01070020 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
21578 FLINTSHIRE ST J K MASONRY 01070020
OWNER'S NAME, APPL17TION S B DATE
CENTOFANTI DOMENIC AND EDITH M 400 HODGES AVE 07/ 09 2001
PHONE: SANITARY NO. CONTROL NO.
( (408) 287-2398
m0 ZO ARCHITECfIENGINEER: BUILDING PERMIT INFO
y— BLDG ELECT PLUMB MECH
a 6 L I LJ
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LICENSED CONTRACTOR'S DECLARATION
ZO Z y I hereby affirm that 1 am licensed under provisions of Ciminero(commencing Job Description
p_�u with Section 7000)of Division 3ofthe Bminessaml Ford.. ria Code, dmyuceme CHIMNEYT REPAIR.
a is in full fore,and effcn. (r/
C w 6 Licim �l
3 LL F Dine�1 Y `-- commnar
so
�jRCHITECT'S DECLARATID
C 1 understand my plans shall be used as public me.Ns
ger
6 z p O Licensed Predications[
o OWNER-BUILDER DECLARATION
1 hereby shim that 1 am exempt from the Contractor's License Law for the
following reason.(Section 703 L5.Business and Professions CW1,:Any ci or earn ' $2065
d p which requires a permit to constrict,alcor,improve,demolish,or repair any structure
a 3$ "prior tots Waimea,also req Teas the pplanti r suchpemus to tile a signed statements "Y- i 2 -s a
,bar be I' eJPiau nnothp sin.of(be Contractor, Law(Chs,w9 3Rn.�wA� t ValU3Il0❑
(c nir'i dh SeaR 701"of Div"on 3 of the Business ad P f cions Cade) �y } t T'dC BB IIYY VL`d V ty. .s .(1'R. 1
or that be is exempt therefrom ani the basis for Ne alle8ed exemption.Any violation 1
of Section 7031.5 by a.Y applicant fen a permit subjects the ap,lisvm to a civil penalty 1�,�,,,y,,,..,
of ria,mare than five hundred dollars fs5W), 101APN llil' HVilATI ON i '"-ti" Occupancy Type
°1,as owner of the prepeny,or my employees with wages as their sole compensation. 312 CHIMNEY REBAR WSTRAPS
'will'Ao'the work,andomcmrc C m intendedLi en a eredLaw for salt(sec. Loan 514 — FINAL PT_1U4a wed W� n.q '
Bill dote Professions Cade:The Camrnctor s License Law does not apply men
owner of property Who builds or improves thereon,and who does such work himself
or through his awn emplaycet provided shot such improvements is sol arewithin
not intended of
-,
cofficredompletion,
for Talc If howevere the building onmproof Prov n sold sv'Nm one y ser of
compose an,Ne owner Wilder wait hese the buNen of proving that he did not builtl or '
improve for puryou of sale.L �
..OI fma,
. . p ropcrtY mexclusively contracting' with licensed contractors t
sera( IDat Business Professions CoThe
Contract
License Lo doest apply e n fp,mpeny hob'IJ improves n
andh4 contractsfor such-pisajects
with litensed.pursuants me.
Contractor's License L
❑1 mPthis
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untle Sec .. ,.B&P C far tti s son `J
Owner '" " - S
'WORKER'S COMPENSATION DECLARATION
Ihereby affirm va&,Family af perjury one of the following declamtima
I have and will maintain A'Cenifcaie of Consent'to self-insure for Worker's O/
C pgnsa(mn, as prusidect far by Section 37W of the Lahor Cnde, for the
- 'performance of the work for which this permit is issued.
111 hast and will maintain Worker S Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is
tax eA My WorkcrsC a ratan) xumnce tamer and Pol cy be am:
Ca era Ley Na / T'T ^
,1"f;CERT FICATION OF E EMPTION FROM WORKERS.' ;7'.Z.as. t
BNSATION INSURANCE "
COMP ...
p I. mug cst nneed'mt be cumplcmd if the permit is for one hundred dollar s I '• (h, ') �s hs,
IS110(yor less.) -
_
ta that f m N Perf race f the ark for which N permit issued.I
shany
all of emI T
P
'YY Pe y manna - t become subject m the Work rsfq"f
`
Cori s tin Laws fCa110 te - {
Applicant _ .I(((ii
NOTICE TOAPPLICANT If.afternmk' g this Certificate ofBx option,you.hould
becomn
e subject the Worker's Cotnpensmian mor provisns of the LahCode,you must
Z O Innhwith comply with such provisions or chis permit shall be detmed revoked.
'CONSTRUCTION LENDING AGENCY '
'I hcrcbY affirm Nm dere is a constmction
leading agency fm the perfarmame .. ,.
,.., of the work for which Of,permit is issued(Sec.3P97.Civ.C.)
L -Lender's Name _ _ .__..._ ..._.;.. ..... _ .._ _ _. ._. _-.
z Lender's Addm,;
61 O I certify that 1 have read this application and sale that the above information is
fzasrieca.I agree m comply wiNull city and county ordinances and state laws relating
O E.T9 rebuilding consuvetion,and hereby awhoiim representatives of this city to enter upon ...!!l...
1* W the above-mproperty for propfor inspection purposes.. _
y.:Y (We)agreetomse.indcmnify and keep harmless the Cipof Cupcnino againxt
VJ liabilities,judgments,costs and eapenms which may In any way neem,against said
V .Zi City in consequence of the granting of this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOUR E EOULAT ON. ' ,4 - Issued by: Date
$igwmre bf A,iNivamAAmc. r - Date r. Re-roofs
HA�R
as detinedlbye aCcanior bOWn rib1ATERIALS OISCLOSUR ,; „
building occupant scoreor handle Health
Safety Type of Roof.. - -
pa per and the Heahh and Safcry
Code.Chapter I
Cod $eclt4n].5532( 1 ^_
°Ye All roofs shall.be inspected prior.to.any-roofing_material being installed_.---.
will the plc or future b IJng occupant use ey l t v vices which If a roof is installed without first obtainingan ins ectiori;Paaree'to remove
e: th Nousar contaminants as defred by the Bay Area Air Quality Marageman, , p t"
D'u t _ all new materials for inspection. Applicant understands and will comply with
°Y - - ` all non point source regulations. - --
I have mail the hazardous material%req i mems under Chapter 695 of the
California Health&Safety Code.Sections 25505.35573 paid 255.1 l understand that
if Ne building dues nm curently have a trnanethic if is my msponaibiliry to notify he
occdpant of,the req:iiremems which must be met priutm issuance of a Cenificam of
Occupant.
Signature of Applicant . Date
Owam or duchonma agent V r Dine All roof coverings to be Class "B" or better . .
OFFICE ...._ ... _. .. .-. _ . _. ..