00020030GESA M ET AL
LICENSED CONTRACTOR'S DECLARATION
I haeby affirm, two 1 sm limmund under pmviaidm of Chapter 91..n,in,
with Scedm 7000) MDivision 3 of the Dominica and professions Code, and my license is
in Poll form and effect.
Limsa Cleo Lie. N
Date Conuaatm
ARCHITECTS DECLARATION
' 1 understand my plans .hail be used d public me«da
Iicaud professimW
OWNER-BUR.DER DECLARATION
I hereby al that I am exempt from the ContrartoYa License Law for the
follinv og rcdon. (Section 7031 S. Business and profusion, Code: Any city a county
which'".. a permit to common, .Iter, improve, demolish, a rspair my moscue
Our to its issuance, also rmuims the applicant for such peanut to rile a signed statement
that he is licensed pursuant to me previsions of the Cdnmumrs License Law (Chapter 9
(commencing with Saute 7000) of DiA6.3 mthe Bonn. and! Profeuiotu Cush) a
Nat he is exempt thacfrom and rk Edi, for tM alleged exemption. Any violation of
Section 70313 by any applicant fm a permit subjects the applicant to a civil penalty of
net mom then five hundred dollars ($510).
Loadw hit, and
propeny,mmYomntendd wlthwaBeauNev role compensation,
will dotb<wons and Out structure isnorimeded Lmi, os Wtapply1.rmic Sm. an Buas,of
sinus
and artyprowho
Code: The Conoaernis . road w law dura nm apply himself lf owner of
properly who build, mimptvvca l such i pn who m, a such work ded!orti though
his own employees, pmddd ri such imprevemmts am not intended a oHemd for
saounr.hvwer withebuildinguimprevenent Iv sold within one ildor completion,Ne
porta c sealdtt will hove the butdu of prevent mat he did nes Web m improve for pu-
pd edwe).
❑ L n owner of the See7property am d exclusively Prostin. with Ilumd conmuvom to
came Lo the project (Sed.. an weer of
and Professions build. or)rnhe C. thereon. nd
cense law dao not eppiy in u owner of pmpens whosepor ant to the Norton, and
who Law, for such projmm wire•contrutoNO iianad purcuammthe Conmcmle
License law.
1 em exempt under Sm. . B k P C for this reason
Owner Dole
WORKER'S COMPENSATION DECLARATION
1 hereby sRrm under penury m Wpm, one of the f0lmvin[ dalentiau:
1 hem end will meinwne Cmificam of Conxent m ulGinsurc for Workers
work fCompen-
rkfor
pmvldhi for by Section 3700 of Ne Labor Code, fm the perfotttunm of rhe
or which this permit is issued. -
❑ I have and will o .,for Workers Compensation 6for hi h his perm by gated.
My Wmthe. Co Code,formsuranc carrier
Ncwolt for which this permit is issued.
Ca Wolters Campcnsatiu Insurance cemier ana Policy numbs oro:
Comer. Policy
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION
INSURANCE
'(Thio action coed.. becompind ifthe permit is !drone hunNd dollop (5100)
or lens.)
I,my that in the my maunceofs1.Isc fmwhbje Nh perm it rlismed,l,hail
not employ any person in any mantas eco n m M1econe subject w Ne Wolters' Compen-
Apli laws of Glifomm
ia. Da
NOTICE
Applicant
NOTICE TO APPLICANT: IL afar reeking this Ceumux o of Exemption.bod you stained
become ccomply it Wortera Compensationprovisions of the Labor Cde,yon Nun
forthwith comply with such provisions or this pctmlr shell be danced rcvokctl.
CONSTRUCTION LENDING AGENCY
1 hereby oRrm that there is a constructions lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
1 unify that I have red this application and sine that the above information Is
correct. I agree to comply with ell city and musty ordinence, and sum laws rclwng te
building construction, surd hereby unshod cd repmaenatives of this city to enter upon the
above-ntemio d property for inspection purports.
(We).grce to save, indemnify and Imp humlesv the City of Cupertino against
liablliud, jdgments, coati and expuxea which my in any way acro against said City
in coneequexs of the granting of dus permit.
APPLICANT UNDERTrANDS AND WI I.I. COMPLY W ITII ALI, NON -POINT
SOURCE RF.GUI.ATIONS.
Sigtarm, of ApplicarwCutnctor Dom
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or name building occupant store or handle haaa dous material
in defied by the Cupertino Municipal Code. Chapter 9.12 end the Health and Safety
Cede, Section 15532419
Yes ❑ No
.will Ne applicant or i me building occupant use muiliotem or devices which
emit herardous air comaminmts as defmed by the Bay Arca Air Quality Managemem
trict9
E] Yes FIN. - ..
I bare tad the hasarddua material, mquimments under Chaps 695 of the Cali.
Portia Hmith as Safety Code, Sections 25305, 25533 and 25534. 1 utMerstand does if the
building dos not mroutly have is aunt, Net It is my scup, o..ihility to ramify the ucupant
of the requirements which must W met prior to issuance of a Cuibcete of Occupancy.
00020030
02/07/2000
400 HODGES AVE
SAN JOSE, CA 95128
CHIMNEY REPAIR
Sq. Ft. Floor Area
Job Description
IN
101 — FOUNDATION '
312 — CHIMNEY REBAR & STRAPS
514 — FINAL PUBLIC WORKS
Re -roofs
Type of Roof
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Owner or authorized ,gem Dam I Signature of Applicant
All roof
OFFICE
Date
to be Class `B" or better
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Blk: Lot:36204039.00
INVOICE DATE......: 02/07/2000
REFERENCE ID p ...: 00020030
SITE ADDRESS .....: 7970 WOODLARK NY
SUBDIVISION ......:
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: STENGEL DESA M ET AL
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4937
CONTRACTOR .......:
KELLEY, JAMES M LIC
W 11823
COMPANY ..........:
J K MASONRY
ADDRESS ..........:
400 HODGES AVE
CITY/STATE/ZIP
...: SAN JOSE, CA 95128
TELEPHONE ........:
(408)287-2398
FEE DESCRIPTION CHK TOTAL FEE PAID -TO -DATE
---------------
BALANCE DUE
BENERGY
------------
A
------------
23.10 0.00
-----------
23.10
BPERMFEE
P
77.00 0.00
77.00
---------
------------
100.10 0.00
-----------
100.10
VOICE ID
DESCRIPTION
VOICE ID
DESCRIPTION
. •
;0 ..........................
FOUNDATION
........ ............................
312 CHIMNEY REBAR 6 STRAPS
FINAL PUBLIC WORKS