02070176 (2) OF
CITY BUILDING DIIVISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21203 OROGRANDE PL 02070176
OWNER'S NAME: APPLICATION SUB DATE
ROMELFANGER MICHAEL V AND HIL 07/26/2002
PHONE: SANITARY NO. CONTROL NO.
z ARCHITECIENGINEER: BUILDING PERMIT INTO
w BLDG ELECT PLUMB MUCH
a n CJ G l CJ
z h i LICENSED CONTRACTOR'S DECLARATION Job DescriptionO z=O I hereby afirm that I am Iicenud under provisions of Chapter 9l commencing
withsecion]ow),d Divislon3onne Buslnessand Pronasions Code.andmyicen.e SPA HOOKUP
=yyj
is in full home and effect.
z c 6 License Class Lic.g
a�3 1, Dao Contractor
p ARCHITECT'S DECLARATION
I unde-stand my plans shall be used as public records
w
,S S O K Licensed Professional
OWNER-BUILDER DECLARATION
b.z�` I hemby affirm Not 1 1 exempt from the Connncmr's License Lew for the
b.Z< following reuoa Permit
703 I S,Business and improve,
de oli Code:Any city s county $800
F 0 which requites a permit to conswct,alter,improve,demolifi,or repair any sulamem
e that be imiensedpalso Tequirhe lhcopplicaat foe Contractors
roicense awdsuiplar9
Wan"roAiaasepursuio l9 ntr pf Division
the,hc B.iofslioense lswi...Cer9 �'fT,+❑].a gIII or[��pa. Valuation
or tat a is alien,bt,mboro'Bl of Division J of nhc Businexsm. p.6. ry v Code) r•�''�, 1 3.6 'li"�:y p.,'(JjJ"n;j„s:tt�,r .i�j 5s•
or tat he i3 eumbn therefrom and the basis for the alleged elemant run
Any violation
-of Smion 703 1.5 by any applicant for a p<min wbjevls the apPlieenno a dell penalty •
,o(notmom than five hundred can.,SSOY. 304APNM5'MG7I ELECTRICAL Occupancy Type
01,as owner of Ne pm,my,or my employees with wages as than sole compensaide,
will do the'work;'and We'atwcu a is at intended ror offered for sato(Sec.7O4,1: '-' -'-"" - - - --' ---'-"-----"-----'-”-
Business and Professions Code:The Contractor'x Liaise law doe:not apply to an 505 — FINAL ELl9t44tXV(!TMctions:'',':5
owner of property Who Wilda or improves do man,and who does such work himself
or through his own employees.provided that such improvements em non intended or _,_....._..__..—_...___._._. _._._..___................__...._.____.,..1...__,.._
offered for sale:If.however,the building or improvcmenr is.mid"within one Year of -' _.._.. �......_._.._. .
completion.We owner Wilder will have the Wrden ofproving that he did not Wild or
improve for propose of sale.).
-v ..._. ___..__._.__.._._ ___............ ...._..___-_.._
owner o(ihe _........ ......__. -.-__..__..._.._
,GI, (Set.
lam Bo,inevelyco Profession, iicensno Cimnorsto Y;'It!s;Vs; °e0.1;.r.,,•
:-
construct the project(gee]flMl,Business and Pmfessiom Code:)The Conmcsar's „?S 11'1
License law does not apply no on owner of property who Wilds or improves thereon, 1R.II p p� '-'
and.who contracts for Such projects with e.commctor(s)liccnud.pursuavuo the .._ ..._ _..._......
am axes License Law. _f(iI exempt udder Sec.- ' s'�' .1t,e'•.P';", ',rt'J'`B'&PC for Wisrt ii^ t si li?Il
01 W I.ER'S ,MPaIt5 7DE R7C1'I0N ���� :O ����
1 hereby affirm under Penaltyf i YX° f}hefollowin declarations
.
BUILDING
0 1 have and wil(mainuin a'Cenifidhie of Conant to self-insure for Workers
Compensation. as provided for by Section 377 of the Later Code. for the
'perfonuattc,of the work for which this perm,is issue.
01 hevehe will'mainuin Worke'r's Cmr,m ation lniumnce.as required by Sccdm
3700 of the Labor Core,for the perfomuneof the-nddrk'for which this permitis
issued MyW k 'a Co pen.at on lnsumm dPolicy be
"I' I LA
T. -
Camer ,t L.1' ,..sI ,C Policy No.. .. ,+ ..,1..}.. vt'i.'e 'Yi.{ ,it,?4
:CERTIFICATION OF OF EXEMPTION FROM WORKER$ "" ,` , .
COMPENSATION INSURAN
.. _.CE
. ...... ........-.__.... _..__. _ a
' M s section need not his,completed if the .it is for me hundred dollars .. .
($100)or less.)
1 n fy.nh t i the perf int de f e wo '(ar wy' h th permit is issued l
Sh 11 t employ any in any m W e R J nje t an me Worker"
Ca pc sa i Iowa al( ' D
N TO APPLICANT If e(ur making this Certificate doE peon you
inshould l:iL Nf
became subject y it Workers provisions
wuon Prov it shall W d labor Code,you must
Q O f- __ .comply with such provisions or this permit_- , domed revoked.
Vit •' -'\ CONSTRUCTION LENDING AGENCY
�•' > I hereby affirrin that timm is a construction lending ag cy fo We performance - -
ofineworkforwhichthsperms sissue l5 ' 309],Civ.Cl ...___... _..__-_... ..........__...._ ..._ .. .. _......-__._ _.__ ..... __.
IILI "Lender'i Name_ .i , s-.:•_s.._..�._cn.;:,i _` _. __.__. ..—.. ._._... ..
7,Z tj,....:.q
V ,+.,�1 certify that i have read this application and state thauhe above information is
•comet.1 agree to comply with ell city and county,ordinances and state laws rtlming
Osf, ao Wilding consnuctton:aeA hertb'mmhodie representatives of thii city in enter upon
the alm.-mamimmd property f -inspection p rpo
0.i (We( g eto save.indemnify and 1w phaml:citne City of Cupertino against
Vit liabilities,1 dgmrm t d penu h n may n any ay cme gai t said
C,7 Z city n 9 ce cf the granting of IN V n
AI PI ICAV7 UNUERSTANDS'ANDWf OMPLYWTTHALLNONPO T
Ity ce RF ULATf�t',g!� �? - �7 /� Issued by: Da[
gn s fAppl¢andCo for l l `,,/, Re-roofs /
I HA7AI MATER AIS DISCLOSURE-.
wn th ppGe t or,finum Wilding occupotstore or haralle hand s mat 1
as deb tl by th Cupenm Mu pa1,C h pt 912. d th He IW a J gafety
Cade s t n 255)$1 I s t . .''. 1 a ( '. ._..._
t` "• .a - e All roofs shall be mspected.pnor to„any roofing material being installed„-,
with, PPL t t W ng ocapsnn es p n devices. n ch If a roof is installetIwithout first obtaining an inspection, I agree to remove
did h e d Mit m m.a ended by the Bay AreAir Quality Ma8 0
Dsna all new materials for inspection Applicant understands and will comply with
4Yes ❑N r _ t . _. .. .. ._....
all non-point source regulations ,.A,.
1 havq read the hmaienals rcyu rccnd under Chapur 'of 695the
ous m
Califomii Health&Safety Code,Sections 25505.35533 and 355.34.1 undenund mat'
iRnhe building does not cupently have a¢ .t
too”
is my"IPopstbility to notify she - -”- .... ..... .. .. .__. - _-. -__._ _. _ .. _ _
'occupant of the requirements which m' mel,prior to issuance o'a Cenii a of
c partcY
7 "v Signature of Applicant Date
Dem
All roof coverings to be Class "B" or better
OFFICE
e
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