03010017 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOWINFORMATIONr
BUILDING ADDRF_SS: PERMIT NO.
22004 BAXLEY CT 03010017
OWNER'S NAME: APPLICATION SUB DATE
ALAN STOCKLMEIR 01/06/2003
orZONE: SANITARY NO. CONTROL NO,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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`OO LICENSED CONTRACT'OR'S DECLARATION ��DCSCiIp titin
�Zj F 1 heady affirm that I am licensed under provisions of Chapter 9(commencing
<� with Section 7000)of Division 3 of the Business and Professions Code,and my license is
a in full forceandeffecl. TEMP POWER I] �m
License Class Lic.0 ua��ka
Oy— Dare Contractor
ARCHITECTS DECLARATION
--y
g o+ l understand my plans shall W recordsJAN used as public records O p 900
to 0. C
H LL 0� L'¢enseJ Professional ��
OWNER-BUILDER exemp ER DECLARATION
fy,u�22 I herehy affirm Net I am cacmpt from Ne Cumranors License Low for tW C®IJt G
12 S O O following maam.(Second 7031.5.Business and Professions Cole:Any city or county I tl
se ii IKi which rtyuircs is permit ,,consumer,am
alter,improve,deolish.nr rtpan any shut
an prio,I.its issuance.alsnrcyvires theaPPlicam Maxima permiuo flea signed statement
££mm< rhatheislicensedpursuamtntheprevisionsofrheCuntracmr'sLicenulrw(Chapter9 Sq. Ft. Floor Area $YzOtOttion
yFO (commencing with Section 7")of Division J of the Business and Professions,Code)or
y $ Nat he u exempt therefrom and Ne buns for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant so a civil penalty of 3bkW9 PU Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,end the structure is not intended or offered for sale(Sas 7W,Busineu 103 UFER
and Prafeasions Code:The Contmdora License Law does not apply to an owner of 304 - ROUGH N.L11�1..�.x1l:HLIOnS
propeny who builds at improves thereon,and who does such work himself or through his
own employees,provided that such Improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did nut Wild or improve for purpose of
sale.).
u owner of Ne propeny,am exclusively contracting with licensed contractors m
consumer the project(Sec.7PW,Busineu end Profusion Codep The Contractors Lh
cense law does not apply Iran tenor of pmpeny who Wild,.,improves thereon.and
who contracts fortech projects with a emimacsm(s)licensed purauanr m the Cimmu a'a
License Law.
0 l am exempt under Sec. B&PCfor this re on
Dale
WORKER'S COMPENSATION DE INION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Confirm
cation,u provided for by Section JJW of the IaWr Cale,for the performance.f the
work for which this permit is issued.
❑I bane and will maintain Workers Compensation Insurance,as required by Swam
370I1 of me Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number em:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This seninn raced nut W completed if the permit Is(mane hundred dolled,(SBD)
,it less.)
I cenify Net in the perfoptlance of me work for which Nis Permit is jawed.I shall not
employ any person i�n��f,,j�sannef sWaau'hLfYtnefubjut to the Workeri Compensation
Laws of California.
Applicant
he ;1 Jp APPLICANT:If,after making this Certificate of Exemption,you should
McorrrpT]hhleci to she Workers Compensation provisions of the labor Code,you must
OO fanhw th comply with such provisions or this Permit hall W deemed masked.
z .~Ni CONSTRUCTION LENDING AGENCY
[—i I hereby affirm that there is a construction lending agency forte performance of
(x > the.,it for which fair permit is issued(Sec.3097,Ci,C.)
W� Q Leadera Name
z Lender's Addreu
V 1 cenify Out 1 have read this application and sum that the above information is
ki. E' correct.I agree to comply with all city and county ordinances and state laws rooting m
OU building eonswetion.and hereby auddree representatives of this city to enter upon the
W shoe-meminned Property for inspection purposes.
(We)agree or save,indemnify and keep harmleu the City of Cupertino against
y liabilities.judgments,costs and eapenses which may in any way accme against aid City
V Z in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WIL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER /ATIONS.e L '�
`� / Re-roofs
ignawm of Applicar/Canwcmr ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(more Wilding occupant more or handle haardous marerid
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 25532fg7 , / All roofs shall be inspected prior to any roofing material being installed.
❑Yea LTVO
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit handfous air conmminants as defined by the Bay Arta Air Quality Management all new materials for inspection.
District/
CYos u 1
I have read the hnvardou namerials requirements under Chapter 6.95 of the Califor-
niaIlcalm&SWety Code.Semlons 255115,25537 and 25534.1 undersand thatif lW building
Joes nm currently have o¢stent,Nat it is my responsihility m notify the rccupunt of the
i men ich must Wmc 6o irso eCcnifieze, aWppne/ Signature of Applicant Date
Owner or emhmiacd agate /•/K� ff -y/V/Ofa'c All roof coverings to be Class"B" or better