03020055 CITY OF CUPERTINO.
BUILDING DIVISIONPERMIT ,,CONTRAC•TOR INFO MATIION , -
BUILDINGADDRESS: PERMIT NO.
JONES MASONRY
OWN EE)IaaAPPLICATI A
1049 DELL AVE
O
4083777512 SANITARY 0. CO3
ONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG" ELECT PLUMB MECH
0 0 0 0
40o LICENSED CONTRACTOR'S DECLARATION
M�� 1 Wnby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
a� withllto..711affecpivision3of Ne Business and Professions Cade.And mylicenm is ������®
in full forte And effect.
iqz Licen:cch,� Come REPAIR CHIMNEY
ate 7enntract r
a ARCHfTeuse D ADN - FEB 2 7 2003
y�u I undenrand my plans shall W used a public records
3 Licensed Professional -
Dat I Am
DECLARATION BUILDING
to F I hereby maxo e(Sec Inn 1 1. exempt from the Contns Co License taw for Me
x00 following mane.rSectiun 70JL5,Business and Professions Code:Any city at county
x 5 which requires a Permit to consumer,Alter,impmw.demolish,or repair any strut ion
prior to its issuance.Alm required the applicant(orsuch permit m file a signed statement
NO O Nal W is liceosumu
ed pentI.Me provisimsor the Contracture License Law(Charlie,9 Sq. Ft.Floor Area ZV21y1AUflon
$ (commencing with Section 7000)of Division 3 of the Business and Professions Codd or `f V
.. Mat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Me applicant to a civil penally of {ger Occupancy Type
not mon Man five hundred dollen(1500). 3 Mk4�Ttl . O 0 P y yP
❑Lasowner of Nepropeny,ormyeroployms;with wagesas Meltable compensation,
will do Mework,end Me$"Cie.is not intended brotterad fouale(SecJDf/,Business ]$e�j p
and Professions Code:The Contractors License law does not apply to an owner of 101 - FOUNDP@?id Inspections
property who builds or improves Nemon,and who does such workhimselforNmugh his 312 - CHIMNEY REBAR & STRAPS
own employees,providedmre
Mai
n t such improveents anot Intended orartedepictedmrsale.If,
however,Me buildingor improvement is mid within oof cont lesion.the owner-
114 — FINAL PUBLIC WORKS
builder will haw Me Wtdca of proving that he did not Wild or Improve fur purpose of
sale.).
❑h as Owner of Me property,am exclusively contracting with licensed contractors to
concoct Me pmject(Sec.7044,Business and Professions Code:)The Contractor's LI-
mose,law does not apply to an owner of property who Wilds or Improves Mcmon,and
who contracts for such projects with a contnclor(a)licensed pursuant in the Contractors
License Lew.
❑Lem exempt under See. ,B&P C for this moon
Owner Dets
WORKER'S COMPENSATION DECLARATION
I hereby efNm under penalty of perjury,one of the following declenllons:
1 lave and will maintain a Cenificne of Consent to self-Inure for Workers Compen-
tion,ae provided for by Section 3700 of the Labor CMA,for[be performance of the
work for which this Permit is issued. .
❑1 have and will maintain Workers Compensation Insurance,as requited by Section
3700 of MC Labor Code,for Me performance of Me work for which this permit is issued,
MyWorker nmp5psetion ld5pnna cbrricand Policy mneran:
J l/C-YI/•ly..FP/•6r rCU: hey ..
JJJ"' 'CERTI GATE OF EMPI'IONFROMWORK RS'
COMPENSATION INSURANCE -
(This section need not Mcompleted lithe permit B foram hundred dollen($I00) ,
less)
I cenify that in the performance of the work for which Nis permit Is issued,l shall not
employ any person in any manner At As At become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE To APPLICANT:If,after making this Cenificam of Exemption,you should
become subject in the Worker's Compensation provisions of the Labor Code,you must .,
wJO forthwith comply with such provisions or this permit shall be deemed revoked.
'Z "•� CONSTRUCTION LENDING AGENCY _
(ti ti I hereby affirm that there is e censlruedon lending agency lot the performance of
C Me work for which this permit is issued(Sec.3097.Ci,C.1
GQ Lender's Name
,7,Z Lenders Address
V Q 1 certify Mas I have read Mis application and note IMI the chew information is
[k, H cored.I agree to comply with all city and county on inancaa and mute laws relating to .
Q C.1 building concoction,and hereby authnite representatives or this city to enter upon the
kT1 above-mentioned property for inspection purposes.
(Wc1 agree to an,indemnify and keep harmim the City of Curnninu against
L.t V1 liabilities,judgments.costs and expenses which may in any way accrue against said City
V in consequence of the granting of this permit.
APPLIC T UND RSTANDS AND WILL COMPLY WITH NON DINT Issued by: Date
SO GUL 0
Re-roofs
ignature,o pplicanulContnctor Doc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Be,applicant or future building Occupant store or handle harsNbw materiel
As defined by Me Cupenino Municipal Code,Chapter 9.13,and the Health and Safely
Code.Section 25532Q)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes PINo
If a roof is installed without first obtaining an agree to remove inspection,I
Will the applicant or forum Wilding Occupant ltsC equipment br devices which P
it hanrdous All con an iamis As defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yes VIN.
1 have mail Me Wra dAmmmerialamquirements under Chapter 6.95 of Ne Califor.
Am Hes SafmyCa1c,Socdbn 25505,35577 and 25534.l understand Mat ifthe Wilding
does met, elly havea nen4 Met it is my msmmibility to nn' the occupant or the
red msec whi m met prior
AnissuanmofaCertificetoo uPm Signature of Applicant Date
nnrorauthorin agent „e All roof coverings to be Class "B"or better