000601701 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
NUILIMING ADDRESS: - PI3Nh11'I'NO,
:757r, qHAnnwHTu in BOB GERE MASONRY 00060170
OWNER'S NAME: APPLICATION SUH DATE
ANE III AND El 17ABETH 480 C OSSLEES DR 06/26/2000
PHONE: _ SANITARY NO. CONTROL NO,
_ C
n O O ARCIII' ECI'/E,NCINITER: I11111.DING VHRMI'I'INPu
W F hu El.HCr PLUMB MECH
mei I_I 1� l_1
F y�' Iac1iNSEn C.oN'1'RAcrOR'S DECLARAHON Job Deticrip ion
O
�+o hurchY union mm I nif licensed under pa,okiolf,cl Chapter 9 avnnnencmg -
wFv wish Section 7a IDivisin LdlheBmineenmal
%J,/(exsi�unx9CS�nJ mylicens
¢Y I- is in lullf Oe rw7J� !�f
IneensecL„ � I.ie.x REPLACE CHIMNEY
xoa� Dee_ r .,-
yAltClll'I'ECT'}(PY.IY�WlI'IA�`-��l '
i�� I u r tans nnY plans,hall he used us puM1lic rcennlsm�i/ '
'a.i0O LittnuJ Profcssionvl
ec OWNER-BUILDER
ils I in U iapu r na the CRATI(lN
hereby uffrm that mal uBiver ,an the Co ion,Co,blame law bar me
followingui n.annit to
703 1 comm It.of and Ive.d is Calc:AnY city nr county
EzC e whoh requires 1a n t t after. p ll I.1 p Y.tru arc
5 r tprior hat h t I. 9 [Be %ionsapplicant f M1 pe 'u issigned- t r em
a. that he udpursuant r m n ns unec t t r, I (Ctrp de) Sy. F[. Floor Area Valuation
Icnmimnc newth Smeinn9n, nmich m3urthe caNt, l ..ndlro(m,nt,CWq
or So ec is cicntpt my a,li and tee beers liu'Nc all gcAsuon,ptinn.Any vlulatinn -
nf Seclinn IDII 5 by unY hundred
oll far a permit,objects the applicant m a civil penahy
nr nm nm,rc man Eve nnmma amlar.asap. A PN Number Occupancy Type
❑I,n,owner of the propenyl nr an,employees wish wages as Inch wle con,pensalum, 22
will do me work,and the sfmcam wall inlended nr nI'I'cred for sale(Sm.]1144. -
Nuanessand Prnre....orr,Gwc:'Ilie Cmna.or,uanan I.nw tines as apply to an, Required Inspections
orr of property Whn Inti Ms or impnocs thereon.and won does such work himscu
through his nx'a emplo)ee,,provided Ih:o such imprmnnenw arc not intended or 101 — FOUNDATION
offered for sale.11,however,the building or improvement is sold within one year of
cmnpleion,The nw'ner-hoilder will have the harden ofpmvingthm hedhl not bulla at 31.2 — CHIMNEY REBAR & STRAPS
in prove for pnrpoae it ewe.).
514 — FINAL PUBLIC WORKS
❑Ln,nwnernnnepu,af,arneml.,ivelycmda,ling„athreenmcicmtt...torstn
enmtmet the project(Sec.II14,liminess and Professions Code:)The Contractor's
Liccnnc I,uw doe.not apply to an owner of propcny who hall Ids nr improves thereon,
C%ndwen ,mraatn for,ueh p Ju a ecwill, .....otana all licen.ad per..taro ,,the
haenr'.License Law.
❑1 mal exempt under Sec. .13 A&P C for Nis reeu
Owner Dare
WOItKEMSCOhIPDire ION DECL.\RATION
I herchy aflirn,under penalty of perjury one of the following decloratiun, j
1 have and will maintain a Ccnifcv¢ u
or Consent ,self-insure for worker'%
topensanon, its provided fur by Section 3700 of the Labor Code, (or the
do
u nunca of the wnrA for which ibis Pcnnll is ixawJ, 1
o .and will naimain Worker's Compensation Insurance,as required by Section v
f the Labor Code,for the performance of the work for which this permit is
.sued.My Woorrlkeerr's Courn,a ,ion Insurance carniy��"�j,Ilc'y qun*71,
C rrl y Nn.✓ f 7 // _
CERI IPICATION Op IiXEMPn(lN PROM WORKERS'
�pA'D CONII-12NSATION INSURANCE
('1'hh wniun need int be enmpleted If Ice permit 1,Iia one hundred dollars
IS ran nr lex.)
I certify that in the perrnmumre of the work for which this permit is issued.I
,hall not employ any cro n in any manner,o as to become subject to the Workers
Compensation I.aw,in California hale
A,,beewu
NOIICH'By APPLICANT:II;"her making this Cenificarc of 17ve f,linn,you sem.Id
beco n,subject a,the Workers Contpcnsinion provisions of the Ufor Cole.you must
O z0 forthwith comply.m ids such pmviann.".this out hall be JnmN rcrakcd.
z CONS'1'RUCTION LENDING AGENCY
I hemby apinin that IhmM Is o con,nmdon IaWi,agency for me perli...u,r c
of the work for whish this permit Is issued(Sec.3197.Civ,C.)
L C Under',Name
= Z Under's Address
C.1 O I cenrfy Nin I cmc mad thio all nod sate that the shove ulhnnull i is
4. [~ cr neo.I agree to comply with nil city and comny urdinnneee and.tam laws relating
O r,) In building ronwracrlon.and fetch,ounowe m,re,emmi—afoul,city to cmc,open
} k2 he aM,ve-meminned property for impaction pugtoa,.
(We)agree u,save,indemnify and keep harms,the City of CuMnino against
Vi IhaMEf Wine x,cosi.and exlwn hw Y any way accrue ngaimt said
V Z Cit' con,gncn nl,T grmnine• n
$ inn nn
� ICA TAMy$A .COttMPL�YW�TN ALL N-POI aaa%���}}}i Issued by: Date '
( E .I 5 ' . . / / /14 y
.ignumre of Applimuu/Contmooq C/ Dare Re-roofs
HAZARD) MA' .OALS DISCLOSURE -
wEltheappheanimfol <laul ng ala„nam store or eunJlc hveurJnu,nna¢nuI Type of Roof
as defined by the Cupertino A n I Code,Cl 9.12,and the Health and Safety
Cale.Section 25532(ap '
❑vea I All roofs shall be inspected prior to any roofing material being installed.
wurmn,tpplieantar,n n,e nnudntg neeapam n,e egndpmc,n alevice,whlclt If a roof is installed without first obtaining an inspection, I agree to remove
ani,hvarJous air cal thu ima .ala defined by the Nay Arca Air Quality Management
Dnmey all new materials for inspection. Applicant understands and will comply with
❑ve, r all non-point source regulations.
l ��hnvu rend the emus us on nxN requienmnt.under Cmrlci 1.95 of the
in Health N Safety Cswc.Sections 25505,25543and 25534. malestaud that
hir,swx mol cuman”
hnvan Lena .rho ismyrcerymsnbiliry ) olifythe
the menu xhich must m prior m i,snuntt of a eniEca of
1"Y airs _ - — _ �� Signature of Applicant Date
,r aamnriaed agent Date All roof coverings to be Class `B" or better
IOFHCF