02010051 (2) CUPE
CI sot DI G DIIVIISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS'. PERMIT NO.
10211 RICHWOOD DR LEON MASONRY INC 02010051
OWNER'S NAME: APPLICATION SUB DATE
MIKE SIMPSON 240 MOSELLE CT 01/14/2002
PHONESANITARY NO. CONTROL NO.
(408) 365-1660
Q O z° ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
L__I
Z8?Z LICENSED CONTRACTOR'S DECLARATION Job Description
O I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section]BW)ofDivision 3othe business and Professions Coee.ana ,ylicense REPAIR CHIMNEY
sY f is in full force and
ed a License Class _ <z Lic.N
><°e.° Date O— Continnor
m 3 u.H ARCHITECT'S DECLARA 10
y.,u.O a I intervened my plans shall be used as public records ,
i p p Licensed Professional
OWNER-BUILDER DECLARATION
vi=y 1 hereby affirm that 1 am exempt from the Contractor's License Law for the,
F Z following reason.(Section 7031 S,Business and Professions Code:Any city or county $1675
Y F C which y porn t t t rhe p demolish, p y counterc
ad Cam .-prior to itsissuance.also requiresthe official fsuch Permit t File a signedstatemnt
that heslicensed pursudintt the Provisions of the Contractor's License La (Chapter 9t F Or a. ' Valuation
(co B ith Sc i 9000) fDivisi 3 f th B si d P f ss ns Code) 1 'r y = .3 6�0'x.4°2.. 0�, ,f r
."bar he is exempt thdEfmm and the basis for the alleged exemption.'Any violation
of Secdon 9036.5 by any applicant hard permit subjects the applicant to a civil penalty ANN 1r,I,� -
itfuminoretltanrvehandreddidIms(ss0o), 101Pb' �UNllATION Occupancy Type
❑1,as owner of the property,or my employees with wages as their sole mmpemaian. 31-2 .
will do the work.and the noway,iss-not intended or optimal for sale(Sec:7064, -- -"
ownerof for n Who build, r improves thereon had who does s such weak If 514 - FINAL PL; BYtCed> RtS'nsli •t
or th n E e d that such _
pgp rpnm o p e P P g or unpmrc proving t. of intended d or ... ._._. ._... . . .- ._.. .. ..__. _. __.. ... ._..
Business d Professions CoJ The Contractor's License does not apply l n
l
completion,
offered I ITh Ih b 'Id t Id th f I 'L
mothe b Id will h the burden 1 that h did I build or
m
El 1, LIC c par opny-a ed ex cliortIY c out vating witM1f d en,utra couhar
construct the project(Sec.Aoa Business and f..ons Cc,I The Chinhavor
Liermse Law mass nl apply loan ownerorproper,who b Id,or improve,thereon,
and t. f such.Pr 1 t w,h amnmuctnrs)licensed pueseem en-the.
Co in LicenseLaw.
.__
L
❑I imp Jeri ` B&'PC ft thisreason -
Owner
'
WORKER'S COMPENSATION DECLARATION
Ihereby affirm under penalty of'perl y 'ne ofthefollowing ecclamtio s:
O 1 h 'd will I �Ceaitic,to ofiConsent N ielf-mesure for Worker's
t Compan.btian av provided for by Section 37W of the Labor Code. for the
performance of the work for which this permit Is issued.
01 h and t will'mv Worker%Co p n n Insurance,as mqulred by Section
;.:. 3]00 of the Lobar Cade.for theperfurmance o(tne work-for which this permit is
'is d.My`W kchC peep 1' b nQP I<y b rc:
:. .' : Crt ' J��➢JCI gwic3 'Pal yN i.Cl7 U— \J'L�' - '..�. e x ..`t •- .. ..� •
' COM1IPENSATION INSURANCE' -�=
(This mien need eat be completed if the permit is for one hundred dollars \
(SI001 or less.) i ..
_
I em toy at thepc f < fin - In which thispermitthe issued,Worker I _ s I -1•( L
'Shall t employ any p lif n any marine, as m bccom ublea m[he workers
0
'Compensation Laws oFC alifornia.Dam' -'
Appu cant
NOTICE TO APPLICANT',It,after making(his C nifcme f Exemption,you should
hoc bjeel Into W k Co npen t p '.Ions of the Labor C de you must
forthwith amply with itch p '.inns helm.,pe t shall be di,mird resolved.
~ I h C CONSTRUCTION LENDINGl nd AGENCY C
r+ armana
y'a 'sm d(S 309] Civ C.1'arch kf hch th p t
.Q". Q' ..Led Address... .. .. .__:.. .:.._ ._ .._ .. .It _ ...._ _ . . ._......_...... _.. .. ..___, .._.. .. ... ._ _... _ ._....,. ._..
� LeJ .Name
ts' •
.V
1- ioyotoh rc 'msl.
I d.rh bn f
rano
c l. cnPly 11 tyand county J esd state relating
(, tib 1 gfnli and hereby aind
eoor Sd osenmlV othis c[Y eoenupon
the above-men property for in,ection urpoee
W)'gmmn, ddfyhnik phatm 'aih City fWino gin
liabilities l dgml nd xpens h ) nn ydruvat against
zCty aemovd,ridime oftha
g a14, t
UNDERVp'SVT . ILL M
COPLY K'ItH ILL NON'POIVTIssued b Date
IT
' UI CF REG 1 i DNS,
y'
r.prApp i<an ora<t US '. s '. ,SC. •-,Date•.., Re-roofs
Will the up HAZARDOUS h1ATER,AL5 DISCLOSURE - T'-
.. 'ares. im o n al Heda,alth as t I _.Type of.Roof _ ,. ,... ._. . ...=i, _.
.. t 2
and Health and Tet v -
P�e YP r
p t t hung(,,,.,art.t
a df dby th Cpenn M plCd Chapter 91 y �f sr
C le Section 255720 a ,
ior to
roo
r w n me a°a t ten n,hr b 'Id s v t - q p t which Ifla roof is risialled w t Pout first obtaining frog mection;Is agree g.in
remove
e t h a d .der d by theB AreA Quality Management
an inspection;I' gt0 remove
D t <t P all non-point source regulations.; and will comply with
all new materials for inspection. Applicant q _ _....
nderstands
❑Ys
1 M1 Ho read the Safety
Code mat talc re cements malf,d 255 Cha lee 6.95 0l the
u
--
if
uil in Horth&Safety Code.Sections ant:th t it
and sponse 1 ity torstandnotif then
•If the building does not currently hive ammnC then11 is my responsibility to notify the -' _ -
-c yuirc ems wl' m prior m,lsso:ince of a Cenifcme of
n t one to m :'b m i Signature of Applicant Dae .
m
P Y ,
,ri.ea g.m I ,Dale All roof coverings to be Class `B" or better "
•
- '.""OFFICE-._.-"-... . .... .__ ... . . . .._ .... . . . .. ..