02110033 CITY OF CUPER'rINO
BUILDING DIVISION PERMIT CONTRAC>TOR INFORMATION:
8
u1rA*6&DD ATHERWOOD DR BLACHLY GARY L AND MARIET RT NG2110033
1`vRL1A@HLY GARY L AND MARIETTA APPucArP2st"T1.2002
PONE: SANITARY NO. CONTROL NO.
ARCHITECfIENGINEF.R: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Ca LICENSED CONTRACTOR'S DECLARATION [p n��^
Ser I hereby affirm that l am lieensed under provisions of Chapter (commencing REPLACE WATER .fQ�IJ,�rs:�Wtlon
ywish ciiuou"o of Uivisinn]of Ute Businesx and Prnfec innscnde.and mylittn.¢is n ti1GIICC
LL in full fomcandeffect.
&j= License Class Live.g
owg Dart Conuacror
ARCUITF.CT'S DECLARATION
xSy s< I understand my plans shall he used as public records _
OyU
LL_O Licensed PrltfC:ilenal
OWNER-BUILDERexemptDECLARATION
¢�a F. 1 hereby reaso affirm second
1 1. cacmpn from the Cnsions C's License Law litr dm $700
a a O O which re reason.(Seaton conalr,Business and Professions Cade:Any tiny Or country
a�;3 which requires a issuance,als tit construct,alley,intforsu demolish,nr repair any tatement
HZi that hoiuesedppursuant(I)
the applianldre Conch perminofleasi-sw(ChNmem n p
Ibuthcisliccmnd Pursuant uuhe provisions of NC Cammnss Littre lson C Coke)
3ffiy9 Et6IFI@�AEh9 Valuation
FFG lathe is xempth Section71100)ad nl Division]ofrM Business pt Professions Crtion or
y�$
that he u exempt Ncmanm and he basis for he alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applian
no a civil penalty of PNN Occupancy Type
not mom thane.ehendmddollars(s500). 506 — GAS TEST p y YP
❑1,as owner of the properly,or my employees with wages in their sole compensation,
will do the work,and lbe structure is not intended or offered for sale(Sec.71144,Business 507 FINAL iG
and Professions Code:The Convectors License Law does or apply to an owner of equire nspeetions
pmpeny who builds or improves mereon,and who does such work himull through his
men employees.Provided that such improvements not nen intended or offered for sale.If,
however,the building Or improvement is mid within one year of completion.Ne owner-
builder will have the burden of proving mat he did Out build or improve for norpom of
sale.).
0 1,as Owner of me progeny,am exclusively contracting with licensed contractus to
contract the project(Sec.71144,Business and Professions Code:)The Conoacrnrs Li-
cense Law does not apply to an owner of properly who builds or improves memo,and,
whit contracts for such projects with a carnation)licensed pursuant to the Contractor's FEB 1 4. 2002
t nu Law.
dam to rap under Sec. ,B&PC for this mann
ORKER'.COMPENSATION WLIpRATION
I hereby a Rum under penalty of perjury one f the following declarations:
I have and will maintain a Certificate Of Consent to sel6imum for Workers Cogent
ralion,as provided for by Section 370g0 of the Labor Code,for the performance of the
work for which tis Permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
370s1 of me Laver Code,for the prlktrmance of me work for which his peoma is issued.
My Workers Compensation Insurance carrier and Policy number ere:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This suction need nal he completed if the permit is Buono hundreU dollars 01100)
I,,less.)
I cerlfy shut in the pefntmunce of the work for which this permit is Issued,I shall nm
employ any permp ma mannerm av re Mcomc suhjcn In nrkcrs'Cnmpcnxminn
Laws Of Calif nia. �-
Appliam •- i
NOlO kr making Nis cmlicatc of Gat lion,you sMmIJ
becom sect m the Worker's Campcnsalian provisions of the Vver mlc,you must
O O forthwith comply with such provisions or this permit shall be deemed honked.
'Zti' CONSTRUCTION LENDING AGENCY
(•+ � I hereby afford that here is a construction lending agency for the Performance of
fY, the work for which in,,permit is issued see.31197,Co,C.)
W� Q Lender's Name
z Lender's Address
U O 1 certify hal 1 have read this application and able that the above information is
{L, F correct.I agree to comply with all tiny and county ordinances and state laws relating to
C)U building construction,and hereby aulorim mpremnutives Of his city no enter upr the
li7 aMtve-mentioned property for inspection purpases.
6r (We)agree to save,indemnify and keep harmless the City of Cupenim,against
o-F.t y liabilities,judgments,costs and capenses which may in any way mcrve against said City
U 7 in consequence of the groan ng of this permit,
sem- APPLIC NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:3 Date
SOURC'REGULATIO pp
Re-roofs
Pgnah Apprcan"BPllllfraxourDate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will he applicant or future building Occupant store or handle haaasdous material I
in defined by he Cupertino Muni 'pal Code,Chapter 9.12,and he Health and Safety
cede.Sevin 25532bD1 - All roofs shall be inspected prior to any roofing material being installed.
❑Ycs
Will the applicant nr future building occupant u.se cgnipmenr or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit Iwsurdous air contamioms as efincd by the Buy Area Air Quality Management all new materials for inspection.
Disvinl
of,
1 have read the hazardous materials requirements unAcr Chapter 6.95 of the Califor.
mla Health&Sato Ctxic.Satins 25515,25533 and 255]4.1 understand that if the looking
does not currently hast a tenant,that it is my infidel to notify be weapon,of he
require on which do he,.,I rinrt . anccaf cenmate of Occupancy. S ignature of Appl icant Date
kill wnrmamnorlmd ago, All roof coverings to be Class "B" or better