02050071 CITY OF CUPERTINO
\BUILDING DIVISION . PERMIT CONTRACTOR INFORMATION:
Ball1�^,�CyAJp"RhRRITT DR PERMIT NO. 02050071
r l y yy 1l �N`'1l
FRANCES M
PHONE: SANITARY NO. CONTROL NO.
'+a'i0'O ARCHITECDENGINEF.R: BUILDING PERMIT INFO
.re be BI.DG ELECT PLUMB MF,CH
so
S?y
z LICENSED CONTRACTOR'S DECLARATION Job Description
1Z Ihceby allionilot l am licensed ud provisions of Chapter 9(Commencing RE-ROOF
H� th Swa rm 70(IQ)of Division 3 of the Bus d I' [,s ons Code and.1license ... .,
X y m I ll force ind effeirl ,.
a
'Danatc,g t t
or
ARCe DECLARATION 1 understand my plans shall M1all bW e used
d as public rccoNs
zl
i C p7
Licensed YmPossional - ^
°'o i -• - OWNER-BUILDER DECLARATION
=+ 1 hereby arfmr chat I am exempt from the Contractors License Law for the
t-? following aura(Section 7031.5,Business and Professions Code:Any city or county $9000
Y F C which requires a permit to construct. It -roprove,demolish,or report any structure
i 3 m
famorm to ala reclaims limapplicam f h faconift to Ill...igned sa¢ment
+ J"u, A 11 ._..,.. ... .___....
,bathe sf[e dpSectionorhe pro air i lith ft trust and Pr lawons Code)
, Iso: / 31�3@fFYon33r Attila. Valuation
C'. they nS nh Semon,in a (Divas Division thelei+essaaxer.Any vi Code) ( ,iJ tl c a;, _
C'.
thin h<Ls.31.5 b tang applicant
and the basis for the alleged exemptmn.Any l Penalty-of Section 7031 n.5 iv any hundred
d ll for n permit subjects the applicam to civil penahy
notmortthan menandredeonaa($suo). 305APNFI"9&E .' Occupancy Type
❑I,asIowncrnnhepropennarmyemployeeswithwagesastheirsolecompositio,n, 307 - INSULATION
will do the work,and the struma is ret intended or offered mi sale(See:70,14,'
'Bnsineta and Professions Code The Comm<tnrs Li[cnse Law-J«s act apply m an 601 - R OF TEF�g��'Inspec[ions:.: .- ..
owner of property Who builJsmimpmvcs thereona and was a«s such work himself 602 - ROOF PLYWOOD NAIL
or through his own employees,provided that such improvements arc not intended or _
..alit«aarmvile.u:howeveemellhaveimprovement- i.amdwedidnae r ._ _ 603 -ROOF- BATTENS.. -- . - -_ ...___..._.._...
Ifn,tEe F.'e ofbuilder will have he burden ofrhes he did not year
or
`mpro��inr male). °`a�tas 604 - ROOF IN-PROGRESS
purym u
v,aat cs[lusivd ...t i with
❑nr.act her injecf het
prone Y Ycm+mcingwi ode)The C.macrsln
_ Liciwa the does
no(Se[.]014,Business and erylim% inns GdoO The improves
them n,
License Law dos not apply. an owner of propcny who builds s improves thereon,
.: ,and who<ono-aa for su[M1.pmjecrs with a comructor(s)licensed Pursuantm the ._.. _. .. ___.._...._. . .. __.
�tmctols License law.
]I sin Wer",under Sri'.' ' B&PCfor this reason .. .:., j'rll''t -
'i,t^... WORKERIS C01 EN�ON DECLARATION,.-
- r I hereby affirm under pcnAty of pcijuiy,ane of the following declarations:
f ❑ 1 have and will maintain a Certificate of'Coment to self-insure for Worker's
Cumtatownsm, as provided-for by Section 37W of the Labor Code, for the
pciformance of the work for which this permit is issued.
(a 1 have mal'will maintain Worker's Compensation Insurance.as requited by Section
37N of the Lvhor Cnde,far the pt hormance of the work for which this permit is
.
tissued.My Workers Compensation Insurance carrier and Policy number arc:
:. Cdr, 'if .. i t -
r �,_ r ,CERTIFICATION OF EXEMPTION FROM WORKERS' , il. s• tt, '41�sI t ..).. ' +. i
trl'h+s u<nodtiteJ nm be completed f the permit is for one h J J Jailam t a L
uHgB.,J to
'Ic n(I lht n@e per(mmc Tth wolif ' hch tl p m V,'I -- - „ 1'1 cow+ I ,t'+.' ��• — � .
issue
shall t pl Y Y pr n nY n "so as to brc'ome i ct t dhe_X'orkers
APPtIafYR -f-
v. FCal.f6mm De e
dSQEez
Compensation ... . ._._. ... ... _._ __ . .
,Nt3T1 TOIAPo the WirkANT.If Comp k;ngtns Cerirwteo EC1Wr le.you must •• t
z 12 bec0 ahcoin subject y the Workers Colons or Prov s ons of the Later Cine,you must
forthwith comply with such provisions or this permit shell be deemed revoked.
•M ';r! 7 CONSTRUCTION LENDING AGENCY'
1 hereby affirm thanhere is a construction lending agency for'he perftermmice +
of the work for which this permit is issued(Sec.3097,Civ.C.)'
(� Lender's Name
'�.
.fez L<ndee's arfly
V O I<a'—rh comply read all application and! d hate t that the above law,r nn is /l//•,'t/lt/_—_
.W F. '[ivrect 1 agree t comply with all coy aM countyordinances chi state laws relating
�.f) tub Id g< a ctinnpndhcreinspecanr< p lives of thsnty to enter Upon
T (aj the ebo(We)agree to pn+penY for inspection purpoxs.
F0: eWe)agmets,cos.ts andnifyabs kmp whshamay inss rhewayacrim of tior,against,
Vi liabilities,judgments,costs and expcnxs whkh may in any way accrue,gains,said r
in comml of
V,^ APCitPLICANT UNDF.RRTp granting
}N4ILis°L�'COM PLY WrfH ALL NON-POINT o'
.R 'RCER GI/LA'r1�N5.:7"rZO i w��'/';> S Issued by: Dace
gnmum of ApPlicruni/CorontmonrX/'"""'''_'"—l` —Dar'. Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accupam more orhandlc hsazheous material .. Type of Roof
as d lined by th Cupertino Municipal cod Chapter 9.12.and theH IN and Safety : .1
Ctd s ion 25532(a)
11y" All roofs shall be mspe_ct_ed gnop to any roofing material being installed.
w'u n pPi,:'a t r M1 ld ng pan u.c cqa p d - P wn,n If a roof is installed without first obtaining an inspection;I'agree to'remove
emit hazardous contaminantsu defined by the Bay Arca A' Quarry Manage em
D onetO Yes1 N . all new materials for inspection Applicant understands and will comply with
�,. all non- oint source regulations;.',- -
�1/ 'l 1 h vc•read the'ha dons m(mals requirements under Chapier 695 of the
CSIi(omia Hcaith A Safety Code Sections z5s05,z5533 end z553Y.1 understand Char
tithe Miilding does no currently hove a maant.Data is,my m,fo,eibllay m notify the i�
o[cup''th of the requircmrna w i h must be met prior to issuance of a Certificate of
a".`y SY r✓ -02 /Si ature of Applicant Date
_..
nyr yr aptnna:ea agent ;' ate „ All roof coverings to be Class "B" or better
OFFICE -