03010088oq.
W�
Fp. ZU
b6
o0124
ggmrg
u� 3 °��' IseI--
LLOJ
ZY
L�
O0
z14
a�
�z
UO
QUU
E+ 0.Wi
U4
I
CITY OF CUPEWfINO
BUILDING DIVISION PERMIT
CONTRACTORxINFORMATION
�.,
BUILDINGADDRFSS'
BOB GERE MASONRY
PERMIT NO.
833 ALDERBROOK LA
030 0088
OWNER'S NAME:
480 CROSSLEES DR
APPLICATION SUB DATE
KELLY MARILYN A
01/15/2003
HONE:
(408)972-1285
SANITARY NO. CONTROL NO.
ARCHITECTfENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
LICENSED CONTRACT'OR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
p
with Section 700 of Division 3ofthe Businessand PnNeasiom Cade,andmyIiccnreis
mmurareeandere®_
Lkena Lac.N CID
REPAJ_R ,j*TLEj� ®OM FOUNDATION
Date Contramn
r�NNQQ��
ARCIIITECTS D' ARATLOI
I undersund my plans Mall Iterated as public records
JAN 2 4.2003
Licensed Pml'exam.l
OWNER-BUILDER DECLARATION
1 hereby affirm that 11. exempt an the resins Co License Law for the
reason end Code: Any city err county
ID3sru
1'
�Following
BUILDING
t. dBusiness
which empires a Permit t improve. demolish. tar repair any swment
anpmm, alter imprrsu
e.alsore
h Permit signed aammcm
d
prior m its issuance, assent the the applicant for such penoiuoice
Sq. Ft. Floor Area
that to thcofDProvisions s
eLaw(Cods)or
$59A4iltion
sion3the Business ndProfessions Cade) or
(commencing with Section 7olgi of Division of tip
(commencing with
r aged exemption. Anvi
Thal he u exempt them(rom and the hints for flp alleged exemption. Any violation of
Occupancy Type
Stretch 7031.5 by any applicant for a permit subjects the applicant m a civil penally of
col mare fun few hundred dollars 450(0.
❑ I. as owner of fm property, or my employees with wages or their sole compensation,
18 1 157"
e r sp�ct�el
will do the work, and the wuc,am is not intended ororfered ohmic (See. 7044, Business
and Pmfessinns code: The Chanticleer Liarue Law doe: hot apply to an owner of
property who buildsor improves thereon, and whodo ssuch work himseifor through his
own employers. Provided that such improvements are not intended Confuted for Gale. IL
312 - CH I MNE AP S
514 — FINAL PUBLIC WORKS
however, the building or improvement is sold within one Sear of marpiction, the owar-
builder will have the burden of proving that he did not build or improve for purpose of
ink.).
❑ I, as owner of the pmperty, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Basin. and Professions Code:) The Contractors Li.
area Law does not apply to an owner of protocny who builds or improve thereon, and
who contracts for such projects with a conmctrnm licensed pu luam to the Contractors
License Law.
❑ I am exempt under Sec, . B A P C for Will reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury, one of the following declaration:
❑ 1 haw and will maiman a Ccnieeak of comenl m self insure for Workeracampen-
mtion, as presmad for by Section 3700 of the Labor CMC, for flue performance of ft
work for which this permit is issued.
I arc and will maintain Workers Compensation Insurance, as requimd by Section
3711 of the Tabor Cale, for ft performance of the work for which this permit is issued.
My Workers Compensation Compensation Insurraanncee and Policy number rum-
�c,,arrier
Carrier- : i Policy No.; /I -0
7E
C RTIFICA'TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed iffp permit is ho me hundred doHnot($IN))
or leas.)
1 cenify that in the performance of the work for which this permit is issued, I Mail not
employ any person in any manner an as to become subject to an, Workers' Compenmlion
Lawsuf California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this C'enlficoc of Eaemplion, you Mould
become subject to the Worker's Compensation previsions of the Labor Code. you must
forthwith comply with such provisions or This permil shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm inn there is a construction lending agency for the p,ohnmmet, of
the work for which this permit is issued (Sec. 300, ON. C.)
Lender's Name
Lender's Address
1 cenify that I have mad Nis application and sum that the some information is
correct. I agree to comply with all city and county on inamxs and state laws relating m
building consurcmdon, and hereby ar thorim representatives of his city to enter upon the
above- memioned property for inspection purposes.
(We) agmtr In save, indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmenu, emu and expenses which may in anyway meet, against mid City
i consequerecofthegnntin fOis permit.
APP D AND WILL COMPLY WITH NON-POINT
Issued by: Date
//ALL
R E I�T10 - =�
%) 'J
Re -roofs
Type of Roof
�� /S
YS
argnamm of ppRuH bntrWOUS MATERIALS DISCLOSURE Dote
Will the applicant err future building occupant store or handle ha ardous material
M dofuned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
CMe. Secfhh 2553201)? (
All roofs shall be inspected prior to any roofing material being installed.
❑Yas n
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant, r future building occupant sex equipment err devices which
mil hazmdnus air comhminanu m defined by the Bay Area Air Quality Management
all new materials for inspection.
Nsuict?
❑Yes J51 Nn
;
I have mad ft bamNous materialsmyuirements under Chapterb.95 orthe Califon.
its Imthar Safety Cade, Sections 25515, 25533and2553J. l communal mid ifthe Wilding
I ope n umenlly have a mount, Nat it is my responsibility m no fy the occupant of the
te arwiaaanceoracemfica ran try.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or authoroid e Dale