01060165 NO
CITY
BUI DING DIIVI.SSIIONNDPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10240 BUBB RD 01060165
OWNER'S NAME: APPLICATION SUB DATE
•HOVER ELIZABETH B AND WADE H 06/28/2001
/ PHONE: SANITARY NO. CONTROL NO.
0,-,. ARCHITECf/ENGINEER: BUILDING PERMIT INFO
U BLDG ELECT PLUMB MECH
L171 L-1
LICENSED CONTRACTOR'S DECLARATION
5„- lob Description
O to_ 1 hereby Bann Nat 1 em licensed under provisions or ns Code.(commencing
6 vnFw wiNgenion70(p)of Division Jofthe Busineuand ProfcssionsCade,add mylicenu REPAIR EXISTING CRACKED PURLIN.
m iz in NII fort<and eR t.
z 6 Lic<nse Clnss Lic.M ), RC
Dau - - Cantrxtor 4MSL �7A6M
ARCHITECT'S DECLARATION �et4 a.T•
'=O 1 understand my plans shall be used as public records '
�Y
p O Licensed Professional
6 p'
OWNER-BUILDERDECLARATIONthe RATION
tr� 1 hereby affirm thin 1 am exempt win the Cessions Co License Law for the
E?< following reason.(Section 7031.5.mi Business and we.de ions Cod,:Any can st aunty $2500
2 x❑ which requires ti permit de sins;Ile alter,imppro��,demolish,or repair any swcmrc
E:Q...that
o e is nc al rc9 tru prvidons nt
of theConpawnmicnusLaw
N sedpu nudthep svision the @ntmcmrsLnenuLaw(Chaptere) gt ggI� orA�,a I Valuation
or(commencingeiswithSet )IXIDIof ebn,Inooththe eaBusnoesdnaPn.Anyv caem i;Llt;'n;-i'35 2iU.0L20. O J, Uir1A).R): ' '
or odaiSac,be Is 11.5 pf tin, ,,In and the basis for the xn th d ezempuoo Any l violation `
-of Semlon Il1,31;5 by nnY t'PPlimmt rnrn p,nnit snhjreu the npPlicnm m v dull pennlry
mf not tram than five huod.od dada lSS(llo. 516AhN �'$}� t BUILDIN i10 Occupancy Type
❑L as owner of the properly,or my employees with wages as their sole compensation,
will dm'the work;and the structure is nor intendedor offered'for'sale(Sect 7044. s+,J
+Business mhaTnifensions Cade:The Convector's License Law does not apply to an Required Inspections^':•
mer of property Who Wilds or improves thereon,and who does such work himself 1
ow I
o through his n empl see..provided that such tmpm t is said
are not intended or _ __ _ _
offered f 1 If,h r thel have t ser tap n of Prot' s Id withinone year of -- -"''"-
improve
m --
completion,n the owner 6 e.) 11 have the burden of proving that he did of build or +� �D
imp o e farpurpose f sale.).
,�IyI Ilr.1T
e. OI as owmar.of the properly,um exclusively contracting with licensed contractors m U: t ,.
: = con wn the pro3ect.Sec 7814,Bus oases and Profcssiorm Code)The Contractor's
License law dos nwt apply m vn owner ar p10 of who bui ds or i rounn thio dn, N�
_arta.wno.contracu.mr.xoch. is wild contmcm s lica- - t.m Ne
m.
C o d. License Law.,-, ,
Olam uemPt under Secy'' ,,8&PCfor this reason
ner6rq One
WORKER'S COMPENSATION DECLARATION
-1 hereby affirm under panty of p,rjury one of the following hclmmims:'
-a. t
C1 1 hvv add will'mainthinsit Certificate of Consent,to self-mome for Worker's
Y,G Compensationru-providel for by Section 37M of-tide-Labor-Codc.for the
'performance of the'work.for which this Pewit is issued.a +
0 have`and'will mainnin Wo}ker's Comperionioni ln'sumnce,as mquired by Sat_ - 37M of Ne labor Code;for the peff.mance of the..,k for which Nis permis is
iswed.MYWorkers Compensation Insumececa p�an.d��Policy numbv are:"
ECO l 7.1 t ..
Carter. NOFEXE,PTIO fa0 i.In 4 J�k t'tirr4,+p Y (�•r. + 'Y,tl Lt" .7 '. .
. s„r ERTIFICACOMPENSATION INSURANCE”' KBRS'e - �. - _4 r I+-T_ tl <
COMPBNSATION INSURANCE..
''' °i senior need oat be'complemJ dtM permit is for one hundred dollars �'-' ' I .
f91001 ml,".)
Com nsat oo Ld
t PyY wnynf7'.Inco mdse sof h hth p tt ......,
I rerl r tRlt ll¢ rlornunce of New is ed 1
'hill m I sed e n n m 1,corde uh c no tfieWaiters' •..'�Ltl l D ( ' j, 'tt".' ` - '
__ _ _._.... ... ,..__ ., __.,_.._ - _... .-. _...... .. .f ._ _... _...-......-
NOTICE TO
APPLICAN11 Ten k t
ttetakCrptitC d;yo I
buc pC fh nt
lwith
othO forth tb mPd v+
..
fallout hall bc deenned ra,okad +
'I CONSTRUCTION LENDING AGENCY - - '
a.' l+ 1 be hr f6m that Nee conn t lending agency f Ne perform rinxlT
of the kf which tht ,
� Q Ixr Name paver <,si cd(h 31147 Civ
d 1 a,_ , . -w._.-. _
z Lender's,Address;' - Irl' +.+, ;'i
! V_C) i r
1 candy that I have mad Na application and state that the above information is
LoneaO I agree ta,ennply with all city and taunts prdmancev,andstn¢laws relum,
- QgrJ 'to buildingcomm iu^,and bcteby unhodic'rtpre5enmtives p(dik city menta,upon.
the above-mentioned property for inspection purposes., ... -. ..._.
._ F.GL IW,I,agrce to sive,indemnify and keep haimlessttie Cityof Cupeninoagainst
&n liabilities.p+agmems .,is dad expensei wh h may in any way accom tigolin, said
V Z Ci, n consequence f the of thl pewu
:Wpy IC NT,UND RSTa SA D WILL COMPLY WITHALLNON-POINT A S
CIssued by:
Date
I . NA -7Ci-o I
Stgnmurc of Appl,a UCs L y D1 Re-roofs
.H\ZARDOUS MATERIALS DISCLOSUR
Will the applicant or Room building occupant or handl htii maal ...Type-0f Roof-._ .
sex d fin,tl by the Cupertino Municipal Code Chapter 9A2.and the Hi W and Safer )
Code"Cl yet, 'N” 1 t -lt rU C'1wit, 'J"
sI, . l '-alkUllil
- 'ng All roofs shall be inspected prionto-any.roofing material-being-installed.--,__,._....
Will he applicant f building occupa t cq p dt devices which, If a roof is installed without first obtaining an-inspection I+agree to remove
,m t hazmil wmmant a.defined b the Ba Ara At
' 6 t
.Distinct?, ,, all new materials for inspection. Apphcant understands and will comply with
❑r y7t.o t .._ ... _
+ "I have read mem 1 d ax mamnalx r< airernenti'd a< to iter 64 all non- omt source re ulations,
P g t.
t v s r r s5oms n set td ntotif,that .
y p 5'ofthe
q
C hf m HedIIH'&Sala Cal Sections Y5505 2551]and - _
i entn ,to!! it rO
o u nt yr N must rt m°t pr '° a f°c Signature of Applicant Date
N b Id due n B n � p Y Y
P R n to hh .. _. .._ .. -. ... ... ... ... _..... _. .. ..__
Certificate t'
` '.o araaNt r. 1 tat t
Date,,
All roof coverings to be Class `B" or better
.OFFICE . ._... .. ... . . _..._-.. .. .. . . . ._ _._.. . _... ...
rr r I