02080147 OF
CITYILLDING DPols.-Nc CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT NO.
19624 HOMESTEAD RD BLACH CONSTRUCTION COMPANY 02080147
WN NAME: APPLICATION SUB DATE
GObgD SAMARITAN UNITED METHODI 1650 LAFAYETTE ST 08/26/2002
(' PHONE: SANITARY NO. CONTROL NO.
(408) 244-7100
q 0 OZ ARCHITECDENGINEER: I BUILDING PERMR INFO
kLw❑❑ BLDG ELECT PLUMB MECH
a i W f_—U LJ L_I L.J
as
LICENSED CONTRd under S DECLARATION
0 S y 1 here- affirm that 1 am licensed under s of de, (commencingJob US tlOn
pz_ y� provi mnao P RE 7T T
p��8 wiNSeai-n7WB)ofDivision3ofthe Business and Pro(essionsCode.and mylicense � S ON- -IN HOUSE USE ONLY
�WsS is in mu force a Ad effect. (ORIGINAL #02040033)
K m< License Class Lic.g
a°2 aO Dam Communistw 3 m{n ARCHITECT'S DECLARATION
O 1 understand my plans shall be used as public records
T
O O Licensed Profcasional OWNER- S
BUILDER DECLARATION
w$ 1 hereby.(firm on 1 tan exempt from the Contractor's c Any c tLawy o for the
Fg? following recon.(Semon 7onstru Business and Professions Code:Anycity structure \
a D which amasses a permit re comwci,'lira improve,demolish an.6 any awmurc
panoitshenned e.p'laorcto do,es Nevpions of fas ormorats nmfiks Law(ad summem - - - -- - cation- --
Nat'hef;licenwdpurstimi70lle'psfDivision3oftheBucmpsLiavelasimsCoe)Chapter 9 , ,Sq- Ft Floor,Area-„ , Valuation
(commencing
with Sttuon 1000)-fDivision3of the Bysirmsa aad Pmlessiorts Code) (_1j_''y'I'F..;t,.'i4'rr. 63r3:•'v e•..!r:Zr",i1e)°�': i
or shot he'is exempt N uirr"end the basis for she turgid cerdptlsn.'Any violation
of Section 9031-.5 by any applicant far a Permit subjects the applicant to a civil penalty -
of not mom than five hundred dolhara($5W). APN Number Occupancy Type
01.as owner of the property,or any employees with wags as their sole compensation,; 3 OS - FRAMR
Business
ofW empessions loyees. rovidetlthershtmcohodosarchworkhmsafj 307 - INSULATIIFd�uiredInspections 'fig
will a e work.and the structure is not intended o Ifim l fur sale(Sec 7046'
e:rhe Contractor's
nse Law does not
own
isimprovesNerconmp improvements Wn'Inotinen aIf 601 - ROOF_ TEAR OFF
olird(.propertyWho p einem .._._ _ . . ...
ale ¢h <<`m<n id g p 60'2-'--'-
completion. ROOF PLYWOOD NAIL 1' '` .
the owneoh Ider will have the burden of mmothat he did nm Wild or
impmv<(Dr p4pxrse-r sale.). 603 - ROOF BATTENS
.r..:_ ❑i:ei owner attAe prom
py,am- commctmgwm
exclusively licansco eontamorsm " .6.04 -...ROOF- IN-PROGRESS"
consuun the project(Sec.7816,Business and Professimu Code:)The Conwctoh ,
- - - License Law does not apply to an owner of properly who Wilds or improves Hereon,
and_whocunuvns.forsuch.Pmle<Is.wiN.a conuacmrls),Iicevsul.Pursuom.m.Ne� _�. .___.._. ..._ ......._...____..._._ _..._-________..._......._._..__.
Cramomemes License Law.
❑I am exempt under Sec::" _ B kPC fonhia recon
Owned. oma
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of p ppury ane of!befollowing dcclaratiom:
❑ 1 have'vnd will meidn. v CenificWn of Convent'to self-insum for Worker's
Campanmtion, as provided far by Sermon 3700 of rhe L.hor Cale, for the
- - performance of the work for which this pemdt is issued... ,•
❑1 have nd will maintain Worke's'Co pe 'i 1 'umnce as Squired by Semiim
37M of the Labor Code far the performance of the work far which this Permit is
Issued.My Worker's Compensation Insurance camism fid P lie number m;
C Pul cy No " r •:.. •.
c RR __..
t 1, �CERTif,GATION OFIEXEMPTION FROM1_M1 i1'3 i'l d•!° ITh- 'tl� i(_t c4� . 1 ''/ 4 rl
YOMPENSATTON INSURANCE .
(Th s action need not W cornpleied if the permit is for one hundred dollars ''
IS I W)or less.)
i
y 1:em fy Nat the per( anynde im i s t f w-¢h this ct to t s issued 1
)hall n-f employ any person m any manner s-as b bac-me§unlen m the Workers
Comp<nsaiion Laws of California.Dam'
p NONCE comesubject
APPLICANT:IL ager making this Certificate o ofExemption,Labodyou should r r
become subject y the such p s Cuionsi m tion previsions of the lnba Cade,you man
z O ----with comply with such provisions-Nis permit shall W deemed revoked.
"F Vj . 'r` CONSI(RUCPION LENDING AGENCY '• t' 1 '
I^^ 1 hereby affirm that there w n I lending Agency for the performance
"24 taf the work for which Nrs pemut is issued(Sec 3(97.Civ C) -
Q -'tender's Name-` :_...___ _,..:...
Lmder's Address
d n fyN t 1 have mad this application and am¢that the above information on is
O' :'mrtem I g t cit pIY hi all city and ,county astree J state lows or mixing
rob Id' gcnnstmw on ndheehyapec :pre mativ. hhi city menmr upon
the aWve-:neniicncd property for inspection puipsaes. -,.
(We)agrce to save:indenamfypnd keep harmlexsthe Cityuf Cupertino agamst
FL y liabilities ties 1 dgment. c .t and expens s which may in any 4y actrue against said
t� Cly in n 9uenc2 f the6 ming of thisperson.' _
APPLICANT UNDERSTINDSAND WILL COMPLY WITH ALL NON-POINT
SOURCEREOULATIONS t 1 Issued bye Date
Signature of ApplicamlContiacmr,.;': .,: . " ". .,Dam Re-roofs
i. HAZARDOUS MATERIALS DISCLOSURE
wit doe ppb<ma future builamg occpaatn handl hawdous matrs,al -. Type - .._..,..-
�ins claimed by the Continuum Municipal Code Claam 9 12 fid N H Ith mW Safety •v .
Code Section255J2(al i ( " ' •J 1} 2°t yFY x• ppa kT - n'6•:+ \ -
t OYee }r ❑No Ir FIC9Y t. 1T ..l i•:J}f. t•r . l 3..
9 All roofs shall be inspected poor to.any roofing.material being installed.-.--
WifthapplicantorBoomWild gcompantmeequipment r devices which If a roof is installed without first obtaining an inspection;`flag i'ee to:remove
•emit haurdous air contaminants as defined by the Bay Arca Air Quality Management
DiAnii3O _ all new materials for inspection., Applicant_understands.and will,comply,with
-,• ores -o Na• - all pori-point source regulations„ ,t
i
.I haveread the hamniuus mammals riquvcmce s�order&,Asm 65 of the '
'California Health&Safety Code.Sections 25505,25533 a Ad 25534.1 understand that
ifthe hn,ofI ,docc not rquarementmlyhave atenant:thm rior1ryoue responsibility naific. Ne-
occup'm of In,reyitircmenB which must be mer prionw iui,. of a Cmifcate uf.
"`par`r _. Signature of Applicant - _ -, .Date
Owner or uuthmiledd Agent Date.L All roof coverings to be Class"B"or better'
OFFICE.... - --- '