00080042 (2) CITY OF CUPERTINO - PERMIT NO,
BUILDING DIVISION PERMIT CONTRACTOR'INFORMATION:
BUILDING ADDIUISS:
SANITARYNO. APPLICATIONSUBMITIALDATI
OWNER'S NAME:
11102 WILKINSON AVE BOB DERE MASONRY "'c 00081cfQ43E'L"
PHONL: ❑
ARCHITECr/ENGINI 480 CROSSLEES DR at
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Z O y= LICENSED CONTRACTOR'S DECLARATION
04_m
1 hwby aRnn Nu 1 am licensed undo provisions of Chapter 9(..1., Job Description
a' with Section]000 of ion 3ofrhe BaaircrsaMRorermaseode, mylicsmeis
C y In full force sed
`e Liantt Class Lia N
u�3 use d Contrectw
FeI�jY,o Pn2,Wy�RhallITECTsS Dss public rcmrds CHIMNEY REPAIR
C W<I (�
w i°° Uceved RofcuiorW
aOWNER-BUILDER DECLAfRATION
I bunchyaRnp do,I.exe.,,from din C toh
Lcense Law,fustian
aF° folloin8 never,(Sectims]OJ L5.Business and PoeationsCode:My city a money,
. m which lecturer rm
ruires a peit to construct,War.improve,demnfsh.nr repair any lWarc
c
3- prim a its isauaac.alsorequrnsthe applicant fam
suchprvttoriteaaignelsuamem Sq. FL Floor Area Valuation
Net he in licensed W..anuo the paviaiuns of the Convsetorr.Ucmtt Law(Chaper 9
(commencing with Sadon 7")of Division 3 of the Business and Pmfeuimts Code)in APN Number OccupancyType
Nat he is ur mpt therefrom and Nbu
e rs for the alleged exa mpiu.Any violYiu of YP
Suction 7031.5 by any applicant For a permit subjects the applicant to a civil penalty of
not moa than five hundred dollars(S500).
❑1,a aowoerofthe,property.wmyemptoyaawho..gaastheirmineompsnestion. Required Inspections
will doth.work,and the svumurc is am inu aded or offered for We(Sec.7066,Bayou.
and Pvresuom code:The Emuramm.License law dao M appy a an owner Of 32fw 17@75. 0@
properly who builds m improves theram,and who does such work himself or though
his own employees.provided than.ucb improvements an,two Indaded or offered for
sale.If,however,the Wilding or impavcmem is sold within mm ycurcuf mcn,lariu.the
er-Wader will have the budenofproving NatMdid art Wild reinromvefor par. 101 — FOUNDATION
wa19f
❑I,uIoonaw afar the Sce.70 auhaivcly and cutrating Cid:iTheedcnnuacana 312 — CHIMNEY REBAR & STRAP'S
construct the project(Ser.]014.Business and Profeuiom Coda:)The Convectors U.
came law doer trot apply to an owner of property who builds or impmva delete.and 514 — FINALPU LIC WORKS
who contracts for each pajecia with a con iscar(q licensed pareaut to the Conatears
Liana law,
O 1 an exempt under Sec. .B&P C for this reason gyy
Owner Date („g
WORKER'S COMPENSATION DECLARATION .`
1 bcrcby affirm order penalty of perjury We of the following dalantiaru' V
have and will maimun Sudan
n 37M ofConttnuo Eau.sort for Wmten Comae- O,waw
section,r provided fa by Section J]O0 of Ne IaWr Code,far the pctformena of Ne v
wort for whichpermit is issued.
1 have sod will
ode,fon Worker's ante oftnew Laurence,h reunited by Section
3700of the IaWr Cade,for do performance of the wort for which Nis permit is iaued.
My we, om cnsao nncc anter and Policy nu Ler
Came Policy N. /�j---
fMPP ION FRO R N St (ER
COMPENSATION INSURANCE
(This aectinn rte d.Werarpleted ifthe permit is to.Wedaed dmla s(31M)
or las.)
I certify That in the Performance of the weak for which this permit is issued.)shall
not employ any penon in any manner so as to Wcome.mbject in the Woken'Coman-
saoion laws of Califomia.Data
Applicant .
NOTICE TO APPLICANT:IL an,malting Nis Certificate of Bxemful. ,you should
become subject to the Workers Compar cation provisions of the tabor Cade,you must
forthwith comply with such pmviaions Or this permit scull he clamed rooked.
CONMUC ION LENDING AGENCY
Q Q 1 hereby affimo then them is a constmction lending agency forthe perfoms nce of
Z tiNe work for which this peram is issued(Sec.3097,Civ,C.)
Lenders Name
> lenders Address
W Fz 1 artiry that 1 have read this applicafu and ewe that the above iNormetion is
Lsect I agile.to comply with ell city and mum,imicamm.and ante laws relating o0
Z building construction.and hereby manna mprerenistiver of this city to enter upon the
C.) 0 .bovcmemicar d%open,fa inspection purposes.
ka F (We)agree in cave,indemnify and keep havnlea On City of Cuanino against
0 () Iimilities.judgran,cats and eapeac which only in any way rcnue egr ni said City '
txi
in ec,nwi,icam,
nconwquea,of the granting of this strait.
[�, L APPLICA 'U, )BRSI'ANUg AND WILLCOMPLY Wo IF ALL NON7 )INT
V z SOURCE iGli A'rIONS. S
SiguildrE of Appl' d/Com nor ott
DOUS MATERIALS DISCLOSURE
Will the appfcaut or future Wading cmupannune or handle hassNaas material Re-roofs
a dented by the Cu,mdnu Municipal Cede,Chapter 9.12,and the Health and Safety Type of Roof
Code.Section 2553200?
❑Yes Ap(t10
Will the applicant or future Wilding oeeupmt use minimum or devices which All roofs shall be inspected prior to any roofing material being
amitbcuradivaair eomaminentsasdefinedbythe Bay AnaAir Carla,Management installed. If a roof is installed without fust obtaining an inspection
Dixuict7
❑ I agree to remove all new materials for inspection. Applicant
I ha.ve.. g
mad the hamZ-J tcna4 rtyuirtmenv under Chapter 6.93 of dm Cali Understands and will comply with all non point source regulations.
Forms Health&Sere,Cade.Sections 2W5,M533 and 25536.1 makers=it that if the
Wildingdaaut currentlyhaves a Lthaitismyns ibiUtymMify Neoccupant
of the tnyui nla which --^mif[ c
Signature of Applicant Date
tithuna V
gem
All roof coverings to be Class"B",or better
OFFICE