01070033 CITYBUILDI C DIaVL� NOISSIIONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20658 KIRWIN LA 01070s0pp33
EUGENE C AND PATRICIA ASP�`11�M01
I'M PHONE: SANITARYNO. CONTROL NO.
❑O Z ARCHITEC'1]ENGINEER: BUILDING PERMIT INFO
w BLDG ELECT PLUMB MECH
a a L.I LJ 1_" J LJ
LICENSED CONTRACTOR'S DECLARATION
o z y n 1 hereby affirm that 1 am licensed under fChu ter 9(commencing Job Description
°N_o provision,. p g ROOF REPAIR SHAKE TO SHAKE
t-w with Sem,on]IXo)uf Division Jof th<Busincss and Professinm Cal .and mylicenm r
a'SS, sat full force unJ effect.
z W< License Claw �/ Lic,n S S I
3 c.w U Dam Conaaz or
f-w ARCHITECT'S DECLA A 10
1 understand my plans shall be used a public records
f t�Ir T
.-MC Licensed Profossi...I
o a OWNER BUILDER DECLARATION
1 hereby uffrm that I am exempt from the Contractor's License Law lin the I
kZ Q following reason.(Scoram 7031.5.Bouress and Pridessi.ns Cade:Any city or county $2200
f€G which requires a permit to construct,alter,improve,demol'nh,or repair any structure
w prim to its issuance.also requiresthe applicantf - h pemduo file a signed statement.
that he is licensed pufmanuo dim provisions of Ne Couvetor;Lcense Law(Chapter 9 ,•-r 3rCm nl3. 8a r Valuation
(comate 8 nh Sat 7")of Division J of the Business nM Professions Code) � 1 �-•.. y •s-�s'.31.'A01.IsWO•'_+O`.l-�`(:\5 +. ]
or tM1 t he is exempt reactions d he basis for the IIetic+l oxemp0on Any v olmi m
of Section 7031.5 by any applicant for a pemti,subjects the applicant to a civil penalty
,of not mare In.five hundred dollar,(s500). 3 0 5AP-N VRME i' Occupancy Type
ol.as owner ohne properY or my employees with wages as their sole comp<nsmnm. 307 - INSULATION
will do the work,and the'smotm,is not intended.r oRemd for sale(see.law. 601 - ROOF TEI}� tQf��lnspec[ions
Business and Professions Calc:no Contmmor m s License Law dues not apply an q s
come, Who builds or improves thereon,and who does such work himself 602 - ROOF PLYWOOD NAIL
or through his own employees.provided that such improvemcros am not intended or
.Bored tar sale.If,now the budding or improvement is sold within one-year of - -- - 603 - ROOF BATTENS
completion,the owner builder will have the burden of proving that he did not build or 604 - ROOF IN-PROGRESS
improve purpose of
pl. if the property,a.e,c[.,isciy miturictin,with licensedemminuarso _ - __ . .... _.... . ._ . . .. _.. . ...
- const n the project(Sec.]ase Business and Profinosimix Cosi The Contractor s
License Law dms not
or.suc t owner a pcnY h Wild p thto the
d who contract for.such projects;with < uactagsl.lrccaed Pursuant.m the
Contractor's License Law.
1
❑lam exempt career Sec. ,B&PC for this mason
Owner' - ENS /
WORKER COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to rel6insurc for Worker's
Compensation, as provided for by Section 37M oftheIaWr"Code, for the
'perfmmance of the work for which this permit is issued.;
❑1 have and will'hunamin Worker's Compensation Insurance,as required by Section
37W0 ofthe Labor'Cade for the ce form nc of the work 1 h'h this perms is
issued My WCompensation k rs In:um e n Policy
Carts:/ / PoliYNo_W� / 31.
VCERTTFICATION OFEKEM"ION FROM WORKERS,
COMPENSATIONINSURANCE" '
- _ -------------
i
.'...-.__._.. .._ _ .. .. _ _...... ___. ..
i"t. '(This section need not be completed if the permit is fur one hundred dollars \,-• '•
(3100).1 less.l _
.I<mpl than in thican i my m of the work for which this permit.trued,I -
Comnot employ any permn in any manner w as m become.mbject m Ne\Vorkcri
Compensation Laws of California.Date
Applicant-
NOUCETjcot the Work,L after honking Cenlfi,ofcato of Labor ion.you
ou most
Wcomclb im tb the Worker's Cuion%or this provisionsll the Labor Cole,you most
r O T t ' ' p y with such pmvisiom or this permit shall be deemed revoked
Z roe . .. .. - _ . .. ... .. .. .. . . ......._ 1 . ... ....
(anhwuM1 mm
F.,in " CONSTRUCTION LENDING AGENCY '
' "1 hereby affirm that there is a construction lending agency for the perfomrecen
of the work for which this permit is issued(Sec.3097,Civ.C.)
a.Q -finders Name
.. ._
'J Z Lender's Addrta
f..) I cenify that 1 have mad ilii,application and elate that the abou'c irri manion i, _
Lit'tr
correct.I-agree t comply withall city anti my d'n nc< u d stat laws rolarng
Q C.7 tobuilding na tion ndh by authorizeP at es fthis city t enter cram
�A. the b menu negprop nY f r in P aiu pry".
1`7)F.• a IN ) gine tom- indemnifyle dA phuntress the Cly wo pen aagaaid
inst
Z Bolo n Jlucom,cot J i pontes erm may in anyway accrue gainer said C.l
V Z APPLIC onseyuence lir the graining of This permit.
APPLICANT 'NDERSTANDS AND WILL OMPLY WITH ALL NON-POINT Issued b Date
.OURCE RF NLATIONS." Y'
C t`�t'. r� Psftix oti 'F-i
Stgnuturc of Apph. t ono t Uac Re-roots
HA]-ARDOUS MATERIALS DISCLOSURE' ",
Wil the app1irzmm future Wilding occupant store or hmtdlo hararaWa mareml Type of Roof -. . - .. ,, . -.
adefined by theCupertino Municipal Code.Chapter 9.l±.and the Hcalsh olid Safny; t _ t ,,.r _ s
Code.Section 23532W1". .�N
oY�, N. 1 All-roofs shall-be inspected..prior.to.anyroofing material being installed..._. ..._
Will he ..sarl or future milifir,wou,sm use alm,smi,ii hrib If a roof is installed without first obtaining an'inspectionr Fitgree to`remove
on.l ardo sear i,orlamiroat,11 dosed by the Bay Area Air Quality Mmmi,cren
Distiien _ all new materials for inspection., Applicant understands and will comply with _
oYe` 0, No all non point source regulations. .
have read'in,hazardous materials requirements undo Chapter 695 of the
CaliforniaHealth&Select)Code.Sections 25505.3357 and 25534.I understand that
ifthe biii1din,does note n0)h c a hamon.thalsmyrepo -bl y to notify the ������������� ��
oupe a,
t of the mo m t which int be m t p at r issuance nilicm
ccuptncy.
f z Cee of T
.c —
Or
- Signature of Applicant - --- Date
or atm om.N agent Dam All roof coverings to be Class`B" or better
4CRxjr<: '.r ! OFFICE - -_ -