01110107 CITY OF CUPERTINO
'BUmotrvc ntvtstON PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21390 COLUMBUS AV 01110107
OWNER'S NAME: APPLICATION SUB DATE
ROB & CYNELEE -ROVETTA 11/26/2001
PHONE: SANITARY NO. CONTROL NO.
w ARCHITECrIENGINEER: BUILDING PERMIT INFO
z , BL11 ELECT PLUMB MECH
- Z LICENSED CONTRACTOR'S DECLARATION Job Descri tion
5,!2-a 1 hereby affirm thw 1 um licensed under provisions of CM1apmr 9(conemencing P
yam whhS ron711W)nrDbh.ion3nnneBaafneasamPrafe..mnaeoae.andmrRana= REROGF .
nrweeana rec ��GJ�'Z�j T/O EXISTING WOOD SHINGLE,
:O I
iarnc Clas> Lic.M
:3 ae` ARCHITECT'S DECLARATION FWXC C WITH 1/2 PYLWOOD &
Oy i understand my plans shall be used az public mcnNs `�tlV.■ p
E 13
3_ p C Licensed Prmessmord ■ 9 4�Pte, :Mr
x,u OWNER-BUILDER DECLARATION JAN 1 7 2002
w-w 1 hereby affirm that 1 am exempt from the Contractor's License Law for the,_1
2< following recon,(Saban 7031.5.Business and Professions Code:Any city or county
P s e which requires a permit construct,alcr.improve demolish or repair any strum e
ca prior: t I q theapplicant for such Permit fl signed statement _-
mah !parrs an th p : of me CommnorsL use le fChapeer9 $7 ��
(commn g ,Tess : '1011% fD 'on Sof the Busness dP f ns cone) v"i r'-* vi 'i.. . ._ al�,ll l,'a %r 4 tion...
or that he:s cxempreheiefrom and,he basis for the alleged exemption,Any violation
of Serino 7031:5 by any applicant for a permit subjects the ap,licam m a civil penahy Ap�y
:wfnntmnrethanfvehundreddnuarsls5w). 36lUSU be6o "I, Occupancy Type
01,as owner of the property,or my employees with wages us their sole compensation,
.111 do the work'and'the'.swcmrt'is not intended or offered'for sale(Sec:'7UW,'
Business and Professions Code:The Contractor's License Law does not apply to an 3 0 5 - FRAME Required Inspections =t: i'l p
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.Provided that such improvements are not intended w 3.0-7 r,..INSULATION
-offered tar sale:If.nowevm,me Wilda ei - e is sold wimidone-eai of
. . ._...
e g or urden o men y ._..... .....-....
completion,me owner-builder will have the burden of proving thin he did not build or 601 - ROOF TEAR OFF iis '"' •' a .;. • '
improve for purpose of sale). 602 - ROOF PLYWOOD NAIL
asowner --- -_. .._ ding ._ ...--_-_ ...... __.._
00aspwnce of n contracting with Contractor's
property.am gwi 603 - ROOF BATTENS e'
contract de present ISec.)to a Business arta Professions ills or The contractor's •, .
..d,welswd«anorapulvmanawnmafimpenrwnsidlicensedprource,odba 604 - ROOF IN-PROGRESS'
-.._ ..and, actorsh. License
for such pmjms.wim a coinraceorts)licensed pursuant m.me. ....._.
Comnctxe License Law...
_ ❑lam exempt under Sec %B&P C for this reason , 2:U':i s,'•'
Data
WORKER'S COMPENSATION DECLARATION
1 hereby alfnm undef ismaltY of perjury one of the following declarations:
❑ 1 have and will maintain is Cerdficare of Consent t°ulf-imme for Worker's
Compensation, as Provided for by Section 37W of the Labor Code, for me
-_ performance of the work for which this Permit is issued.
❑1 have and will m imuin Worker's Compensation Insurance,az required by Section
3700 of m Labor Code for the Performance of be wm1kF.r which thispermit is
ssuM.My Wince d ComPe i 'urnce career n0 PoOcy recta am
c
"-x--
artier Poljr icy No
. ION EXEMPI'10+ OAWR R , }*`. f ��l. N.. +,.Y��-• ; 'S'•'a(els. `i : . .
COMPENSATION INSURANCE"
minim ,tion baa nm be compkm iea if me pemis for one hundred dollars
l 1 I I"'' 1.:.•: i v• —
(5100)or essJ
y n Performa fele A f hmh m pe 'e es eskw l
shall not employ any pc y ncr so to becomm e s bft Ne Wmk<rs'or
Compmsanon w
las of Califmm� ¢
Da " '
Appl
NOTICE
is Certificate
e should
NOTICE bj APPLICANT:IL afar making tats Cemfis of of Exemption.you umst _ -
become
t.6,loalt such
Compensation provisionsofthe
emed Code,you must
C
f«mwial comply with such provisions or lois Parente shall be deemed msnked. s
(~ _`•� ffir CONSemeisa ONLENDIhG AGENCY
�i in 1 hereby which mm m '-a•coned(Sec.
e o lending' 's.Cn) f she pedortwnm „
n.t of the work for which lois permit is issued(Sec.1097,Cis.C.)
5-Z Leaders Address" •+ .-. - .._._..._... .._..._ __- - ......__ ..
Up
U-� •1 FcnifY alta 1 have read alis application and seine ma,sa above information is '
W.F torten.1 agree w comply with eall bb ityout arta corenry.cesturnces andnum laws enter
upon
mmovegconimirdoropeand y f inspection
ofaliscitymenmr upon
me abov e)a,ree m pmpenY for inspection pugwscs.
eWq agree ts save:indemnify and kap harmlesi be Ciiy of Cupenmo!gam,,
V] liabilities,judgments,roses and expenses which may in any way accme against said
City in conseccentric,raining of tars ii -
S T`1p' 'TA�s q'IL Mal.vwrrxai�• Issued by: Date
S eR:cuun N l/ 't
I,. e f _credc nvactbr': ( '• ••e'a• Dam
HAZARDOUS MATE A - LOSURE' ' 'ice: Re-roofs
„•-'WII'mamidicntorfwwebudding moan,aedr<«naiM�haiaAoaametedal Type of Roof _
as d fi ed lie Cupertino Municipal Code Chapter9.12.and me Health and Safety
Cud:Sec,by 115,531001aa
c:
. oY ❑rva ;' '• '` All roofs.shall.be inspectedpnor.to any.roofing-material being installed.
wuamair rions future bu'ming«t p i.equipment aevajwnirn If a roof is installed without first obtaining an inspection;I agree:taremove
emit i,x it comanrtams ss defined by me Bay Area Air Qualp Mawgerrrcm g
°"'""" " all new materials for inspection. Applicant understands-and will comply,with
ono ,., , ' + '. - p ..
Cut
all non-point source regulations .
1 have read Sec ety Cod Se to al 550.25533 a under 4.1 a 695 of tab
Califomra Health&Safety Code Sections 25505.25533 and 25s30.1 utWrnuM,hae
fthe bar ld' gd team tlYh ea¢mn,al t t s Yi'espa -b lit to WV me
'�pan d me recta rcme t h' Rnuse be m e p- m' arab - f is C o fcete'of i kolo/crings
/
Pan Y _ - ---{
' �� LG' Signature of Applicant/ Date
- _ ,. _ . . . _
z .
°w'"==° ° g=est Date All to be Class "B"or better