02020067 CITY OF CUPERTINO 4r'
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: APPLICATION SUR DATE
TROLLMAN JOHN H AND HELEN S TR 387 UMBARGER RD #B 02Z20/2002
PHONE: SANITARY NO. CONTROL NO.
(408) 362-1111
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
cI- BLDG ELECT PLUMB MECH
N6L
v i LICENSED CONTRACTOR'S DECLARATION Job Descri tion
Dy�0 1 hereby affirm 1 am licensed under prhvisiou.of Chapter 9(cotnnsncing P
m F-u with Section 000)ofDivision 3 of the Bmneu and PoWassions CWeand my licenx
,7 f is«Tau ane ettec �( REROOF.
3 � _�3 1
3to nse o Lhne3ya�� Corgi T/O Q LAYER SHAKE, INSTALL 7/16 ' OSB #
_
ARCHITECT'SDEC+LARATION T 30 # FELT & MONIEN CEDARLITE TILE 1 CBO
ft`3i—
e -I understand my plans shall be used as public records
+Y+d o 0 1.¢en.•cJ Pmfessinnal
i x o LL OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
?a following reason(Section 7031.5,Business and Professions Code:Any city nr cormy
F C which requires a pemrit to com+me6 rom,improve,demolish,or repair any sma,rom
a 3 poo t t ce,alsoq Neapplicantfo such pc a flea signed statementis.
that he I«n,Wparsaa n NC Proiliumofth C tmctolsLtt La IChapmr9 S F[:Floorr-Area ,.. Valuation
(romm< cinB thSectin7000) fOs i of the BusinessdPof :ons Code) ,(r,' 3 �s. ..9.:Lfil, ? N�_ X„Y, ',=.,"'�,i'tt,;'y; $
or that heLexempt tit m fnand the hais for the alleged exmpi n.Ayvolation 25000
of Seaton 7031.5 by any aWl cam for a permit subj¢ts the applicant to a civil Penalty
of not mom that+rvehundreddolma($5o0). APN Number ., Occupancy Type
❑l,as ow net of the n, r 34212072 . 00
props y o my employees o f needed or
11rad f r .[a(Sec.7 ion.
-Bulli he work,and rhe ode IT C a inrcndcd'or,a Law for salt(Sec. to0.n, - - - --- -
'will
es and ertyPloWho
Cd,o Thc Commnor's License Lew does hot apply m an Required Inspections''
nwne
r hr propenr won mild,or imnrnv=.merthn.and was due,such work himself 305 - FRAME
of through his own employee..Proxmed that such improvements am not intended or -..3 0.7... INSULA-T-I ON--- _
oReredfoi sale.If,however,the Wildin__ . .-__ t issold within .a yea f - .___ _
'completion,the owner-builder will have the human of cn. that he aid not build or ,
mprove Tor Pumhse or sale.).
r,nv�ns 601 - ROOF TEAR OFF
- - . .._. . contractors- _ -_.. . ....--- .602_..- . ROOF_ PLYWOOD NAIL...._____._ .._.._.....
s; ❑Laowner ofthe PropenY•am Businivelyc Pmfessions
Ciille)no Contifis - --_ - -
=
consumer awthe proem(s¢.]Baa,owner ofandertywhobehaeoThevestmcmr: 6O3 — ROOF BATTENS '
License Law does not apply man owner of property who builds ce improves+hereon, ` ..
:: .aha wnP,eonuama rnr.aarn pmJenta.witn a tommnot(a>Banaea.pursaent.rn.me ._ .. ..__ .604._- ROOF IN-PROGRESS.._.._
Convectors License Law. — - --._.._ ... ......
❑I am exempt under Sac ,BAPCfor this reason \ --- - --
_ Owner ” " Data
WORKER'S COMPENSATION DECLARATION �B .e6E®
I modayalfrm under penalty.ofpe}fury one ofrhe following declarations: ,,f d�'a
( ❑ 1.
I have and will'mainmin a Cenificam of Consent'm self-insure for Worker's MAY 0 1 2002
Compensation, os,provided-for by Section 3)00 of the Labor Cade, for the
performance of the work for which this permit is issued. .
Qy1 have and will mainiain Worker's Cympmutation Insurtnce,n required by Section BUILDING of the Labor Code,fm the performance of the work for which this permit is
blared.my worker's Compensation Insurance scurther and Policy nunder arc: _
tom., sass _ .. -_..
• „s,'Ct RTIpICAT10N OF EKEMFT16N FROM WORKER$ ,;',' ' ?.^, i .ts. „t� ) s
e
- ,,,'._,ten .-, ,-_COMPENSATION INSURANCE”``
"�: (lTss io ne<d nm he mmplemd ifm permit is for one hundred dullart "�---
(5100) rlesc7 -
IcnifYlhtnm pclrm nceofm rkf -whichth p,mad , .sed1 -
shall ram employ any orwo in any manner so is m become aobject to he Workers' _, tit`1Applicl .
Compensation tsws of California:Date "
NOTICE
'NOTICE TO APPLICANT If B k grit C nfc t fExempion you sha Id
Z forth' sobl a +h W k- C pe r pr - o.
mha or e d LaMar Code you must
Z 0 fonhwith comply wnf such provisions or Ns Pamad shell be deemed invoked ,
F. i '*r• -
CONSTRUCTION LENDING AGENCY ' ^"
1h by ffihi ibis titrt .o-(S d'gagency for the performance
Lsl of the work for which this pemtit is issued(Sec.3097,Civ.C.)
0.D a Lender's Name ..-_ .._ .
Vz Lend Add. .. � . . .. - _.. .._.... . ...__. _. .... -_ . ._.
1 ccnify mat 1 have mad ibis apphcaion end stain that tit hove information is —
�T+:(—t ootr«r.I agree rn comply with all city and county ordinances and state laws minting y
mbundirr town coca,and hereby-amhmiie representatives of this city to enter upon
the above-memioned property for inspection purposes
...moi G` (We)agree t6 save:indemnify and keep hannlesi the City of Chis marsegeiast
V]
liabilities.)udgmems,colas and expenses which may in any way,pec against said
U City' consequence of the Brat ND I Permit. I •• /'�
- AP LICANT UNyt'R$bS5N AND WI' OMPLY WITH ALL NOVPO'INT Issued !
7 t
$D c ,t y: Date
tgnpm rAWp wanUConwclor ^^; ., Dme '
- .IT RDOUS MATERIALS DISCLOSURE' t Re-roofs .
'ser�lbd+e pplitani r m w'1a g«t pantstort-.nandmwmra mat 'a1 Type of Roof ., .
Chile Section 255327 Mu p I,Code Ch id 9 12 d m H hit d 5 f ry _ s,
❑v I SHIDn 3 l� ,.'t. J !n '';n aka I P t` y n 1 ;i" ..
• _, _. - i All roofs shall be ins ectad poor to an roofng,ma[eria] being installed.
Will to rpt am art w defiled
ed«t p t a qa a Q., a ,wn or If a roof is installed without first obtaining an inspection;I agree to remove
ain't h M c mmm is as tl'0ned b m B 'Arca A: I t Maris emcnt g
Di""oy all new materials for inspection. Applicant understands and will comply with
> Y Q Y B
. �o .
all not-point so6rce regulations.
1 h e eatl the;hazard mwertels qu rcmenti under Ch pre 695 of me "
Califoriilic i Health&Safety Code Sections 25505.25533arm2553a 1uMerrinalthat
dropech ding ass not arremly M1avca¢nam,Cher it is mY responsibility to notify the - ___. _ _... ..
cupe_t of the no'
re which:mist be met prior m issumcc of a Cenifica¢'af
coup. ., ..
w. ? �' '- _ -_-' ' � o Signature of Applicant Date
own= m6 ,.ee,agt t „ Date, All roof coverings to be Class "B"or better ' "
OFFICE- .. ._ _ ._. . . . . .__ ... _.. ._ ._