02040111 (2) CITY OF CUPERTINO '• - •••• ••
BUILDING DIVISION PERMIT •CON TRACTOWI-WORMATION --
BUILDING ADDRESS: PERMfr NO.
DR BOB GERE MASONRY 02040111
ONTTiR'S NAME: APPLICATION SUB DATE
LARSON 480 CROSSLEES DR 04/19/2002 '
NONE:
(408) 972-1285 SAI:ITARY NO. CONTROL NO.
00 ARCHITECUENGINEER: BUILDING PERMR INFO
i BLDG ELECT PLUMB MECH
to« 1 1 C_I L. J LJ
C v i LICENSED CONTRACTOR'S DECLARATION Job D
I hereby affirm Clu
m that l am licensed under provisions of pser 9(commencmS eSCnIIOn
p
xithSecdm7") fDmumn3pflhe9 ine(:and Professions code.and myluenR REPAIR CHIMNEY FROM ROOF
x f_ is in full forte Ijtcs'1
u w Li<enu Cle f• Oo Lic.,
LL°F Dal[�7 A� S DEC L: G� ARChall k use DEC ,y/ n
i g 1 understand my plans shall be used u public rtcoNs///
E'p o Llansed Pmfesslonal
oma OWNER'BUILDER DECLARATION
-sn 1 hereby ilRrm that I am exempt from the Contractor's U..Low far the
C?< following notion.tSeetion 70313.Business and Prefessiws Code:Any city or county
s�c which napilm a permit to construct.eller,imprma demolish.or repair any structure $1750
63$ -prim to iu issuame.also requite meYppliwmfv such pvmiuo Neasignedsummcnb -- - -- - - - ___ ,
(commHwing r,'ithSmian]000)of Division3of the Business aW Pro@uiou Code) {_.( •,i i'{23 b7Z12 VVg,••`D'U1�;_.t l..'s'?Ice iy Valuation
or thai he is cvcmpi td'viefiom end the buss for the ellegeile;emytion.Any violation '
"ot Seedon'R)7115 Dy any epplicnm for v permit subjem the vpplicmt tv a civil penilry- p
ofriot iborethan evehundredd.11ah55M). 101-PN Nil VUNDATION �'' "''i.f�:o Occupancy Type
❑1,mowner of Ne properly,amy employ^s with wtges u theirsole cmi,enudim,
"-Bin-do the d�ork.and the struclure'is not tendeid-orofl icd foi'ulc(Sfc:](W;" rRx,m
Busit.-lid Professi.ns code:The COmnm'c License Law does not apply tom 514 - FINAL
owner of Property Who builds a impmvv rc
dRon,and who does sued work himself
m Ihrouyyh hisopq emplo)gss.pmvi ied.dut such impmscom-1 att not intended or-
nf(ered f cele.If.Mweve The buildin o Im - '.----- ... -
rompl t •the owner-h Idcr will MnO do burdem f pronving,Nu he did nd build or '^- ^'Y •f) _- —_ _ --- -
improve for purpose Of ole.).
_ ..-• ❑I:as.xmerof themjac Progeny.am Business,
i.ciconvactin .-..___..._-_
Y Bwilnlittmmprom cmrsm Fa NALE® ' >QPSk?Ei U:FJ
_
construct the pmjm(Sv.]040,Business aW Profcssi.nx Cade:)The Cmtnva i
License Lowdocs not apply m en win O(propmy who bullas or improve thereon, =U'.�
and.wM-conuacu.for-such.pmjecu.wiN.a covuaaa(s).BttnrN.puowdd nd d, -___—__.-__. - .
j ConomofslcneLa t ._t ,). ._.__.___ ._. ___ __. n_ ... _ __..__..
❑tun exempt oder Sro ",a$P C fa,Nis rtuon _I-kPR 2 9.'2flfl2. I '
- Owoer - Dale
=. " "' "I WORK ER'S COMPENSATION DECLARATION
ebnde pentlBUILDING
ry of�jury"'ooe af.the.fallOwing'declaudms:...-
❑ 1 Mve vndt.ill�mslnum inCmiOcele'of Coveln iO'ul(-iuuR fa Warkvi
Compensation-as:prosided-fnr'by-Section II o-of she Labor-Cade-fa'Ibe
performance of Ne work fa wbch th gamut u usoed I `.
r M c eW 11 u n Wohc s Coma utw ImurtOce,as requ red Dy Sict on
] of th Who Cody, (w N perfomw ce 6f N work fm h h N s gamut ss
lu ed M Work Ys Co pe uuO Insumae came nd P liq nu be are,
`< 1 TIFl ATION FEKEMPIION FROM.WORKF�.tS ,k.z,k, F 14.. l).. .tet ,. 1,:1 A
'.-1•: rn .. COMPENSATION INSURANCE.' ` . .. .•
:h4:o�suct on ve<d na he cbmpleieddlhe pcmutu fa one huWrtd dollars ' •'•t `:I (.;':,1.�L:d'.r '' ✓J2
ISI00) Ivs) '
5 3'\ l amfY Nat nth peHomunbe,of ine oh'f M1 h Nls -
ssa
shell not plot my perste l a I s eaa
Worke% I:..;.-:1 1 > l 1,j'•C ,,. :, ^ •,:l' .
y net se w beco s b)al t the
Ooinpemeum Wwi of Cabfomla Dam" "
INOTICEclow., APPLIC P Y should _ __ .._ .._._.
O h forth ith c I @ iu h ro ons o th s s ons.f the Libor Code u must
PP
ANi If a(R a4n thsCemfcat ofE em ton
become ubl oto i Workefs Co Pro
P Y p permit sh 11 be deem d revolad
"CONSTRUCf10N LENDING AGENCY
tut �
I IICRDy a(rrm 11101 dKR is a fOrlSlry('llOn 1 polo t`
�i � P a$[nCj'la IIIC pe(f01mmCC
afdR work(o hch tns de iuss ed lSec 709)'C C.) -},
W;G -WWelt Name -.•w _ -___�_ _ u
.--y Z Wdevf Addre s r a., ... .. .. _.._.. ...__ __
�S I cm fy the 1 My read dos tppl cat m d wt-Ihu the above 0 mfamdo.
upon is
tat F cMm.l elite w comply dt ill c ry arta aumY oN vm¢s uW a te'1 wa lating
11,C.) m bu Id nP comes um,end hereby a thbriia rcpresc wuvek o(dus aty to enon
�. t-7 the abovem Ito dp,Vperty to mspegdmprposcs
'a. W IWc)ag a-to elndem fy me kttpMMlcss Ne Ciiy of Cuperi no against
h bob lit a 1 Wg nu ensu a d upe s s, hch may pny way acw age t s
U Z APPLICA R '•2 ',UIb gm t nY of Ihls permu _I
�. / 2,
soLm , gDl�cwf Att ° Issued by: r / Q
Sigma Of Applicav[� ,n Ip .. Date
). p -. HAZARD tATER1ALS DISCLOSURE t i7 ' Re-roofs
'F WB tMappficant orfulma baddwj oocapmtstole ar haWle harallous nluenal Type-Of Roof ..
u deft ed 6Y b.C penin.Mumvpil CWe.CMpur 9 13 d the Heilth and SU ry - - ---
Cade:SOct 2532(a)_r1[, s N I�sy - LNa-IYtas. f 'i•r.• rl. dl.:..rf.0 si{T, r r} _.
r OYc 1 l• - .-11
_.A1Lroofs Shall be ms ected nor to.an roofin
-v .i WIINe applicant ntre occllatR " p P Y gmatenal betng Installed ,•._•,
ns auco um s e0 building by Nn B y Are9q Q",t>°;Y m `cem�", If a roof is iliSialled without fust obtaining an ]]ispechon I agiee'fo're""move
Districts- all new_rc)aterials for,inspection Applicant understands and will complywith
.Oyes N .. .'
' * "; I all non-point source regulations, h1-1.-
f I hod Rad S , Mous materials req immense uadt lr apler 6.95 of the
Cal fomu Heed cry CWS S"dons 35503.-23533 md25534,-I'mdentmd that
.J'IM-.bwld rig duesnm evremly have nenmt duutum ses -_.___—. .._._._ ._.._.__
Y Pmuibdlrym noify lM __...__._._.. _ ----- ---
X. . . . ..
Npallt of he ttqul2menlS which""aS1,De,me[p Or.W i53y oaf• If RR Of !R-N.
CY
: .._
nor or tho r...,g�ntr , :4i1, .,. Signatore of Applicant,.
_Date
�r
roof coverings
.o.v..e_ri.n_.g_s_to
- --- Dae - - -
be Class"B"or'ibettei
. . OFFICE._.._ _....__._... ._.