02010003 CITYBUILD[G DIIVISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10728 DEEP CLIFFE DR FALCONE AND SNYDER CO IN 02010003
OWNER'S NAME: APPLICATION SUB DATE
MOLLARD ROY S AND CATHLEEN TRU 650 LINCOLN AVE 01/02/2002
PHONE: SANITARY NO, CONTROL NO.
(408) 292-9705
BUILDING PERMIT INFO
O O ARCHTfELTIENGINEER: BLDG ELECT PLUMB MECH
—
z
Z 5N= LICENSED CONTRACTOR'S DECLARATION Job Description
Z= I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
F � with Section 700)1ofDivision 3ofthe BusinessanJPmfessionsCoca,a yiicense R & R FURNACE
z ae z< Licensc'Co��r++«�`and eBgt.o
i's U
Data
C. Q__g`L Commcmr
ARCHITECT'S DECLA TIO
�`tu=�� 1 understand my plans shall he used as public rrsoNs
a .M p Licensed Professional
= OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Low for the
Iz?< following reason.(Section 703 IS.Business and Professions Code:Any city or county
$2250
F O which reclaims a permit to consumer,alter,improve.demolish,or repair any income
u13 cod_.prior to in issuance,also requires the applicant for such Permit o rile a signed statement - -
thathei;licensedpuractunnotheprovisionsofNeContrectoesLicenseLaw(Chapter9 rey,,I ]-•' ppr,QQrreea�. Valuation
(commemirig with Seeiion7000)of Division 3of,h.Rodney.and ptafeuions Cade) i, tt,. i .`35'0O4tOF(;�: -!, :f.,•,`s'
or ihaf he is exempt Nemfacm and the basis for the alleged exemptionikny violation
of Section 7036.5 by my applican}for a perrni...bjm.the applicant a a civil penalty
•of not mom than five hundred dollars(S500). 301APN � I PLUMBIN iOccupancy Type
Dl,as owner of the property,urmyemployees with wages as their sole compensation. ��CHAIN J,,,.,,,�Business all do The nd
Code:ctureThe or offered
for sale appy toL 304 - ROUGH E3.lDCS`12Jt!AM
Business end Professions Coni The is mot sten License Law docs note 1 m m Ct10IlS' `
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements am not intended or .__.__ 5,0 5 _ FINAL_ELECTRICAL_
_..__.-..
.Hard for le If'h the building P event IJ thin one year ofFINALq --- ---- - - --
completion.the owne b IJ r will have the burden of proving that h did not build or 5 0 7 - PLUMBING
improve for Purpose of tele.). 508 - FINAL MECHANICAL
_... - .. .- -... -_. -with- - - ._. _ ... . —. _ ... —" -... — --- -7-17 7-- - ....
OI.asowner ofthe property,am exclusivelycontrofeisi licensed c Concrorsto �• "
construct the does n (See.7041.Business and Professions Code)The Contractor's
License Law does not apply toanowner th property ontr who builds n improves thereon a
..md.who is License
L such prolecu.wnh a comrucmr(s).hcenuJ.pursuen tNe.
01miexContractor's License Law.
❑1 vee exempt under Scc' ;B&P C(or his reason 'I
t.
Owner' -'I� " Date
WORKER'S COMPENSATION DECLARATION
I hereby aR.n under penalty of perjury one of the following dedamtions:
-f have'dnd'will maintain a Cenificam'of'Conient to seif-insure for Worker's
t
C2mpensitian, a provided far by Section 3700 of the Labor Code, too the r
- performance of Ne work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section _
3700 of he Isom('ode,for the perfomtance of he work for which this permit is
issued My WorkbYs .pen uon Insurance carrier
and Policy number arc: ,V - _ y u ����y, - ,_ ,,,,•„�,,,�....__._.__
Came L ' Policy Nc /( � O/GOO
. ..('. CERTIFICATION OF EXEMPTION FROM WORKERS'x
COMPENSATION INSURANCE
(Th t union need not be complemd if the permit is for one hundred dollars
1$100)or las.) +
,1 cemplothat.the P rf anynre f the work for com h this ct to the
issued 1 + C
shell not emar,Law,
ofCson it any mann as m become subject to the Work<n
Campcns5tion laws of California:Dale" ,
Applicant
•NOTICE TO APPLICANT:ILa(mi making this Calibrate of Excmphon,you should
z Obear.subject to the Workers Compensation pravisions of the Wbor Code,you muni
forthwith comply with such provisions or this permit shall be deemed revoked. ,
P, CONSTRUCTION LENDING AGENCY
-� 1 hereby aff red that them is a construction tending agency for the Performance
Of the work for which Ni m092 Civ C
Permit s issued IS .3I
4 Q -Lenders Name..,. ... .. ... .
,7 Z Lender',Address '
V 0 I
cc if Nat 1 have mad this application and state Na the obove information is
W'F, Yorre,it.1 ag implywith all ciry-red county ordinances and nate laws relating
O t..7 .Wilding consume ion.and hereby an mine mprcserialives of this city to enter upon
>. (� •Ne ebgvEmenuone propcnyf s tion purposes.,
96 %(Wc)agree aveif., Jkcep1mradess the City of Cupertino against
F l4 liapl rams,judgme is costs ea sea h may in any way vccme against mid
U .Z., C'Ymom I ee fNe iia thi unit, / l --o2 l
4 kLIC'AhTI" D.RST f)5�\N W COmpslyw'ITH LI. ")wrolNr- Issuedby:
Date L C-�
GufcE ae C .a ,t o I,,
signam«ar APPOmnAZAR xt nam" Re-roofs
HAZARDOUS MATERIALS DISCLOSURE,; 'Type of ROOF
v WII Ne applibanl or boom buildin8ozcuPani above or haMl<haraNws.,venal, .. ...,... . .. ....._.. -..-,.. - _..�_.._..__
as fined by,Ne Cuperimm Municipal Cede,Chapter 9.12,and the Health and safety
Code SDY n2551'_(to lr, e '. \... t 1 '
_All roofs shall be.inspecied prior to any.roofing.material being.installed. ,
• Will the applicant or future building occupant use equipment or devices which If a roof is installed'without first obtaining an inspection;'I'agree to'remove
,or t hazardous air c mar. ntz udef d Ne Bay Area Air Q ally Management
District' all new materials for inspection. Applicant understands and will comply with
DYC4 all non-point source regulations.
1e ad the hazado mm Is re r<menu under Chapter 6.95 of the
Calif is Hee h&Safety Cod' Sect 25 5:25533 and 25534.1 understand that
ift building at cu ti have is that it is my responsibility to notify the - ••
ne pant of r quire. which a et prior m lei aadce f a Ce 'ftcme of
cupancy
T�1 r 2— Signature of Applicant Date.
wn<ro,authorizedagent Date Ali roof coverings to be Class "B" or better
. .. -.._ - .. . ... .. - _.. ..OFFICE. .