03010204 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION �;
BUILDING ADDRESS: LEON MASONRY JINC PERMIT NO.
804 COTTONWOOD DR 0'1010204
OWNER'S NAME: 240 MOSELLE CT APPLICATION SUB DATE
fik BARMAN MARC A AND JOYCE A 01/31/2003
IFONE: (408) 365-1660 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
00 LICENSEDmthatICONTRACTOR'Snsedunderp DECLARATION
I Wrehy alf tm That 1 am licensed under previsions of Chapter 9(commencing Job Desert tion
U
with Seed, tea)of Divisi.r3of Ne Business Professions Code.and my license it
in toll mreonn r�euLG 23 CHIMNEY REPAIR ANALE93
�8�jg
Liccnu CI 7 Lia N
:,n Dam Contmcto o N
qq ARCIIITECI'SD RATION FEB 1 8 2003
2 1 understsnd my pore ll W ans shaused as public records
OyU
ia. Licensed l'mRssional
OWNER-BUILDER DECLARATION BUILDING
3 <I 1 hereby affirm that I am exempt from the Contractor's License Law for the
J 00 following rcuon.(Section 7071.5,Business and Professions Code:Any city or county
Q C� which requires a permit to comm st,alter,improve,dro nlish,or repair any structure
us prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant o the provisions of dtc Contractor's License Law(Chapter 9 Sq.Ft. Floor Area $1'Vt4otion
F$ (commencing with ScenonvlXk)of Division J ofthe Business.nd Nnlcssions Code)or
does he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7071.5 by any applicant for a permit subjects the applicant o a civil penalty of
not more than Eve hundred doll...(5500). C Occupancy Type
❑I.as owner of the property,or my employees with wages as their sale compensation,
will do the work,and dimiumudme is not intended or offered for to(Sec.70U,Business
and Professions Code:The CommostnYs License Law does not apply to an owner of 312 - CH I MNE e Ids V'b TRAP S
property who builds or improves thereon,and who dwssuch work himself or through his
ownemphwass,prodded mauwh improvements srnmel inmodedaroRered Battle.If, 514 — FINAL PUBLIC WORKS
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1.as mune,of the Property,am cxvIdAwly convecting with licensed contruto..to
construct the project(Sec.7044 Business and Profeuions Code:)The Contractors Li.
cense Law does not apply to an owner of property who Wilds or improves thereon,and
who contacts for such projects with a comeumr(s)licensed pursuant to the Contractors
License Law. a
0 I am exempt under Sec. ,B&PC for this recon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decivuions:
I have and will maintain aCenificate of Conant to self-insure for Worker's Compen-
sation,as prodded for by Section 7700 of the labor Code,for the performance of the
work for which this permit is issued.
Fl have and will maintain Wurkeri Compensation Insurance,u acquired by Section
37(x1 of rhe Iabnr Crede,for the performance oafrth�e w9irk fur cortico this permit is issued.
M Workec_ri/FCo nwtio�1n-+l�nsuancc.�l1carticr ✓ c numhl!c��r arc:
C�ier.�fA f YU j/d Policy NnY D-rd._0'j,_
CERTIFICATE OF EXEMPTIONTROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed Robe permit is furore hundred dollars OHIO)
or less.)
1 wnify Nat in the performance of the work for which this permit is issued,I shall not
employ any person in any mannerso ser to Wmare subject o the Workers'Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Ccnilicate of Exemption,you should
become subject to the Worker's Compensation provisions of the IaWr Calc,you must
OO forthwith comply with such provisions or this permit shall be deemed revoked.
z(ti CONSTRUCTION LENDING AGENCY
ti I hereby a0rm
that there is a construction lending agency lot he performance mf
a .>.t the work for which this permit is issued(Sec.3097.Civ,C.)
BA 0 Lender's Name
C 0 Lenders Address
U Q 1 certify Our I have read this application and sett that the about information is
D. P correct.I agree to comply with all city and county ordinances and star laws relating to
O U building construction,and hereby authorim repmunutives of this city to enter upon the
above mentioned property for inspection purposes.
L>, (Wc)agree to save,indemnify and keep harmless the City of Cupertino against s5
U] liabilities,judgments,costs and expenses which may in any way accmc against said City l�
U z in APP,CANTeof the UNDERSTt NDS Ang of ts WILL COMPLY WITH ALL NON-POINT Issued by: Date IO/fJ/
GULATIO
G Re-roofs
gnaurc of AlplicaHAZARDOUS MATERIALS DISCLOSURE Dose Type of Roof
Will the applicant m future building occupant store orbendle h rmadous material
neCol
u defined by Ne Calandra Municipal Code.Chapter 9.12,and Or Hcallh end Safety
coda.oty s 25572(a)7 � All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or luturc building occupant tau equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it hvallous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
Noel?
p Yes ywo
1 have read Ne harp dons materials requirements under Chalmr/.95 ul'the Califon
ria Health&$NCly Ctxk,Sadurts 255115,25573 uW25511.1 un hand thvifthe Wihling
not currently have a mnear, tit is my responsihilily to no y the wcuPant nl the
set tswhichmuet met orinI..udafCllI CCNflfine ancy. Signa lure of Applicant Date
Owner authormed ogein \ Date All roof coverings to be Class "B" or better