01070085 (2) L Ce BUILDING DIVISION
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: //j� PERMIT NO.
//VJ( 01070085
OWNER'S NAME: APPLICATION SUB DATE
BURTOS FINALEM 07/19/2001
PHONE: SANITARY NO. CONTROL NO,
JUL
ABOUT BUILDING PERMIT INFO
µ. _ BLDG ELECT PLUMB MECH
Q,J5E_J LJ L_7 I-1
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S N z LICENSED CONTRACTOR'S DECLARATION - JOU Description
z0 z_,� 1 hereby affirm Mm 1 am of
licensed under provisions of Chapter ode9(commencing
wL-u, 1,tofae,inn7awmromi,ionannneen.ineasanaPro Sta� coJ aamyucenae REROOF.
z Y I is in full force un <fyl fees ( U
rees< .License Class�„��_ LIC:M 7 � 0 CHANGE TAR/GRABEL' TO 30 YR. �EIK COMP .
3 a.U Date Commaor --CHANGE
1ad—I O - p C CT'S DECLARA ION
and rsmnd my plans sM1all be used az public records
t
a a o Licensed Professional
OWNER-BUILDER DECLARATION
='to 1 hereby affirm,hos 1 am exempt from she Commcmr's License law for the
following orator.(Section 7031.5.Buainest and Professions Cade:Any city or county
I F n which requires a permit w construct,alter,improve,demolish,or repair any stmctnre
a3 -',mono ie-issua.d1nal ire`Naappllcaut forsuch penduoRle a sigrodstatemem. - -
,Wthe is licensed pursdadtJp the provimons of d,e Conua,o/s License taw(Chapmr9 S Ft Floor Area,:l, ssem�,� 'Valuation
(commencing with Serecom 0001ro"'vi..a.Sof Nc So'Z"
nM.Plofessionx a- ;t1_•. t1 t LSr_�1
or that he'is ekca thctermrii ed id'bins for,hc alleged
axempdan.Any violation s
of Senior)(111 S by any",I,,ntn for n permit subjens.1,applicam m a civil pcnalry- t!tIl C[
�af onmare than dvc M1utdred"'Bars(g600). n`ti36i 7 30o II'n ' Occupancy Type
❑L as owner of the property,or illy employees with wages as their win compensation. LI r - i
will do the work,'and the structure is not initiated or offered for sale(Scc'7(PW.
Business and Professions Cala The Comracmr's License law does no,apply,o an 307
— INSULATI sired Inspections' '
owner of pmpe t,who W ilds or improves,hereon,and who does such work himself
through ough his own employers.provdcd that such improvements are mot intended or _--__....- .601 . —_ROOF TEAR TOFF.... .. .... ...
,offered f I ([Howey th W JJing or smprovcment is sold wMm one yen of 602 — ROOF PLYWOOD NATL `
completion the owner build II have Ne When of proving thus he did not Wild or
improvemrpwpotearsale.). 603 — ROOF BATTENS.
—
-
o:l -p 'f the property,am excloival y contrac ting wit h liced sc d c atilt ac to rs to 604 — ROOF IN—PROGRESS .'
construct the project(Sec 7(94 Business and Professions Core)Fire Contractor's L ^
_c
License law docs not apply to an owner of property who Wilds an improves thereon.
_.and wM1o.can,racu.(orsuch,projccu with it comrarmr(s)licensed pursuanuoahc.
Comszcmis License Law. ,
- ❑lam eserma order Sec. nf, - .B&'P C for[his reawn� v!' 11, t•••
-
-1 Owner are
. . ' ..WORKER'S COMPENSATION DECLARATIONr
1 hereby affirm under penalty of perjury oM of the following declmmiuns:
❑ 1 have and will mdintaid'o'Cenifcate of Canicnt to self-mome for Workeisl
Compensation, as provided for by Section 37W of the labor Cade, for ,he
'performance of the work far which this permit is issued...
❑I have and will maintain Wurker'a Cnmpcoot ldm Insurance,is,require)by Seaioi
3700'of the Labor Cade,for the Performance'of the'work for which this permit is
1 d'e ed.MY Worker's Co npcnaetton Insum re Cartier aid Pol y umbe am:
Cuneri s'. { v. p.a s.. Policy No.: r. N..(..- 41^p4�.
CERTIFICATION OF EXEMPTION FROM WORKERS" +"o-s A ^f` •is,
COMPENSATION INSURANCE""
llTik section nccJ not W completed if the permit is for one hundred tlolluta
(S100)in lead
certify iM1ai the pert a me f di wk for Which th-pe t ie'ismed,I L' t i I I",
shall nos empl y any pedoom do any milaimer so is tui become,.ubdea Im,he Workers
Compen-min Laws of California.Data -_- _
Appst . . _. .. .._ . . -_ - - •_ _.. -
"NOTICE TOAPPLICANT.If, Bc kg,h-Crifatof Esempuan you should
W rrobject m the Worker,C open to p" `tosd eCale,you must
O on'%th ply with such provisions n thispermit sM1ail Wdeemed revoked.
,
.. ._._
--o-Z•t r~�. 't ' i'' "r CONSTRUCTION LENDING'AGENCY
'rt' Iberebyaffirmdr,rehi'nooa wt .10«1:0 fwT,he fumunce
c s g agctuY Por t i
OWof.d work for wnich Nis permit it izmetl ISec.lW7.Civ.C.1
LQ ,Lender's Name ,1 1,
.= Z Lendcr's'Addmss t' t
V 0 4y1 n'ty that Il 'J the applicationand.,, that the binformation
s.
k+ L u,'o" I,g cc ,, ,mpi n] nlloity, r
tntyorft W6t3
alz nzcbn _.
to Wilding cu...... nn:t,un["eby'aulho.izamyti3:utwdsec of lbtwiry m<rtentp,m
} t,he above-mentioned property lot insixaion purposes,,,, ,
. y (Wklagrecm one.irdemmify and keep harsnless,ne City of Curcmno against,
N liabilities.lodgments,ea ri cul asperses wh,ch..y in anyan
,way acne against said)
V zCio is consequence of the graming of this permit.'
jAPPLICA' UNDERSTANDS'AND WILL COMPLY WITH ALL NON-POINT' IssUedby: Date
"
50 RC GyILAT10NS' "' t.•
s g 't '()PPT a wcartrttnar . . 'Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Lap
` 0.'R the applicant or future building sec pad-ire w hal hararJuus material' - Type of Roof � \ v ,- - -- -' - � �-
sm,defined by th Cupertino Municipal Cod C1mpt 9.12 and the Health and Safety' t (.i./
Cade Section 255R(aP , . - - ` f\' ' ." 5 s J s
'ore. - ";.olyo''. 'r�('•.':feP'e?: _. All roofs shall be inspected prior to.any roofing material being installed.
Will the applicant.,r tureb r g occupant qct it t e hen( If a roof is installed without first obtaining an inspection, I agree to remove
emth J ,: -Jet JbY theBill A A Quality of nay L
D , all new mat 'alt for inspection. Applicant understands and will comply with
0,ye, all no
l source regulations.
1 have real the.hrolus materials requirementsunder Chapter 695 of the /
Califomia Health&Safety Cale.Sections 25505,25533 and 25534.1 understand that
if,hetil ip8 Vas ams cuncmly hatsatewnt that it is my responsibilitymnmify the
occupant of the'requimmrnu which must in,met ppor to issuance of a Cenifcate ori,
°c°pp° t ylgna[ure of) pelican Date .
1.:: ow umadud agent -Date All roof coverings to be'Class `B" or better
'OFFICE