02090187 CITY OF CUPERTINO - 0, .jai.,
BUILDING DIVISION PERMIT CONTRACTOR INFORMATIION-
BURP''")'3RElWALLACE DR LEON MASONRY INC PERharb9'2090187
O"ffKA'eGS BURL 240 MOSELLE CT APPLICA'"r5`D.Tf2002
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11 ZONE: (408) 365-1660 SANITARY NO.// / CONTROL NO.
ARCH]11:CTIENGINFER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
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28 LICENSED CONIRACI OR'S UECLARAI'[ON
F I hereby affirm that I..licensed under provisions of Chapter 9(n,mmcming L2XJob Description
� w with S«don ngl(n of Division 3 of melt and
^Prrfuxston,Cede/and lny license i, REPAIR CHIM
mica InacaxsnJ cffp'i.�(e / .csb/.13OC( ALE
OZ— )ale SCO -`` 171e+ `tC'ontractor
�=�'° ARCIIITIiCrS IJr:CLARATION OCT 0 3 2002
�a I unJcrstand my plans xM1all MlTrio!,puhbc vend.v
K Hi
w3u.� Licenced Profcs.,uno
I'=�S OWNER-BUILDER DECLARA'1'IQN BUILpp'yy���/a��
1 hereby affirm that 1 am exempt from the Conuanors License Law fol the ✓NYG $2000
w F CC fulowing reason.(Section 7031.5.Easiness and Professions Cadc:Any city ar county
e K S E� which requires a permit to construct,alter.improve,demolish,or repair any stream
te'y prior in its issuance.also requires the applicant far such Permit o file asigned statement
�z< that he is licensed pursuant o the provisions of the Contractors License Law(Chupte,9 31(11213CWA" Valuation
�Fth (commencing with Section 70aBnf Division 3 of the Basineseand Prolcssians Ctdc)nr
i 9 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to acivil penalty of PN N Occupancy Type
not more than five hundred dollars 0500). 312 - CHIMNEY REBA & STRAPS
❑1,as owner of dac property,lir my empinycu with wages ss their ode compensation,
will do the work,and the structure is not intended or offered for Sale(See7(3x,Business —
and Professions Code:The Contractors License Law tors not apply to an owner of FINAh egUlre Inspections
propcny who builds or improves mcmon,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 building or improvement is sold within one year of completion,the owner,
had lder will have the burden of proving that he did not build or improve for purpose of
sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(.Sec.71dQ Business and Profcianna CM,:)The Contractor's Li-
mare Law does not apply to an owner of property who builds or improves domon,and.
who contracts for such projects with a cortanorts)licensed pursuant to the Counselors
License Law.
I am exempt under Sec. .B&PC for reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of She following declarations:
^I 1 have and will maintain a Certificate of Consent to cel6iraum for Workers Compcm
suchen,as provided for by Section 37W of the labor Cade,for the performance of Jr
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,W acquired by Section
371X)of the labor Code,for me performance of the work for which this permit is isrued.
My Worker's Com``pcnsaaion Insurance carrier and Policy number arc:
C icn SI,AiC FaAN<( Polity N (I
CEPor-[CAT
EOFEXEMMON"QYWORKERS'
COMPENSATION INSURANCE
Cars section need not bea,mpleted if the permit is for one hundred dollars(S Ilay
Icas)
1 certify that in the perfnrmam'c of the wort for which this permit is round.I shall not
employ any person in any manner so as m become su ncet to the Workers'Compemation
Laws Of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the workers Compensation provisions of the labor Coke.you must
0 ,$ forthwith comply with such provision or this permit shall M deemed revoked.
z O CONSTRUCTION LENDING AGENCY
[--i Ihe,ehy union that mere is a conswction lending agency lou the performance of
�. 7 the work for which this permit is issued(Sec.30007,Civ.C.)
ul Lender's Name
G Leadcrs Address
U O 1 ecrify that 1 have read this application and sone that the above information is
F correct,I agree tovomply with all city and county ordinances and stale laws relating to
O U building consuunion,and hereby annorim representatives of this city to enter urym the
uM1ovomentioncd property for inspection purposes.
Fa (We)agree to save,indemnify and keep harmless the City of Cupertino against
N habil'nics,judgments,costs and expenses which may in any way accrvc against said City
U 2 in consequence of the graining of this permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WIT�L NON POINT Issued by: Dale
SIpiBCE REC "ONS.
6V\ Re-roofs
:ignalurc of App mnnUContraaor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building occupant sure or handle hamNous material
as defined by the Cupenino Municipal Cole,Chapter 9.12,and the health and Safety
Cadc.Section 255321ay? All roofs shall be inspected prior to any roofing material being installed.
❑Yrs
4
Will mea applicant or future,building t use a ui em or device,which If a roof is installed without first obtaining an inspection,I agree to remove
pp g«tapan q pm
emit hatardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Uisuia7
Q Yca g�W
1 have mad the hmuNous materials requirements under Chapter 6,95 of the Califor-
nia health&Safety Code,Sc:dnns 25505.25533 and 25534.1 ordemend that it the building
drcs ren c'unently ha a tenant,Nat it is my meponihility Or notify IM Oceupam of IN
meats whim list ,e.prior to ielaancrora Ccnificare'If Oce.1 ay' Signature of Applicant Date
m i,e of c— D•o
ownermaumI, irdagro, Date All roof coverings to be Class "B"or better