01100135 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22624 A VOSS AV MIRACON CONST 01100135
OWNER'S NAME: APPLICATION SYR DATE
HARRIS DAVID H AND RATEKIN KIM 5171 RAFTON DR 10/25/2001
PHONE: 4082642059 SANITARY NO. CONTROL NO,
'+�O O ARCHITECTBNOINEER: BUILDING PERMIT INFO
w— BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
'S h 1 heo f inn that 1 am licensed under fCou t 9(cmmmcn<in Job Description
"`ndProf`° "de a REBUILD CHIMNEY FROM SHOULDER.
with Sec mon 7(1(ad of Division]of the Business and Professions Cadc,and my license
is in full force end effect, 3 ')-16
5 2 W 6 Liaenx Claes l4 Cop r Z J 'Z r li
2O D Oma_fG-1tn/ SDECmr�
a 3 u t, ARCHITECFS DECLARA 1
=u.O S 1 arid ersland my plum shall be used as pontic records
' r
Licensed Profcssionol
ns
OWNER mEtr DECLARATION i= 1 herby.(Sera that 1 nmm exempt from the Contractor's License Law for the
F Z 0 following remora(Season]munnu Business andwe,demolish,
os h,or Any city or county $1235
F o wh ch req se. perms t c .tract alcor. nfor such
demolish .,an y structure
e P611:01
no a t . mdprisnreq theoptician for mcM1permiu 11 signed(Chapter
(commencing
acing. Sect 17th pr eons nfthe 3oftheusineL Le ons Ca r9 x, ,• ads• 9r�{aapS, 9a ,nrt t•YY_4 Valuation
fc thatbes a •tth SaronazB imi Division bais3of the Business ripR professions Cadc) ��lp lv:�U 44_t%r_g L•.t�
or that he a exempt tang appli and the basis for the alleged a pliant in Any l P natty 1
.of Section e than v any applicant for a permit subjects me applicant m e civil penalty
or not mom than five nnmamd muam(sero). 101°xPN 11L�ATION ' I," Occupancy Type
pe
01;as owner of the prory.or my employees with wages as their sole compensation, 312 CHIMNEY REBAR & STRAPS
will do the work.and the atmct°re'is not intended or offered for sale(See 7814,' aIrFd IWEris
514 - FINAL PT '= ..
'Business and Professions Code:The Contractor x License Law does not apply to an
owner of popery Who Wilds or improves Iverson,and who does such work himself
or through his own employees,provided that such improvements are not intended or
'.offered for sale IL however,the buildingor ire rovement is sold within one f
P )'vera
convolve far the purpose
owner-Wilder will have the burden of proving thin he did not build or
improve far mrpou of sele.). .
°1:as owner of Ihepropt am exclusivelyanan onefir,with licensed contractors to
construct the project(Sec.7044,Business and Professions Cade:)The Contacmr's
License Law does not apply to an owner of property,who builds or improves themon,
and who cmmraas for such projects with a.contractons) licensed putsunat to the
Contractor's License law.
°l am exempt under See s, _' .B&P C for this mason
Owner " ''Date•'.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjory one of the following dmlamtions:
❑ 1 have and will maintain a Ce rificam of Consent to self-insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Coda, for the
performance m the work for which this permit is oxiad.
°1 have and will maintain Worker's rotation Insurance,as required by Section
_ 370PdYthe Labor Code,far the Ronnance of the work for which this permit is
. r
issued:My Workeh CompensatioIII
.Mnce artier and Policy number me
(7ani iei. l i ; ;I k t.P,icy No ('' T 4' ( )1' }1 P. d _ P 'vx ° .
'I (CERTIFICATION OF;EXEMPTION FROM WQRICBRS'1 • ��w n. 1.. {. a.I. ♦.v�•'7l'N+ YL_pc ." N. 1
COMPENSATION INSURANCE,. ...,
'(Thissee.tion need not be compIsles!if the permit is for one hundred dollars "' •'1' T �' IC,
L'1r.�Il
15100)or less.)
sM1all'nbt employ anyfpermn in anynman ,.• .. .. .• .. . ._. ._, „., ..,- ..
fceNfytha6nt per of the;work for which this permit is issued;) a^j 1 V•°Li:"11•,
n<T so ^o becomeyubjr to the Worked
Compcnsmlon laws of Celifamia.Date_f C J S •e—/
Appiieani _ _ _ _.
NOT fCE TO GANTC If after making this Cea fieait of Exemption,you should -
O Qbecome subject o the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall W deemed invoked.
^•'•M '•t"'' '"CONSTRUCTIONLENDING AGENCY,'
I hereby affirm Nat Nem is a construction leading agency for Ne performance
of the workfor which this pe t is issued(Sec.3097,Civ.C:) -
Laane
ender's N
.a7. z tenders Address, .. '.
1 and y that I have mad this applicinimi had same bar'he above mornation is
s fst'E. correct.I agree to comply with all city and county ordinances and state laws relating
01U to building construction,and hereby authorize representatives of this city to enter upon
>_W the above-mentioned properly,for inspection purposes. _
. E.•(y (We)agmctdsines,indemnify and keep harmless the City of Cupertino ugaium
(n liabilities,judgments,costs and expenses which may in any way secure against said
U�,Z City in consequence of the gaming of this'Permit
.
.^ APPLICANT UNDERSTANDS'AND WILL COMPLYWITH'ALI)NON-PONT Issued by: Dale
tCEREOUG TIONS., ' .i G-1 Y'
St'hemor,afw,cuffirCumnictor, - . . . .' .,Date Re-roofs
- ' HAT1sRDOUS MATERIALS DISCLOSURE -
Will ife applicantorfuture Wilding p t store orh dl mord smaterial Type of Roof -'-"
as defined by the Caper n M- Wool Cod Ch1 1, apter 9 12,and the Health end 5 fray '
Code Suwon"It, . . I ,,J. `,.f 1•..
°Yes ''" SD All roofs shall be,inspected prior to any roofing material.being installed. .... . _
Will the appnc.a or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection; liagree'to remove
emit haanfdous Dir<nmotion ens,as defined by the Bay Area Air Quality Managm
eent
District? - all new materials for inspection, Applicant_understands and will comply with
El Yes b ° all non-point source regulations. ;
"I hive mad tad haiudouemamdals hap oontems under Chapter'it of the
Califdrnli Health&Safety Code,Sections 25505,25533 and 25534:1 undemmndthin
„f the building does not currently have a tenant.that it is my mponsibility m notify the
dac
eupant of the cequiacmems which must Worst prior to issuance of a Cerificam of
"'"`y Signature of Applicant Date
{•' - /�17 � All roof coverings to be Class"B"or better "
._ F I)Nsr or almri"ed agent d
� 1 .. .. OFFICE -