01050091 / c�TUtorNuIV[SIONNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21977 MC CLELLAN RD GB GROUP 01050091
OWNEW S NAME: APPLICATION SUIT DA'fli
D WN EE' TRUSTEE 8921. MURRAY AVE — 05/09/2001
.PHONE: SANITARY NO, CONTROL NO.
(800) 653-7172
C m> ARCHITECT/ENGINEEN: - ItU11.U1NG PERMIT INFO
r O OF � BLDG ELECT PLUMB MIiCH
Qdu CI
Ha
N 5 LICENSHDCONTRAC'IOR'S DECLARATION Job Description
O y_C 1 numbs ufi,m teat I an,Ilcen.el nndcr pnwinin l of Chaptev 9 Rr+mmcnciug
with Safun J(XXhu1Dlvieiy .t the Rusincw(corn Pn+tesw,mn code Imylic'Is
is in force and _ 9�� REROOF/SIDING 8 TRIM
K w a License Class Lic.Or
O vl LL a.fin Wife Contractor
ARCHITECT'S DEac
'ION
I J .n J ypl n.:h 11 be uJ Phl m Ns
CY
DO LicenvedP f - J /
OWNER-BUILDER DECLARATION
vl n, nY'fl u.T Pc, II C i et c:1. ly tante
lilt g 1. I 911.115 U . ry ro I .. ,Cd Any county
�Ohall nyu n.' ,punl s t.ahc I J mllnl ar rcPdrary aruvtum
w3�' un. inimi...unae.al.omp,im,Iteappllexm forruch pennitmlileasigneJ.m¢•mee
a. than hei.licensed pm.,mnt tome provision of cmnmenas License lane(Chapter v Sq. Ft. Floor Area Valuation
(commencing with Section 7000)of Division 5 of me un.ines%and Professions Code) 510'294
or that he is exempt therefrom and the hasi,r the alloged exemption Any violation
of Section 7031.5 by any applicant for a permit%uhjata the applicant to a civil Penalty
of not more than five handled dollars MIKE. APN Number Occupancy Type
o L ax owner once hnmenty,m ey rn,ployee,who wages a.thnr.%oln em„penution. 3007. 00
will do the work,mal nec Hmc,ure Is not intended nr ufcred for sale(See.7th14. -
Hwinew ami Po,fmdon,Cole I'he Contractors Lirenrc Law dace not apply to an
Required Inspections
owner of p,,,,ny Who build,or imnn,v,,dmrtt.n,mid who does such work himself
nr through his own employee%,provided that such mmrovemees ale not intended or 305 — FRAME
offered for sale.11:however•the building or improvement is sold within one year of
completion.the caro"builder will hine,he handcoofpmvingthm he did not Wild or 307 — INSULATION
mpirmin,rpnpxeor,alc.). 601 — ROOF TEAR OFF
❑l,a%nw�ernnee property.am e.nnsi. color +mgwahreeosedeommetn""to 602 — ROOF PLYWOOD NAIL
a
mama,he project(Sc M4•Rus, a trod P .exams CoAe:)The Contractor"
Licco.cLawdoesran 1 w tywhoWimxc,improve,the +n. 603 — ROOF BATTENS
mA who conrncw � :'t uF trop nnrun Ian.eJ pnc%t ,me
commeo"l"con Law' 604 — ROOF IN—PROGRESS
❑l um cxcn,pl, dor See. _ .If B t no in
owner
'OR I : SA' ON DECLnRAI'10
1 h m1by adinn under penalty of perjury one of the following declarations:
Cl I have and will mninnuin a Ccnifcme of Consent to.elf-insure for Writers
Compc sation, it, provided fur by Seen( 3700 of the labor Clan,, for the
,doonancv ofthc cook for which Itis permit i.i..un1.
❑1 hme.and will moiamin Wader'.Compensation Insural ax lectured by Sec
37W of the[.,Mr Code.Iia the performance oflhe work Iia which this ficnui,is
i.suN.M/yy�W�.rkrkO]e(,}C�am tiro Imumnce carrier an.d�y1'nlicyn.rruyrn�m+ey,r��am
C.mix,:� 1{.[/L�P,IY No.: I _/N�-refNJe7L
lfi l IICAI %EMI'I'IOV IROMMMMM WORKERS'
COMPENSATION INSURANCE
0111(This Ic,d mad not be completed 1f the permit i,br one hundred dollen
(51nr I....)
1 ctaml,that in rhe Penfornana of lee work lin which phi,permit i,i...Ind.1
.hall not employ any Oil in any manner so as it,become subject in the Workers'
Compensation Laws of Czlifinda.Doc
Applicant -
NOTICE TO APPLICANT':If,after making this Certificate of Exemption,you.haul)
beanne mbjcd m the Worker%Compensation pn,vision%of the late Cole,you must
Q O li,nhwith comply will, mh pro... onhis permi,.hull be deemed mvokeJ.
Vi CONSI'RUCTION LENDING AGENCY
a 5I tachy alrnn Ie,thmc Ix a coo.tuntion lending agcnry for the pe list we
of tee work In,wain,Ihi,Penni.I, %.ted(Seas 3097,civ.C.)
y p I.eader,Name_
z Isndcr'%Address
V Q 1 certify that 1 have mad this applicati ,an, , C that the above information is
C) F correct I ague m,c.only wit in an 'Dunt datives,and alae laws r apid
Q C.7 tobull e, iagam n , v uta, Item emeiveeof%and thistate it)Li aupnn
} the uhavc-menti, soon a any. .1 t m pu
d nes.
(We), a t,.e re+ifs tit . the City of sunoagmina
VT liabilitic..jo t -.,ens :t cop ve, 1 h may in ally way: c e :gaia,t and
rar
V Chy I,, n yucnse i t min of this rah. �(
ApPlACa 1' t+ iR I- S 1) V COMPLY W 1 . .I's']/,rIQ CI r Date
SOURC ., LA ra// Issued by: �nC�
�,z,L�
signature of A,pl nolo,,raw- I m Re-roofs
AU,RDOUS MATERIAI S DISCLOSURE
will line applII'cant or future building oveupant mom or handle heard..,mammal Type of Roof
as di facd by the Cupertino Municipal ,Chapter 0.13.and the Health and Safety
Coda Section 2553'00.. v '
❑re, No All roo/shallbeected for to ' y fang material being installed.
Willthely+pr„Im or lnnme bn fit up:u,t n- .rvirmem mdecia,winch If a rooit fi ai g an inspectionI agree to remove
mit cumardous air nv,ramimm�,u.,def J by rhe 11a ranAir entry M:mngn 1Diall newsp p 'cant unde stands and will c {n withoyes all non- egI have lead the has n m y , meth, m mite,6.95 of he
California Health K Same, oc�Se on 5 Sill 514.1 unde an, hasif,hennildingdce.not' m Itly e n nl y pomibilhyu mY the
,ccupaeofthereyni a I% rahn priu onceof a C til ate rf
OveYpuncy' Signattlt Date '
uwmrnr 1 -— — All roof coverings to be Class`B"or better
OFFICE