02120036 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUlQt)@;4A1)&ESSTOKES AV BOB GERE MASONRY PERMirNO2120036
QwORI-R&ORDAN THOMAS L AND VIRGI14I480 CROSSLEES DR APPucATT2SJ"Ty2002
At
ONE: 408 972-1285 SANITARY NO. CONTROL NO.
ARCHEFECr/ENGINIiER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MCCH
nee,
LICENSED CONTRACTOR'S DECLARATION p
s�F IWreny art mnlam licensed under provisions I)[chapwry(commencingREPLACE CHI MNE�b F'fZ`60Ft?'�)UNDATION
baa with section 7glo-,r2 On,i.ion 3or the Busuncismal profession,n,le.and my Bcen.His
in fmllnaca rets a� ,s
Z'e Daenec��Cyyvv Liep
FNF� Daa�(J� Com 1r18n� C/��y/ct—!a T
ARC11meroo Of da Arm
reon< IunJcrdanJ my plans,hall beuaJ as puhlic ramrds
6OyU
3 a Licensed Professional
=� OWNIiR-BUILIJER DECLARATION
Y r 1 hereby affirm that I am exempt from the Contractor's License Law Int the $6900
a 0 following reason.(Section 7031.5.Business and Professions Code Any city or county
a X'm which requires a cmlil to c merucl,alter,improve,demolish,or repair any structure
prions itsiauanec.alsorequireaaheapplicani for such Permit o file a signed statement
$L'ie That he is licensed pursuant of the Provisions(If the Contractors License Law(Chupter9 3S46Bt710dJi9Ai!0 Valuation
ae (commencing with Section 70)(MB of Dlvlslon3oflhe Business and Prolesslnns Code)or
i; that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703 L5 by any applicant for a Permit subjects the applicant to a civil penalty of PNN Occupancy Type
not mom than five hundred dollars o5af). 312 - CHIMNEY. REBAR & STRAPS
I,as owner of she pmpeny,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.Wbd,Business
and Professions Code:The Comsacmrh License law ares nut apply to an owner of egwre Inspections
property who W ilds or improve,themon,and who does such work himself or though his
own employees,provided Ihatsuch improvements ere nal intended or oBerad for,ale.If.
however,the building or improvement is sold within one your of completion.Ne owner
builder will bare the burden of proving that be did not Wild or improve for purpose of
sale.).
I,as owner of Ne property,am exclusively contracting with licensed contractrs I•'oto r NA LE®
consvun the project(Sec.7014,Business and Professions Code:)The Contractor's Li-
sense law does not apply to an owner of property who builds or improves memon,and DEC 2 0
who contracts for such projects m
with a conuacr(s)licensed prsu
uanl to the Contractor's 2002
License Law.
O 1 am exempt under Sec. .B do P C for this reason
Owner Data BUILDING
WORKER'S COM PCNSATION DECLARATION
I hereby atfimt under Penalty of perjury one of the following declarations:
1 have and will maintain a Ccnificutc of Cnnsem n self-insure for Worker's Cnmpcm
cation,as provided for by Section 371M1 of the labor Code,for the performance of the
work for which this permit is issued.
1 bare and will maintain Worker's Compensation Insurance,as required by Section
7o)of the laWr,Code,for thc perfnrmanm of the work for which this permit is issued.
My Worker'T.a Compensation l nsumnce eamerand for icy umber are:
Garrlm:_'17W a- FU//O Pofioy N..5?1 22 2--—
CERTIFICATEO EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
renis action need not be completed if the Profit is fnfine hundrod dollars u 1010
less.)
I certify that in the perB,monee of the work for which this Permit is issued.lost[not
employ any Person in any manner so as to become subject to the Workeri Compensation
Laws of Calr omia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Mcnme subject to the Workers Compensation provisions of the tabor Code,you must
O O forthwith comply with such pmvisines or this Permi,shall W deemed ra nked.
z CONSTRUCTION LENDING AGENCY
[-. �. I heathy athrm mat dare is uonslsuction lending agency for the imfofmanim of
lYi 7 the work for which this Permit is named(Sec.3097,Civ.C.)
Lq p Lender's Name
Z lsndcr's Address
V Q 1 certify that I have read this application and swat that the abuse information is
comet.l agree to comply with all city and county ordinances and some laws reining to
0 V building Offirr ion,and hereby authorim representatives of this city to enter train the
W aron-mentioned property for inspection purposes.
(Wo)agree to on.indemnify and keep harmless me City of Cupertino against
F's N liabilities,judgments.costs and expenses which may in any way acemc agmeadoid City _ 1
V Z in consequence of the granting of this Perm it.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature or ApphcaDam
HAZARDOUS Type of Roof
Will do,Applicant if,fmurehui Cook.Chapter
cnr handle Ifeardousmaterial
As defined by the Cuienino Munrgipal Cade.Chapat 9.L2,and the Ilealm and Safely
Codc.Section 25532(t)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the aPPlicam t fumrc hmlding occupant use equipmentor devices which If a roof is installed without first obtaining an inspection, I agree to remove
Will the ivirdfican,I
?,
coil mondous air comomrn nu as board by the Bay Arca Air Quality Managcfcnt all new materials for inspec n.
District?
❑Yes Nu
I ban rtad the ha- Nnusmaa.iJs requiremenga anJcr Chapter fi.95ofthe Califm-
arm IhalthASafetyCale,Sections 25915,25533 and 25534.1 understood that if the Willing /� �;X_2-_
Js cntIY base a mown it is my responsibility m fNfy preoccupation, the
oo
m me prionnismanceuf.comfica¢ Oce ,prey. Si, atureofpl a Date
wncr or authnri¢J seg Date All roof coverings to be Class "B" or better