02080102 CI
BUILDING
BUILDING
ON PERMIT CONTRACTOR INFORMATION:
4,
BJtI1wDj[JCA W66DLARK WY LEON MASONRY INC PERMIT020g80102
IfR'�DA 240 MOSELLE CT APPLICArI()!`IIIf�ylAP2002
PHONE' (408) 365-1660 SANITARY
NO. LU CONTROL NO.
eco zO ARCHITECT/ENGINEER: a BUILDING PERMIT INFO
m BLDG ELECT PLUMB MECH
i I= LJ ILJ I- -I
y= LICENSED CONTRACTOR'S DECLARATION g�
o '—rte IM1ercby aKrm that license)under provisions of Cnapmr9(com� ��S'616LR '�tR CHIMNEY Job Description
r:t m wiN Semion]DOlp of Division l of NC Business unJ Profc......Code,and my !Y1
a � is in fan farce and erceu, a 62339`7
E z.a Licens�e C�lJasds��.ZS`_Lz�a1 Lic,n
3 a DataCmU
/ CT'S DECLARATION ' G 2 1 2002
St_ g I understand my plans shall be used as public records
Licensed Pn resnmal
e� OWNER-BUILDER DECLARATION 1 /�
u ^_ I hereby aRms that I am exempt tram the Conractor's License Law for I LDI1 p�V G
Z< following remain.(section 7031.5.Business and Professions code:Any city M camy $1700
SFC which requires a permit to construe,altar,improve,demolish,or apart any swnure
ca prix t t. I. requiresth applicant for such Pennlu fl signed tatement ...._ . . ..._..__... .._....._
Neth "dpursuant odreptucaMsmif the Connothre,License La ICn,cr9 136BIOBtOBODr@.Qea�: a tt` r , Valuations
(commencing with Sateni]000)of Division 3 of the Buwne dPofossons Code) Cif),'s ). d\;ls, !v2%, It\a +JCewY 1,.�.`
or Nm he is exempt therefrom and the basis for Ne alliged esemytion.Any violation
of Section]0315 by any applicant for a permit subjects Ne applicant to a civil Penalty
of not more Nao five hundred dollars a5NO, 101ARN 190MMATION Occupancy Type
D1,as owner of the property,nr my employees with wages as Nen sole compensation, 312 - CHIMNEY REBAR & , STRAPS
..will do the work:'and the amemre isnot intended or offered for anile(sec.]oto, 514 - FINAL PU
t Business and Professions Code The Contractor's License law does not apply to an lflFed'IRY.S ❑S
owner of profit Who builds or improves three,and who docs such work himself
of through his own cmployccs.provided Na such cmcns are wt intended or
-offend for sale.If.however.Ne building - is sold whnin one..�of
art en ofpry
oprove for
M owner-Ivildcr will have the burden of proving that he did not buil)or I a
completion,
mprove for purlwsc of mlcl.
r^ ❑1:as uwncronne n �-"�-�� "--�
pope y,am Business a contracting with licensed Contractor
I. j
- - License
et theLaw
does
n (Sec.]Ors,Business and Professions Code:)The Contn i or, -
License Law docs not apply m en owner of property who builds se improves thereon,
j. ..and who mmranse L such.projccu wiN.a mmrenor(sl licensed pursuant to N<. .. . ._ .....__..._._. ..._.._....... .. ..............____..__...... ..._... _-_......_._...__ ___. ....".. ._.-.
Contractor 1 , xe License Law. -
- ❑lam exempt under gc � � � ,B&PCfor hiareaann �"•s I.':�r�i :"•t"
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
.'I D 1 have and will meiniain'a Cmifcam of Consent to self-insure for Worker's
Compensation, as provided for by Section 3]00 of the Labor Code, for Ne
performance of the work for wh.It this permit is issued.
D 1 have and will maintain Worker's Compensation Iroumnce,as required by Section
,p....
3]ql of the Labor Code,for the performance of the work for which this permit is
issued.My WorkeIrs C p t Insurance carrier and Policy number are:
Cart er��Aier �f IPOI'cy No o y6_ �Z t.;� ` 1 `
.'..CERTIFICATION OFF%EMPTION FROM WORKERS�' `x - a a
COMPENSATION INSURANCES I00) ,,. - ..__ _. ... __.. 7 ..4"_ _ _..... .. . .... ....... ...
or le senion n eJ nm be cbmplmeJ if Ne perm t is for one hundrtd dollmrt s ' ' .l
1 certify That in the p in any manner
the work for which Nis permit a issued,1 (:• _'l i; r
shall min employ any person in any manner su as to become subject to'Ne Workers
Com . n Lows of Califomia.[)air
NOTICE TO APPLICANT:IL atom making this Certificate the
Eailtsm o d.Y Ushould
b ahwith comply
o the such provisions
Compensation provisions of Nc labor Code,you mon
Q O forthwith comply with such previsions or this permit shall to domed invoked.
rvtA -- .. CONSTRUCTION LENDING AGENCY 'I
�.^' I hereby affirm that mere i4aconmm�ion lending agency for the performance
� ofthe work for which Nis permit is i...ad(Site 3TN],Civ.C.)
Q Lender's Name
od --' .+.___:.t . .. . ...._. . . .. _ .. ... .. .... ..... ..- _
Leer
I Add:esa ' I „ Q
U O . cagier that 1 hale read Nis city anddon my orate that the abuse%rat inaws relating
is
tT+
E. cortidt I agree m comply with all<ity and county ordinances and aurae laws rdaing
Q-U to building construction,and hereby authorize representatives of this city to enter upon
},W the above-nrntioned property for inspection purposes.
F.. 6 I We)agree to save,indemnify and keep hamless the City of Cupertino against O
-V1 liabilities,judgments.costs and expenses which may in any way acern against said (•-J'/`J
V.Z City in consequence of the granting of this permit. Axl ]
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b Date
SOURCE REGULATIONS. Y< 71,
Signature of Applicam/Conmcmr Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
is"I'l'me apoiMart or future building Occupant than or,handle haossionsmateaal .Type of Roof. - _ - •- - _ --. - ,-.
as defined by the Cupertino Municilsd Code.Chapter 9.12,and the Health andSfety
Code,Setin2553-(') ,.:t fCy t'. il rl" t 'q h.li e.ta. : fP
D' a, No All roofs shall be inspected prior_to,any roofing.material being installed.
WIILNe applicantor fart huilJing occupant use cgmpmcm or devices wnrn If a roof is insiafed without first obtaining an inspection, I'agree to remove
emit hazardous air comamimms as defined by the Buy Arca Air Quality Management
91strico 1all new materials for inspection. Applicant understands.and will comply with
CYea, 5- " ' ' all non-point source regulations.
1 have read the hazardous materials requirements under Chapter 6.95 of the'
California Health&Safety Cad,Sections 25505,25533 and 25534.1 understand thin
ifNe building does n
uot curtcndy have atanant.Nm it is my rcspmnsibilirymnmify the'
am
of the oquir cs whi0ch amt he met prior to issuance of a Cenificate of
oc c
.. -i icy:
2Signature of Applicant .- _.. _ Date
caper or aatnodzed agent Date All roof coverings to be Class"B" or better .
_ . .
.. ...., .. ._ ... .. _. . ". .. OFFICE