01040090 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS; PERMIT NO.
11220 LA JOLLA CT MIRACON CONST 01.040090
OWNER'S NAN1I7: APPLICAI'[ON SUIT LATE
ON DR 04/18/2001.
PHONE: SANI'T'ARY NO, CONTROL.NO.
408264209q I
o s z ARCHITECT/ENGINIiER:
BUILDING PERMIT INFO
I° O LD EI.ECIPLUMB MECH
F�Ro
O y LICENSED).CONTRal rade t'n URC r,of CON Job Descrip ' n
_ hien 70alumoo I.3ofl1w dmNcr anviromald,arter Code.o(mmmeaense
F'_tw ilp Smtio.andd of Dlvision3Ofthc Rusinans mol Rafesiaro CMevnd mylirenw
<y..� nrnrcaneelreyr� 1y :21 c, REBUILD BRICK CHIMNEY FROM ROOF.
s a C last.(') ��— Lic,p a
j LL V iaalcn�'_ _= Canlreelnr
F-a ARCHITECT'S DECLARAi
1 undcrsemd my plane shall be used m pnM1hc renndx
ce
ce Y
ti O II
Licatwd Yralc.......
OWNER-BOILDER DECLARATION
w oi I hereby ufrrn Lha I inn coodp,Rom the Cnnimetor'x License law far the
t Z� following mason.(Section 111.115.Buslnco and Pr)fceainnh Code Any city ur emarty
O which reemms a permit to aommuct,after,improve,demol on.or repair any nhuaum
ce
ce, prior it)ns issuance.aim)requires the applicant ba such Permit o file a signori stimulant
Ibar he is licensed punwnllo the prooion,of the Connectors License law(Chapm,9 Sy. Ft. Floor Area Valuation
(commencing with Section 11X)(0)of Division t of the Business and Profession%Cale)
or that he is c¢ntm therefrom oral the basis for(he alleged exemption.Any violation
of Section 7011.5 by any urdir ll IDI a pernut subjenn he applicant lin a civil penahy
Of ant more than Eve mmdmd dollars Mail. APN Number - Occupancy Type
❑Las owner of the pmlxny.or my cnoploycos will,wages as their mole Grunts motion. - 00
will do the work,and he sI,ucturc lu not me lad or ollcted liar,ale(Sec.144. - r
Room—and Profession,Code The Contractor:License Law does not apply to as Required Inspections
Owner arpropeny Who builds in impmvc%thereon,and who does such work himself
or through hi,own employees.prodded that such improvements ate not intended of 101 — FOUNDATION
offered for%ale.If.nosrever,the Wilding or improvement is mild within one year of
imimpletion.the na'neobodder will have the burden of proving that he did not Wild or 312 — CHIMNEY REBAR & STRAPS
prove for purp:ne al sale.l.
❑.I.axawnc,nfin,pranenr.antm
esela...at,commchhgwirans.duumctm
more514• — FINAL PUBLIC WORKS
msa'a,,tic project(Sce.9144,Busines,z I Porexvione CoduO'The CunhrmhnY
Liccm'c Law dues nm apply in an owner of prnlwny who build,or Intpooes thereon. -
and who comma,liar such p,,,jet,,with x ainmavartq roc..cd pursuant e,the
Contractor',License Law.
❑1 um
aiming,under Sea. .R&P C bar this rcmnn
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby ammo ander penalty Of Iw ay One sone following declaratimoi F ^\L
p 1 have and will raina i o a Cenireau uI Conwal ,,sclf-inxam for Wodsi. Ep
Compchsalion, as provided or by Rection 1901 of the Labor Code, lin the Y MA
perfimnance of We work lin which Thi,permit is issued. A 0 7
O 1 have and will maintain Worker',,Cumpersollan Iawmm ,as myuired by Section 2001
31M of the IaW,Cade,for the pee orreare of the work far which this permit is - -
sued.My Worker',Compensation Insurance comer and Policy number am: BUIL
Lrricr: ensaPolicy No: TNG
06
CEO IFICAI'ION OF EXHMP'I'ION FROM WORKERS'
(IOMPENSA'I'ION INSURANCE
(Thi,section head not W completed if the,wrnit is for one hundred dollars
($101)or less.)
I cenify that in the pednmmnee of th�eywinkIyfor which this permit is issued,1
ehxll nor employ any re,at in any manner?��S noco ye,abject m he Workers'
Cntnpensaliatt 1.wa of Car Ennis.Date_ S LL
pbcam /
Ooov vah I',,11he ..or,s ober makingn l'mon, of of Labor inn,yn oa it i
nu,imp y the Wa ker'u COnymmr don provisions of e d Luber Cada.You onuxt
Q O Emthwilh ,imply wit....h poovisiom or❑tis penult nhn11 he JcaneA revnkcA.
Ftz)= CONS'I'RUCI'[ON LENDING AGENCY
� 1 hereby uflimt that thea is a connmetion lending agency for the performance
of he work for which this pemtit is ism.hd(Sce.3M1,Civ.C.)
❑ lender's Name
7
Lender's Address -
U Q I certify that I have rcud this application and state that the above inhrruutlon Is
W F correct.I duce on comply with all city and county adboadcas load state laws relating
O tobu'ddiagcnpmcltna.naUocrobyuudtnd.e minrla
entiva,nl(history toat
eer upon .
y (m abmonwmi I prala'aty to now,inn pu,pncs.
(We)agree loore.'indemnify sad keer,hanalesa the Citral Capennto aquina ' /
'n liabilities,judgaen,o,coats and expenws which may in any way acerae against said / p—ol
U 2.VSIRCE
nwquence of the granting of this permit. 0 11
ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
REGULATIONS. Ally'r rettmlCommuor Dae Re-roofs
I I ALARDOUS MATERIALS HSCLOSURE
win me arrl,adtn tar nttammtnemg:a.,mattt stn�e or ltanmel,mardoox tmnedal 'Type of Ro
u darned by the Cupenino H
Mormipal Coir.Charter 9.12.and nhe eath still sarety
Cole.Rection 255)2(x):'
❑Yes ONo All roofs s all be inspected prior to any roofing material being installed.
Will the applicant or future building occulrutlt use e9aipment or da,;eea ashen If a roof is installed without first obtaining an inspection, I agree to remove
emit haannlom air contaminants as defined by the Bay Area Air Quality Management
. D;sn;etn all new materials for inspection. Applicant understands and will comply with
0Yva °No all non-point source regulations.
Ilav::read Thu ha/al'dnns materials mquimmalt.under Chapter taus of Ilse
Cniu I1emh ye Solely Code.Sections 255115.25517 and 255 34, xtu
1 undetod ata
rbc Wilding docs nut currently have a tenant.That;t In my m,onmhild,m nilly the
aupam or the occloircruch,,'which nium W met prior m issuance of a Cenifcute of
Occupancy.
�� y ��� Signature of Applicant Date
Dwr orm,,r::a.gcnI Data /-- All roof coverings to be Class`Blit or better
OFFICE