02100104 (2) CI'T'Y OF CUPERTINo
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
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fftffLbrv"UbWPMANDY WY BOB GERE MASONRY PERMrrNO2100104
owFa--RAI3TE:VY-DZA ET AL 480 CROSSLEES DR APPLICATI1?11DsIBi94TY2002
IONIi: 408 972-1285 SANITARY NO. CONTROL.NO.
ARCEITEC IENGINEERt BUILDING PERMIT INFO
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Qm IhcrchyalfiulhIIenREPLACE CHIMNE bPfts5t
RIOULDERS
with Seclion]tNXp ofDivisiOn3nthe OusnssnJ ProfesionsGmJe.nnJmy licence
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ARCIITE-CT'S DECLARATION
ECLARATION
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I understand my plans shall M used as public rcnnds
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� OWNER-BUILDER DECLARATION
aP 1 hereby affirm that 1 am exempt from the Contractor's License law Built $1990
ca
¢n O following reason.(Section]1131.5,Business and Professions Cedc:Any city or county
e'js m which requires a permit to construct,alter,improve,demolish.tar repair any.aruclme
11—'^ prion its issuance.also requires the applicant fonuM permit o file a signed statement
�z< that be is licensed pursuant to the provisions of Ne Commetors License Law(Chaper9 33>g6Bt3H(Go7AQ@ Valuation
aFO (commencing with Scaion](XXB of Division J of the Business and Professions Code)or
y $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penalty of 'U;kPNN4AA4# ATiUNOccupancy Type
not more than five hundred dollars(s500). 312 - CHIMNEY. REBA & STRAPS
❑L a Owner of the property,or my employccs with wages as their sole compensation, S14 FiNAE3
will do the work,and the aruauti is not intended or offered for sale(Sec 70,4,Business
and Professions Code:The Commetors License Law does not apply to an owner of equlre Inspections
E rupeny who builds or improves thereon,and who docs such work himself nr through his
own employccs,provided that such improvements are not intended or offered for sale,If,
how,.,the huildi ng or improvement is add within one year of completion,the owner-
builder will have the burden(if proving that he did not build or improve for purpose of
sale.).
O 1,as owner of the properly,am exclusively contracting with licensed contractors um
consruct the project(Sec.7044.Business and Professions Codi The Contractors Li-
cerue Law does not apply to an owner of properly who builds or improves diction,and,
who contracts for such projects with a Canuacmr(s)licensed pursuant to the Character's OC I7
qoo�
License law, la L
l am exempt under Soc. ,B&P C for his reason
°w" Date BUILDING
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations
1 have and will maintain a Certificate of Consent to Self insure for Worker's Cnmpem
cation,as provided for by Section YNX)of the labor Cade,for the performance Of the
work for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
I of the Labor Core,for the performance of the work for which this Permit is issued.
My Wnrkcr's Cumpensatim Insu a carrier and Policy number am:
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Caticr.STE �Uh Policy NO.:�
C17RI IFICATE OP EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
folds sectitm need not he completed if the permit is boor haadmd dollars(SRXI)
in,Ica.)
1 certify that in the Iarlormance of the work for which this Permit is issued.)Nall nm
employ any Pewm in any manner at as become subject to the Workers'Compensation
Laws of Calif orma.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you Should
W,ome Subject to the Worker's Compensation provisions of the 1aMn Cox)c,you must
O Z fo0hwnh comply with such provisions or this Permit Nall be seemed avhked.
z O CONSTRUCTION LENDING AGENCY
po-N. P hereby affirm that there is a construction lending agency funhe psrornanCe of
a7 the work for which this Permit isstand(See.3097.Civ.C.)
f+7 0 Leader's Name
Z Lender's Address
V 0 f eerily that P have read this application and state that the above information in
W (~ correct.l agree um comply with all city and county ordinances and state laws relating to
O U huilJing[Instruction.oeu.,and herebyeemnify ad representatives i. a Cay of m enter anon the
st /U /
r W above mentioned po,crty l m inspection purposes.
(We)agree m save,indemnify and keep harmless the Cayof Cupertino against
FyItablltdes.judgments,cosLandexpenseswhichmayinanywayaccaneagainstmidCity
Q in consequence of the granting of this Permit.
^ APPUCAM'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
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fit/ �O�y �_ Re-roofs (157
rgnamrcut Appcal LA'act US MATERIALSDLSCLOSURE Dae Type of Roof
Will IM applicant or future building Occupant store or handle ha udous material
as defined by the Capetian Municipal Calc.Chapter 9.11.and IM1e Ilealth and Safety
Code.S«den25532(a)] �� All roofs shall be inspected prior to any roofing material being installed.
❑Yeo JQNo
Will the applicant Or fu ore building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree[o remove
mit harvrdnus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District'
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[have«ulthchaiccuons550:.2553 ircme5.iundcnden,undinnifthe Cnlding
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Wm&SalctyCmtc,Sccunns155B5. myne d155341uno it, thaliflparn it thethusitismyion,, I l+ilhymnntily the•rcenpnm of theecui at met tnfasnanaoI Cemfieamol erPan S7gnatureofApplicant Datei All roof coverings to be Class "B" or better
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