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01100143 CITY OF CUPERTINO j BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: BUILDING ADDRESS: PERMIT NO. 21421 ELM CT PETERSEN-DEAN INC 01100143 OWNER'S NAME: APPLICATION SUB DATE MACLIN GEORGE F AND NORMA J 7980 ENTERPRISE DR 10/26/2001 PHONE: (510) 494-9982 SANITARY NO, CONTROL NO. O 0 O ARCHITECT/ENGINEER: BUILDING PERMIT INFO kC Ivi 8L ELECT PLUMB MECH 8 y i LICENSED CONTRACTOR'S DECLARATION lob Descri ti n 5 Z ❑ 1 hereby aRnn that I am licensed under provisions of CIaMor,9 Onmmencing p me withSeclion]fNq)ao�fDcisv,ision3oftheBusinessandPtofessionsCwle,endmylicense REROOF. �y5 ,an Poll force and(..; J oau Lice"x L.LClzss _ t ID ua.« T/O SHKr RESHEET 1/2 "CDXr i3 u'~ Dair i ale C A�kCH1TECT'S DECLARATIi ADD 40YR. GAF COMP. SHINGLES . 2to I undementl my plans shall be used as public records a�O 9 I-menxd Professmnol k oro 2 OWNER-BUILDER DECLARATION m—m I hereby affirm that 1 am exempt from the Contmcl License Law for the C?Q fullrovirg reasior.(Section 7031.5,Business and Profeasions Code Any city or county ❑ which requires a permit to construct. lter,improve,demob h o p r any suucmrt m pit t t ane 1 req the applicant for Myth Perrot m file signed st,emem- .__ . ._. _._ _ __.... .__.., _ —_._. y _ _.W ..._.__.__. ._._ .....__ that bribittlictimatel patmostrilt the priadsions of the Contractorv Licinne Is (Chapter 9 m meg tgse t a rD'v a on a the all geb «e iory Ac�de) CID' , (;�S9: r- r" a r,; lzaMIN 1.�'al1J:- 1 $1-04�ation or S the is 31 i5 b therefrom anJ the basis for the ch,th a¢tempt on Any l violationpenalty of Section]031:5 by any applicant for a permit subjects the applicant m e civil penalty ' ofnet'..Illnfimhandled doll.,($500). 362'aWPblil6n.1148 r"'.,'r•" Occupancy Type ❑I;as owner of the pmpeny,or my employees with wages as their sole compensation, will`do the work,and the structure is not intended or offered for sale(Sec.7044, 'Busineis e 'Profe ndssions Cade:Thc Coinmcmr's License Law does not apply to an 305 - FRAME Required Inspection§10-roP r,:,;1 owner of pmlval Who builds or improves thereon,and who does such work himself or through his own employees.provided that such improvements are not intended or 307 - INSULATION offered for sale.If however,the b ilding or improvement is sold within one year of - - "-' dmple ion,the owner bueder will have the burden of proving that he did not build or 6 01 - -ROOF TEAR OFF npnceforpurpoxafsale.). 602 - ROOF PLYWOOD NAIL e DI as owner of the pro fairly,am a x clusively contorting with licemand I eonotion to ._ . 603 .-ROOF` BATTENS._._._.r._.._ Lonstruct the pro3ecr(Sec.7044,Business end Professions Code.)The Contmemr's icense Law does not apply'.a. .net who builds or improves thereon, 604 - ROOF IN-PROGRESSa:.Dr. -L-Ili r, _and0 1 h t is fo h ps ns with is cot ror(s).licensed pursuant to the .. . .___.._ _ r�— Contractor ont t s c lop not SeciB&PCfonhis reason tr"d N4 `s r4m'� I _ Ownei' Dam _ uo L� WORKER'S COMPENSATION DECLARATION 1 hDEC 0 2001 ereby aRmi under peiupy of pe jory;onla e ndl following declarations: C ❑ I have and will 'maintain a Ceaiman of Consent to self-insure for Worker's .3 Compensation, as mweieed for by Section 37M of the Labor Code, fm the BUILDING perfornal afthe wmi forwdch this Remit is isaued. . �pf,��i h i d II trio t W ke a-Compe S t Insurance,as required by Section /J)00 of the labor CWe f the pMRrmarice of th ork f which thisperm tis is's d W lon's Co prow a l7aurancec carrier,end PolicynuImlb c Carne f ra Poky TIONFR 7��Y 7 y� _ ..r >• y.+. _ _I _ ' i,cpbyiP AT OF EXEMPTION PRpM WORKERS'l i. f $ F1 r�E�. azo - e p?',1(v;} kjt�h. :�_ COMPENSATION INSUPeR�NCE. _...... -- ' ' (This senan neednotbe'comleiee if the t is for one handled dollars `t•"" 'i•' i 'i' i.�t•. (J..CL{ ❑ -1 t,(Iti. (110f)or less) ' carry yahot in the performance hhfwhich the permit is uschad,1 _,Ci.l!' "I' :'i�t.Vi4 b'"• _ shell m not employ ink person n any ' n r so as t become bat to theWork is' Compensation Lawsof California,Dale,' • i Applicant ... .. ..... .,.... . ' O NOTICE TO APPLAhe Cerfr t of Exemption.you should ihould CZ became subject the W Corrt n prov stopof Lab CoeYou Forthwithmust comply h such P Provisions othis pe ,tshall be deemed revoked. I I,,,•i„i Vaa FQ _ CONSONLENUINGAG,.ENCY > rem that themysa imiao1agency f.nJ he pcffbn`i: n_ne ofthew owhihs 's suet IS 307;Ci.C) Lentl Nam Lend¢ Arbon rb s i, ...,..,. i;_, .. W bum y agreenfilly that 1 have read this city and on and state tnat the above information labor, ' E., ea.r agree tr comply with all lot and county ordinances and state laws relating - V the Mom-ancring aarmado,aid fiereinspection rtommsematives of this city to enter upon y_W 0e b e) t oriindo inspection p p s (W) get a droit fy and keephannl s the City of Cupertinoagainst Fr Vi liab i 1 1 dg ms is u d xp n es h h m y in any way scame against said V City in consequence of dsi granting ofthisp t -' APPLICANT UNDER$t ND WILL CO YWITHIALLpNo�01 T ' SOURCE REGULATIONS 17 Issued by: Date Sign nue of ApphcH Z ' HA,ARDOU A.ERIALSDISCLOSURE ' ° `"! Re-000f$ p p mate al Type of Roof Ntl Silt the ppl ant err boom butt n aril ant sin r Bandl hazallou as defined by N 53 mit M ici o W Chapter 9 12 rid the Health rid Safety Code Sect 25532(¢) '- - r rs#^ tlI' '� 'S 1 w t a N1 ❑Yes ySfd Nti,6 '�Sg . I t°1 s ''i.•.} x 1> � i'i 'L tilt {) 1]. All.roofs shall.be inspected poor to any roofing material being Installed. _ will the applioce t Pomre bu,ld'ng sopa t equip t p devices which If a roof is installed without first obtaining an inspection 'I'agree to�feinove emit 1:2 ardo m ants es def d by th B y Are.A Qu I ty Manag m m District? - all new materials for inspection Applicant understands and will tom I with ❑mal�,. ❑ o.'.. " p.y_ * - ) _ all non-point source regulations 1 h ,'read the hazardouej mai rials requnements under Chapter 695'6(the Califomin Health&'Sefery Code,Secu6ns 25505;25533 and 25534,.1 understand that m t hich mu ew t th t it responsibility to blify the r Occu t f N t currentlyhave a ssu rice of a C ',fcete'of i t c u n does no v g Kv 're p m t r r `p Signature of�plicant Date P P Y ' own antno :ed Da All roof coverings to be Class"B" or,better OFFICE