031101180O
Z..
Er
fg1 Q
y
�z
UO
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTt�R,INFORMATION
;.
BUILDING ADDRESS:
43 STANFORD PT,
JONES MASONRY
PERMIT N'03110118
R'S NAME: -
PERMIT ISSUE DATE
PRICK LAU
1049 DELL AVE
11/20/2003
NE:
SANITARY N0, CONTROL N0,
4083777512
ARCHITECT(ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby a).f Nat I am licensed under pmvixiom of Chapter 9 (commencing
with Scene 7 fQ)of Divisionlof Neo and Professions Cole,mel my license Or
Tans orae Tram.
.yS—cj
REBUILD CHIMNEY
_Za'
cense Clo I Llc. N
laic comgclor
ARCHI'tECI'S D�gW T N
r
I dnd.rstsnd my pla ix,lual he loud b hlic rtchat
t
)'
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby .(Sean that 11. exempt from the essionsra License Law for the
encs
11
following arson. 703 Buinus and um CM.: Any city or counts
I�i�J
which (ansa t alter improve, e
requires a re roar improve, demolish.repair any sanctum$6000
s;
Sq. Ft. Floor Area
Valuation
its issuance, air h pen ii t file
prior m its iuuanm, ossa requires the applicant for such r.tmi0Lice s signed statement
the
he tad pursuant 70th) Comrshoes iLicense Law (Chapter
theof
(hei
of Diviansn
commencing the and Professions Code) or
exempt Section 7000) or Division de)or
that he is and f r the alleged t
Net M 4 exempt Ncmfmm antl Be buss for du tllcgctl eumpdon. Any vlola6on or
Section 7031.5 by any applicant for a permit subjects Ne applicant o a civil Penalty of
3 WUN63riberO0
Occupancy Type
P Y YP
not more Nan five hundred dollars (5500).
❑ 1,uownecefthepropeny, ormyemplayce, with wagexo theirmleeompuuadan,
Required Inspections
will do Be Wars,and the aWc1aR Itis lnfina ar offered forme see. 70ml. Business
and Profession Cade: The Cnnlnctora Lt... Law it. not apply to an owner of
property who builds or improves thereon, and who does such work himself orthmugh his
own employees, provided Not such improwmmts are not ntended oroRered forule. If.
however. the building or improvement is mid within one year of completion. the owner -
builder will have the burden of proving BOB he did out build or improve for purpose of
nlcJ.
❑ 1, as owner of Be property, am exclusively contracting with licensed contra lors to
cmLtwct the project (Sea 7044, Business and Profusions Code:) The Contractor's LL
.
ttue Law does not apply to an owner of property who builds or Improve, demon. and,
who contracts for such pmjecu wish a contrmen(U licensed pursuant to Be Conwctofs
License Law.
❑ I am exempt under Sec. . B k P C for this moon
r Date
WORKERS COMPENSATION DECLARATION
1 1 hereby starts under penalty of perjury one of the fallowing declinations:
I haw and will maintain ACcnlOcatc ofCoonnl to self -insure for Worker's Compen-
ntian, as provided for by Section 7700 of the Isbor Code, for the Performance or the
work for which Nis permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, u requimd by Section
7700 of Ne Labor Cad., for the performance or Ne work f which Nis permit is issued.
My Workers CColmp//o����ssee��U�a Insursnec carrier ar ' (icy nu r are
Ca mr. 544_1 10 � Poli N .: b s r
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE CZ
.
Mil.metion recd not becompined Bills, Permit u for ane hundred dollars (tsps)
or less.)
I certify that in the performance of the work for which his permit is issued, I shall not
employ any parent in any manner an u b become subject to the Workers Comremauon
Laws of California. Dau
Applicant
NOTICE TO APPLICANT: If, after making this Cenificam of Exemption, you should
ICeotse Subject on the Worker's Compensation provisions or the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is construction lending agency lot the performance of
the work for which this permit Is issued (Sec. 7097, Civ. C.)
Unice. Nam.
lenders Address
I certify that 1 haw read this application and slow On, du show inrom,nion is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby aothorin mpresenutives of this city to enter drum Ne
ahave-mentioned prop.rly for Inspection purposes.
(We) agree to an, Indemnify and keep humless the City of Cuperlleo against
Liabilities , judgment, costs and expenses which may in any way accrue against mid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N POINT
Issued by: Date
SOURCEJ
Re -roofs
Type of Roof
S net c of Applin lbs Commcmr Datc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant tore or handle havmdaus material
an tl.Bned by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safely
. Section 25532(.)?
C Yea
All roofs shall be inspected prior to any roofing material being installed.
I Will the applicant or future building Occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
m h.urdems air cm uminanu u (nand by the Bay Area Air Quality Management
all new materials for inspection.
dict?
QYcs N,
reumW c2n5u534.1
ria FulINhe&wSrefevtysC 4hu.u5aNtiwasm2o5a3n15..la2m55q7u7i
unCdhnaputerhN.95ir he, building
Jars n�WA.4Net It is my rtsponsiniliry w nn y du necupant of Nc
lrcdorm CcdlScaw Oecu m.y
Signature of Applicant Date
�issuancour.
All roof coverings to be Class "B" or better
cr-
Dam