02040155 T
UPERTINO - i. ' 'DIVISION PERMIT CONTRACTOW-INFORMATIONSS: PERMIT NO.HILLCREST RD ROOFCO OF SILICON VALLE 02040155
D ANN BUSHWYLER 844B EARLE AVE APPj.l�Ay1QNaSuJ�1A]E2
'HONE: u // L`� L U lJ
(408) 795-3335 SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER:
O O BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH'
a c U C=1 L 1 U
2 LICENSED CONTRACTOR'S DECLARATION
¢=Cpp thereby of,.that l am licensed under provisions of Chapter 9 lrommme., Job Description
rnF with Section 70007 of Division J of the Business and Profc,xians Code.and my license RE—ROOF
Y Q
is in full fob/atydtife3g Lia.a� /e. 7 3
z e.U Liren�class S..c!
Cmnnc r A
3 DaX ARCHITECTS DELL ATION Fe N,t9e'�LIG
S 1 undersland my plans Shall be used as public¢cords
goo LicensedProfe...°^°' MAY 0 9 2002
,ca„ OWNER-BUILDER DECLARATION
t-z a, 1 hereby aRSm that 1 oto exempt from the Contractors License Law for the
o following...(Section 7031.5.Business and Professions Code:Any city or county $8973
re which requires o permit to convect,aper,improve,demolish,or repair any structure BUILDING......._
iv3� '.prior to swmsc,ulso requces theaTppfcant for such I.ilI file a Signed statement - - _
thea he I nsed pootar no the pito,cars of the Contractor s License Law lCh.p,,,9 tom,, gg�� AM
(commencing with Sat ;7000)of Division 3 of the Business and Professions Coble) ' ti3`L;A t6V titi�Y/-ll f�1' Valuation
or that hers exempt therefrom and the basis for the allegod s.opti n.Any violation
of Section 70715 by any applicant for a permit subjects the applicant to a civil penalty'
1drna mire matt Rye wnaree annnr5(sseun. 3 06PN NFaktiE Occupancy Type
❑1.asOwner of the property,or my employees with wages as their Sole compensation'
307 — INSULATION
"will"do rite'-work:and the structure A not intended°r-offered for sale'(Sec,"7 J4,-
ButidaiS and Professions Code:The Comnctar',License Law does not apply to an 601 — ROOF TE ui��iThspections'-
owner of progeny Who Wilds or improves thereon,and who does such work himself 602 - ROOF PLYWOOD NAIL
or through his own employees.provided that such improvements are not intended or __ __
'(.(raid for sale.1!,howexe the building.11 mPtovemcai is Sold within one car of --"----'-- - ---'--" -�,.�'----- -- --
compinion,theowiter-builderwillhave'heburdenofProvingrhehedidOutbuildw 603 ROOF BATTENS---a ��;i�?:o
improva for purpose of uta). 604 - ROOF IN-PROGRESS
— __"_." ------------._----------------------'--.... ----.....__._....-.__.__.----------._.. ---`-"--...__._ d.,..:.,-- B-rJ -------------'
0 L as owner of the primary,am exclusively convecting with licensed contractors In
- ---- -
conswct the project(Sec.7(140,Business and Professions Code:)The Contractor's
License Low does not apply to an owner of properly who builds or improves thereon,
r.
and who.contracts for..suchprojects.wid,a conuactons)licensedpursuantto fire,. ..___.............._.
'+ Contractor.L cense La
❑I am exempt under Sec lB hPCfonhis reason
AS,,
Oaner' Date"• ' ' `
WORRER�S COMPENSATION DECLARATION
-1 hereby affirm under penalty of perjury one of the fallowing dahndionIt'
jft ❑ 1 here and will maintain a Can fil.hi'af Consent io ul6imure for Workc,% ,
a- Compensation.as;"provided'for by Section 3700 of the labor Cone,for'the
performance of Ncwork for which this pemdt is ixsuN. .
n....,,
❑1 heva ind will meintoin Workdr'a Compenuiion Insurtnce,ei regal by Section
3700 of the Labor Code,for'the performance of the work'for which this permit ie
?Ned My Worke's Campo anon Insurance carrier and Policy numbs rt
.,. 1 t
CYIBer• } Paiiavl �fh`rrr7o�)�/
ION OF.EKEMPTHSN FROM-WORKERS 1>',•- - ' l i
COMPENSATION INSURANCE;;,;"' f
se.. .
net be'complereA if the permit is for one hurMrtd dollen `s-'•' "' ""'�� .p=" " "L (JiY.3yi.'.Il;'Y i\'Cic
(Thu uni.on neeA
IS IW)w lass.)
i
"Z::1 mpy that in rh p,rf itnanee o(Ihe work f hieh dht permit m issued;I ,I,1 L.: Y
Shull of employ any person to any manner so os to become.uo)en loth.the Workers` -
omia.,Dale' `
Compensation Le sof C.I!
AP
ICE
'N ICETO APPLICANT If,after making th:5 Cen fcme of Exempt on you should .1". ;;I, '- -
bednmesubject omptothe SuhasCompenmhnpo om
ts I the Ubu Code youmt
z Q (anti uh comply with such Previsions or thisporton shall be deem ad revoke d
.. - -
f t -CONSTRUCTION LENDING AGENCY ""' V!:::
I hertbjrethnn tha there u'e conswnl9n lending agency,(or,the performance' f
of the work for wh ch this perm it it issued(Sea.3097 nC)
Os Q -Lender's Nems 1 ._._..._--
p;z LeadereA,ddres5,-
V.O
x I certify that l have read this application and Item thin the above information is
0 J" coerui.I agree to comply with all city olid county ordinances and nate laws relating
�;IJ to building con.uuction,and ate audibriie representatives of this city to enter upon
{i2 the all c-mentioned property for i nspcction purposes..
f�rs:0. (Wi)igrecto 5ave:md6nify and keep harmless the Ciry of cupeninb'ageimt
Fn V]
liabilities,jdgments.costa and expenses xhtch May la any way Cs.,against said V
V z City,n cons q cnce of the grant ng f this pertnI '
AP CAN? \DER SDS AN tl'IL 011PLY\\hiH ALL'NyOh 70.T !
s CBR tai: / Pz ��� Issued by: Date
amrt of nppl env ontractw r. D t`—'�•'T'7
's HAZARDOUS MATERIALS DISCLOSURE ''1 Re-IOOfS
"Will the applcad or future to klmg occupier nae or handle Type of-Roof..-
as defined by the C.pertim Municipal Code Chapter 9,12.and the Health and Safe,,
Code Oyes Sobtim.25532(.)', t r. ' l i t s' '•i 'e 's \r✓ 1 __ }
r .. --All roofs shall.be inspected prior to.any roofing material being installed._.....--.,.
IWSII the applicant. f rare ba
udding c pant use equipments devices which If a roof is installed- without first obtaining an`'ins'pection;-1 agiee.fo`ramove w
,ton bezardoun,r c nmmm is as defined by dhe Bay Ada Air Quality Management
Dtsaran , d all new materials for ins ection Applicant understands and will comply with
n _. _. P .. _._....
L OYes o
a all non-point source regulations y
�l have id:oalihe hazWau6-mA mals regwremems Leder Chapter 695'61'the
California Health&Sidty Code Sacddps 25505 35533 and25534 (understand that
t[ihe buildingdo,i'hotcurena 'haus aanant thnnlsm " " \"-I' -- - --- -
Y ympoosrbdnymnolfY the - 6��_ -
`occupant of the rtghiremenrt.x loch most be met p r to issuance of a Com ate f "'"
ccupu:c : .:v ..
nature of
Date
own or aathemoad ant h f 7 All roof coverings to be Class"B"or better
I