01010027 (2) CITYDIND
BUILDING
ILINVISNPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PFIRMI'INo
10813 WILKINSON ABA SERVICES IXLC 01010027
OW'NER'S NAME: APPLICATION SUR DATE
DIETRICH 108 FRANCISCAN DR 01/05/2001
'PHONE SANITARY NO. CONTROL NO.
(650)222-2860
azz ARCIR nim n:NGINEER: BUILDING PPRMIT INTO
V 0 C FILL)G ELIiCI' I•LUM11 MECll
,e
~2�
Z O 4 LICISNSIIII COcensedNI rde,p DECLARATION I,R]0m,c Job Description
O ol a hercbv aflirnt rival n 3IIills,B mWcr pnd Prole of Chord. (d nmtn¢nse
with Section]tXMq of Division J of the Rusinc��and Pmlcoions Codc.and my license
F=C d1lan ����d�y t r 8 p REPLACE CHIMNEY WITH DURA/LINER
< Lice w"Ise 1J`-1- I.ie.«_� J_ �—
wO d Dare" Contmcter
s
An%shall
tv use as public record,rd
C LL I undemmmJ my plans eM1nll In used as public mtt,Mx
w E m O Licemcd 1'moswiono1
c c OWNER-BUILDER DECLARXI(ON -
I nacby allion that 1 sem eaampl I)nm he Cbnmoaor',License Law for Inc
Ibllowing itoson.(Sccrion 7031.5.Business and Pmfe,sien,Code:Any city ar comny
a,F C which requires a pcnnit to construct,alter,improve,demolish,or repair any structure
Po t al-op II jil'c t(ll'lolli'll.nonl II g I,anmtatl
math licensed Parati a Illp , fth C I lar',L LaIChapter9 Sy. Fl. Floor Area V1 tion
(commencing with Section 9(910) IDi i, J fro H ince,Id1rfe.- ,Celle) $1.3�
tr that oc ra a Inpl merelrvm mal that h,rda rnr the alleged a o.plinn.Any violudnn VJJ
III
section 7031.5 by any applicant rile a pe.oil subjects the aside.,In.civil pnohy
of not.mare den love Imndnd Ill($5(9). AP,N Number Occupancy Type
OLaaowne—fine pmpeny,or trey employee,with wasexa.meirenm enmpensmoir 35607021.. 00
will do the work,and are.Immo.I,not intended or offered lanae(See.nldd' Required Inspections
llto . m mn
� and Profc, Code:The Contractor's License Law es oto apply a
,irofpropny WhobuilJ.s or intproveuhercon.and who doessmh work himself 101 — FOUNDATION
t dnongh his awn ctnpdoymx.....sided thin solo intpmvancma are not wil,odel nr
offered lot safe.If.however.the budding or improveotcm is sold within one year of 312 — CHIMNEY REBAR & STRAP'S
ontrlelion,the ownurhudlder will have the burden of proving that he did nor build or
nn,rloffor parsocofxaf,.L, 514 — FINAL PUBLIC WORKS
❑1 (if Ike 1 ptY I . cIY cortirccling withl J ret t sm
construct the j t(S ](W Ilusimses,and Proresonne,C d :) I he L I mr's
License Law does notrapply
such fp prey h b'IJ rep thereon.'he
iLndm t' 'I. i .ropers w Ih rule wlortq I' - I pr nr ant In roc
Comet exe pt unsc low.
❑l Owner
exempt render See. It&P C Lim this mason
owner Dale /
WORKER'S COMPI?NSN'ION UR:CLARA'1'ION /
1 hereby afhnn under penally of rcrjury otic of the following declaration,: s/
• ❑ 1 have and will maintain a Certificate or Conscnl ret %ell Mone for W'orker's O/
Contpenaion, as provided for by Section J]W of the Label Code, for the
perfnnnunce of the work tar which Ihix pcnnii is issued,
❑1 hove and will maintain Worker's Coetptnai"n Insulates,as required by Sminn
3)19)of the Labor Code,lin the pedorinamr,or the work lar h.,h Ili, noil'"
wed.M�yw Worker's Courreensalion Imurana carrier and Policy nnuummlser are:
IldC:uricr:y-y C'ICA'I NO'Eatficy No.11'R0 )vLlt
(DMPENSAliON INSURANCE
('this rection need nor be completed if the permit is(crone hundred dollars
61II()mlcm.)
1 certify that in the performance of the work for which this purmlt ie issued,1
shall not employ city pecan in any runner an its to become subject Io the Workers
Compensation Laws of Cnlifomia.Dae
Applicant
NOTICE TO APPLICANT:If,tile,maAing Ibi,Cenitimne of I3actmnin I,yon should
become subject m rite Workds Cmntpenwfion provisions of the tabor Calc,you muss
O O IoRrvim annply with well pmvisi... nr Ibis pcnnit dell he dcemeJ evoked.
Z
CONSTRUCTIONoI,c ,sLENDING AGENCY
a > Irk Ill,allich recd mere In II creed(Sec.
Icnding......y fon the pr(mnutncc
s� of the wok lire which reds pcmti(is dolled ISce.3W],Civ.C.)
G Q Lenders Name
Z Lender.a Address
V O IocrifythatI have.udred,cpplicallon and woe met Ibc above fnfotruniI is
E correc
Later t.I agree to comply with all city and county .w
ori mirwos and ale Ia .,wtelli ng
O U to builiingrnnstruclinn.and herchy amhorim wpreantalives ofthis city mender upon
U] thcal c.mmlnancJ.namely Ill, nf,,l inn porpo,c,.
E„ G
(We)a,. indemrm
nity and keep halmthe e City of Cupertino agwoul
Vy liahililicx,juJg ornam coax and cnpmc,which may in any way acmegains
at,aid
V Z City in colncqucncc or Ise'ra.(dreg of If pern.t.
PPI M ' DERS ySSjkND WILL COMPLY WITII ALL NON-POIm'
�R1 ATI P. Issued by: Date
Jy//I-/�J� a!/L/--✓
siy LpilOrc o(Appli[anUc;nVacull -/= Dan, Re-roofs
HAZARDOUS MAI FRIAL.S DISCLOSURE
Will ore applicant In turn.bolding meal,atl.dor.ar handle baaadoua roelettal Type of Roof
a defined by the CupeNnn Ni ipal Code.Chapter 9.12,and the Ileallh and Safety
Oil,.Smlin 1255.12(.)Y
Cl Ye, S No All roofs shall be inspected prior to any roofing material being installed.
Will In,applieam or far are buddia,ceeupartl use egmimtteml"r dcvicex which 11'a roof is installed without first obtaining an inspection, I agree to remove
coal haaanbus air conlsnia defined by the Bay Area Air paali(y Afanagetnent
. Dislricll "tad all new materials for inspection. Applicant understands and will comply with
0 Ye" No all non-point source regulations.
I olnc re,,,i the huranlo I,minerdnb.god.ntcln,,order Chapter 6A5 of he
California Health&Safety CoJ,.Sect i"os 25505,25533 and 25534.1 under,land mal
if the building Jens nor currently have it tenant.(hal it is my responsibility to notify the
cupam"I the r•gnlrenmnts which num.he amt prior m I,xuanm da Ccnitiv'ala of
ae Al '—, � Signature of Applicant -Date
o tetra agent Dale All roof coverings to be Class"13" or better
OFFICE