01050089 (2) CITY OF CUPERTINO
.BUILDING DIVISION' PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS' PERMIT NO.
21979 MC CLELLAN RD GB GROUP 01050089
OWN17R'S NAME• APPLICATION SUB DATE
GREEN KATHLEEN R 8921 MURRAY AVE 05/09/=001
PHONE: SANITARY NO. CONTROI,NO.
(800)653-7172
n m z ARCHITECT/I?NGINEER: BUILDING I'ERMI'I INFO
O�
E w� BLUE ELECT PWAfB MECII
FJE
S y i LICENSED CON'TRACTOR'S DECLARATION Job Description
Z1 herehy at5rreIhm 1 um IicenmJ under Vmvi,ion,of ChaPmr 9lcunnnencing
awl-n�iwish Scniun]IXq)of Divixinnlof the Bueinns anJ PruJ c,,c...m.�w Cr e,an Intense
d�6� 's'in let]ce"Chat, ecu. REROOF/SIDING R TRIM
a , unset cnnlmcmr o
,u,v ANCTITECT'S DECLARAIION
='to S I undersand my plan.%hall be used as public not
rc O O L acnacd liol'c,vinnvl
d c OWNER-BUILDERxcirpr m the Contractor's
¢I u I naso eRnn that 11 ante from 0e G,ntmao o I.imme Lew for the
C z 2 which ins Lemon.(Section 7onstr ct,alter, andmp ve.de m demolish,
Cale:Any city or county
F❑ wni"M1 regninn n peter.,re construct,TEE t altar,in,pmvc demolish.or repair any awcture
3m pdonn,licensed vuaon, ,,res thu uWthe ...,,ifillillift for unall Commnniuordou 1'.oCnammat
that(commehatwifpm,aammXXBofDiviki 3of[lintnnnes antipre.av(Chap'de) Sq. Ft. Floor Area Valuation
or that a is ewith Sectionomaof Division3ofeaBuede x andion,Any vi Code)
or that he is exempt Zany applicant
li and the basis for the alleged exemption.Any violation 1171294
of Section 7031,5 n by live
ka appliennt for a Iwm,il wniats the applicant m a civil pewlly
af.mt mareth.at five haaeed dauars fESBUI. APN Number Occupancy Type
❑1,a,rwmer.,r the potpen),m ter enmla>ees win waNe,a,mar,ale...mpemsulian. 35713006. 00
will do the work.and the mum ,is not intended or offered for sale(See.7014,
ILo ne„and Prmla.,mn,Cam:Oe C....ar mm',License Law doe,mm n1,11man Required Inspections
r.�f properiy wltm heid,a•latpn.,smar....a:.re who does Each hinelf
o„ m
through las awn empmycesmnt
.provided than such i.nparvees are not intended... 305 — FRAME
offered for salt.If,however,the Wilding ar inamovr lem i,s dd within one your of 307 — INSULATION
ntodetiom libu e—evaibullder will have the at of a he did not build ter
mnroveforpti,nee•t m 601 — ROOF TEAR OFF
❑In,awreranhe property xcla mat aBrF ,I t,r.ened c.aararos.m 602 — ROOF PLYWOOD NAIL
Lomwa the project(See I u d o6,: as Gbc:)'Ihe Con.".
icense Laveduc,mmn. y a ownpit ryw ,laildsorimporos,the m, 603 — ROOF BATTENS
.ad who.ommcu to ,u reject , n a a parsn a he
Owmman..t,Li.e.nc saws x'U `�
o tart event pt ar rSee.' _ _ _,Ilre C Ib 504t ROOF IPI—PROGRESS
Owner— _ m Q FINALED
ONKIiH' .OA iNSAT10N IIiCLAR,VIU
I not,y uflina unlur,mlty of Perjer,one of the followlns dmlmminns: - h'1V•1j/ U p q
❑ 1 have and rill maintain a Certificate of Consent to sell-insure for Worker's IY0 2001
Compensation, as provided for by Section 3701) of the Lamm Calc, for the
,iformanm allhe work for which his permit is issued.
O I have and will meinmin Worker,Cmnpm,min i Imuranec,ax required by Section BUILDING
3700 of the Labor Cade,for the performance of the work for which this permit i,
issued,My Wmkd,Cam ISttI�{ ncc carrier an I Poliey/n}um�Mra
CnrriccO�M IM No,:
� LI.VR
CE TIHCA' ON IIP EMPTION I'R(yb WORKERS'
COMPENSATION INSURANCE
(I his senior ncd not be.......tried if the permit i,Intone hundred dollar
(61BB)nr loss,
1 verify that in the perfumnn v of the work Iia which this permit is issued,I
shall not employ any person in any manner so as to become subject to the Wor)er'
Cnnt.cnsminn Laws of Culifomia,Dam
Affi...I
NOFICH 10 AVIELICAN'P Il:after askins this Ccnilicane ul Exemption,"m should
become,object to the WEE Courfamo am provision,of be LvMr Code,you most
forthwith comply with such provisions or this permit shall W deemed revoked.
F ^ CONSI1IXUC'r1GN LENDING AGENCY
> I herehy alBnu 111.1(here is a cnnammion Icome,asene5'lite the pertbnnanc
W
The work for which this Im an is issued(See.3091.Co.C.)
L (" Lender's Name
z Lenders Addre„
U O I.envy that I nave read this Cppccadon and nate ere se inhnmaean is
;as E,. carte t 1 agree to comply with c l,a d con. . c (am In.,mlat ns
U nbu wcf.r,and by r th P a the city to enter
Fa Ih hIWo -t a 1p P ll k m,pvcp is lh uarflao u us; ns,
liaM1 lit :,lu l,ment, a f, ad. , y y y .air, F'n> sea J
U 2$ City to consequence the m ago d'
APPLICANT UND ST A ' 1 Ct 1 L ,' 'f1 ALL Issued b Jy�)CC, /�11..7J/v_.C'C t Date Jct'
IOURC17 REGUI TIO ,. \ y I
Si,mouncot Ap aneCanuactnr U e Re-roots
HAZARDOUS MATERIAI S DISCLOSURIi
Will the..Nmunt future Wilda,aecurmn,tare..handle Went mammal Type of Roof
xs mfinod by Ibc Cnpenino Municipal .Chapter 9.12,and the Health and Safety -
Cndc,6unlon 255321.0] a
ID No All roofs shall be inspected prior to i r offing material being installed,
Will the applicant ormnreNil goccupantusee .ipmentordevice%which If a roof is installed ithout fir, o ain' g an inspection, 1 agree to remove
emit haaardous air contaminant,it, .sued by the Bav Ar Air Quality Manasemeat
Dietrivt7 all new materials r ins pp cant understands and wil4co ply with
oyes No all non-point so cc r
I have mad the M1a.Me at -cmc s under her 6.95 of he
California Health A Safety e . u 5 255 and .4.1 code,, a t
't,hchuil,inyducdmm�. mlyl mit' c ,,,%ibility to ori the
nt
ve., of the regain cut, .h� a t r to.swan a of a Ce die Win
O.capumv, Signature pplica nt Date
owner m..nmar . ,Pert ;t All roof coverings to be Class "F3" or better
OFFICE