02010066 (2) CITY
BUILDING DIVISSIIONN� PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21597 FLINTSHIRE ST 02010066
ON;NER'S NAME: APPLICATION SUB DATE
PAM MARINO 01/15/2002
PHONE: SANITARY NO. CONTROL NO.
I ARCHITECTfENGINEER: BUILDING PERMIT INFO
w BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
N g 1 herrn affirm that 1 am licen.ed under of Chapter 9(commencing !ob Description
iN_� provisions pe REPAIR FIREPLACE TO CHIMNEY ROOF LINE .
_h;� withSmion 7000)of Division Jof the Business and Professions Chile.and my license
;Yf
"it
s innull fmcl an � YI S�
o r<W Cat se C a c.a
i 3 )ax, Contractor
a N
` ARCHITECTS DECLARATION
C so,
V,2
1 understand my plans shall be used as public records
so
i ape LlcrosW Prnlessimad
OWNER BUILDER DECLARATION
='r I hereby affirm that I am exempt from the Cmtmcmr's License taw Tor the
?a following mama(Section 7031.5,Business and Professions Code Any city or county $6760
E o wdeh requires a prrald to c ammaet,alcor,improve.deoliQl,or repair any dructurc
i3= pnort L'. mace,aim q he m appacuto far such permino flea signed ourment. _ _ -__ _- -_..- .._-_ _
tM1andan emnseeput5umlto Um pro Division
n the the BrctnsLiccnsr Lawon.,Ca9 p Valuation
(c that be s exempt
Sato oin and the basis o t the Busincss and Pmfngom Cada t r 1'• t�3i G',�0 ;�' ?1,1 ii E i4.) Y
or that he is exempt therefrom and the basin for the allegcil ezemyuon.Any violation
of Section 703 k.5 by any applicant for a permit subjects the applicant to a civil penalty'
ornot moretnan five M1tindred emlars tsswk lO�PN "'"DATION Occupancy Type
01,as owner of the property,or my employees with wages as their sole compensation.
will do the work;"and the'swcture-is'act intended or offered for'sale'(Sec.7044;' I� ®
Business and Professions Code:The Commnor's License Law dns not apply to as 514 — FINAL P@ I s '
owner of property Who builds or improvessuc
thereon,and wno does h work himself
or thmogh his own employees.provided that such improvements am not intended or
olfcree for sale.lf,however.the huilding or impro4ement hin is sold'witone year of "" _._...-....._ .._ .. . _._.__... _ ._.._. _................. ._.._ _ _ _ . . _.
completion,the owner, ollder will hove the burden of proving that he did not build or "
improve for purpose of sale.).
1.. ._ the _ ..__.__ ._ ._ __ __ .... _.... ....... ...___ .. _
❑I,asowner urine prSec.71stn exclusivelycontracting with licensed Contractor
onor contractors,
constructLicense
thedoes
limiter(Sec.]to i Business and Professions Code:)The improves
there.,
Liansc law Ons not r aac to an owner of property who builds t imamves thereon,
' and.who eonmens for smh.proj.I with a.camrtuor(x)licensed Pursuant m the _. _.. _ _.. .. . _ __ .. _. . . .. __......... .....
cminac
01 am oe License Law. Dae - - - -- -
❑lent exempt under Sec, - � "� IB&PCfor this rcasnn - i, ,
WORKER'S COMPENSATION DECLARATION / i
1 mertby affirm under Pma1tY of perjury ooe a[the fallowing declarations; //�
�° 1 have and will maintain a Cmificate of Con ma to s lf-insure for Worker's 3/
Compensation, as provided for by Section 3700 of the labor Code, for the Q
performance blithe work for which this permit is issued.
°1 have and will maintain Worker's Compensation Insurance required by Section
37W of the Labor'Code for he perfommnce of the work for which this-permt is
Issued My k s C tKmix! 1romance tamer and Policy duande,'m
n- a ....._. _........ ..-... _..-..._.__...
Came 4 a 1i f PolicyNo ds8-oor47� ll 6
tr--t CATION OF EXEMPTION FROM WORKERS? Cl t?.fr>• ih, is, t�.: 4.
___
I --------
This net on need not be completed if the permit is for one hundred dollars i•'� ` l'. "� 1 l,^
IS 130)or las.)
1 readily that in the pe mmunce of the work for which this pemtit is issued,1 - - - - •"'' ""'
shall not employ any person in any manner,so as to become subject w the Workers'
Compcnstram laws of California:Dam
Applicant -
NOTICE TOAPPLICANT afterpomati this o si ns of the
L Exemption,youshouldmull -
Z
forthwith
subject m thes Worker' C ns or provisions of the lab Cod you must
0 C fnnh. ,rote. - -n h pro'i o s or thispcmi t hall bed etl rc ked.
zn. _ ..
CONSTRUCTION
i' 'r CONSTRUCfIONLENDING AGENCY. -
� ' he 1 hereby affirm that them t is esued(See, lending agency for the performance
M the work for which this permit is issued(Sec.1097,Civ.C.) `-
L ❑ Lender's Name - , ....: ... _ _ .._ _._.._... ._: c
1 comfy that 1 have rend this application and crate'hot above information is .)
[..t 6oiren.I agree to comply with
all city and cpumy ordinances and stain laws relating
C) to baildingodnamme'on.and Israel
authoriu'repmsematives of Nis city menmr upon
W Ute aIds
e-7arm
properly for inspection purposes.,
tiP. (Wgogr to'm'e,indemm"and keep hamdess the Ciry of Cupertino sgainq
N liabilities.ju0 ems,costs rid exile. s which may,in any way ac<rve ega�nst avid
V-^ City in con Ince of iti p n,1 thLpeimiMPLY N'ITH ALL NONPOINT' I
APPL UNDER 9 ` ^G
sou is ' jrd2 Issued by: D e J
7i mturImA.FF canUCo tactor Datc Re-roofs
"- - HAZARDOUS MATERIAS DISCLOSURE
' Will the.1licmt or,future building onupmt store or muscle haieri mmrmil ..Type of Roof. _
-. as defined by the Cupertino Municipal Code Chapter 9.12 and the Health and Sof ty .. - .. _ - --. _..- -
Cash 5 ctio2553 (at U" i ` .^i ry - '. , '! ', ' , .'s I , , .. .. _,.. _..
°Y I� ..All.roofs shall be ins acted rior.to an 4-roofin material beim
P P Y % g.installed..,_
I town m :pill cant m furore balding racby p t eoiequipment r devices which If a roof is installed without first obtaining an inspection,I agree to remove
M1azardous air comaminan¢as dcfinc0 by the Bay Arca Air Quality Management
°isnc1 Qom- all new materials for inspection, Applicant understands and will comply with
1p °v" ° ' - all'non-point source regulations. - -
•.+� I have read the hnzardous'matrriak iequiorma nts under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534.1 understand that
'f the brikh9fAcers not commily have a tenant.mai it is my responsibility to notify the -'
neccuupant?an
y rea quire t which - t be d
Op to issues f e C nificam of
l .. o .. ._ ... _ .. _
/r`(SDl— Signature ofApplicant _ DateL.
Awnum remanded a<t r Dam, All roof coverings to be Class `tB" or better
S'. C i :r...,,,. ...... .. . . .... O
.. -., .. FFICE - ._