Date
Apicant ..
__ .. _ ... __ _ ..... ...... .. ... .. .._
NOTICE TO APPLICANT. If. after making this oushould
ificte fExempr
, • • ,t , ..
become . subject w me Workers Compensation pr you mus
^er Code
forthwith comply with .such provisions or in is pconit shall be chemical revoked.
0 "'t' CONSTRUCTION LENDING AGENCY
I hereby affi.,h.t inert is a construction lending agency for the performance
"
of work for which this permit is issued (see. 3097, Civ. C.)
Lender's Name•. •. .' _ .. ...... ! ....... _
_ .. .- .. .
__ _- . .._. .. ___._.... -.
I sanity mat I have read this application and .state that th<above information is
'correct.
is 1 agree to comply with all city and county ordinances and sate laws relating
to building eonstruaion and hereby nnthoriae mpresenlmivcs of this city it, steer upon
a7 the above-ommioped finish, for inspection mrprses00 - _
y Iwjudgme msave, me against
Mn
%w InchwayaCupertino
judgments, costs andexpels w may in any way accrue against said
Cliabilities.yo ran cot
City in consequence of the granting of this permir.',' '
APPLICANT STANDS AND WILL COMPLY WITH ALL NON POINT
Issued by: Date
L
Re -roofs
Ig acmenr ppb nUCUnda<mr .. , D le:
AZARDOD MATERIALS. DISCLOSURE - ,
w1 . t cf n ,hulling occupant tar rh Il ha:,m nsm terial
Type of Roof
as defined by the Cupcn o M c p Cr haptcr9.12. and the Herdth and Safety
Code Searon2553'lal
' 0Y°' 1OFr C
All shall -be -inspected priorto any_roofing.material being Installed.._.. .
-w111m�appdcnnto.fulomnodn<caPnntuseequipmentordeviceawntan
._ -roofs
Ifaroof isinstalled without firstobtaining an'ilispectiori,p5gree'toremove
emir hnnNnm air contaminants as d by the day Area Air Quality htanagcmem
District]_
all new materials for inspection. Applicant understands and_w_ ill comply with
- • uvea - ono -
all non regulations.
-point source
'1 have read the haindoua mmerial.s requirements under Chapter 6.95 of. the
ety Code. Sections 25505, 25533 and 25531 understand that
California Health &Saf1
_
the Wi Wing does not currently have a tenant, that it is my maponability to notify the
_
ocof the rc wmoa be mer prior to latents of,a Certificate of
cupant uirtmenu hich
-T
0 h_Signature
of Ap li - t _. Date
All roof coverings to be Class "B" or better'
wnar or ambo ed ag t Date—
OFFICE