01050094 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21997 MC CLELLAN RD GB GROUP 01050094
OWNER'S NAME: APPLICATION SUR DATE
WILLIAMS FRANK M 8921 MURRAY AVE 05/09/2001
'IIONG: SANITAN1'RO. CONTROL NO,
(800)653-7172_.
❑z% ARCHITECT/ENGINEHIL BUILDING PERMIT WFO
ku O O BLD0 ELECT PLUMB MECH
LICHNkEUCONTRdunderSDECLARATION Job Description
hcmbyholm Ihlein IliI It Hwulcr Provis... ..f Chapter 9lumuncncing
OmF" with SWlian 7fNHl1 n(Oivi tnl'Ihc BusincssnnA l'rofcxsinns Cn Imyliccns
max= i,inmdloraa^deBel. �G1I4 REROOF/SIDING Z TRIM_
m0 V I.icensc Lfc.p-
3 N Dare 111��� Cr,mrc lir
ARCHITECTS DECLARATION
1 mmdersmnd my pato,shat lie used,,public aboard.
mda 'e Licensed Professional
OC
a Oat I lR;BUILDER ur the R6r10N
L 1 hemhy nll irin hat I alt uusi n frmn the Cu.wacn,r'n :License,l Law for the
C Z C which it aire,a.(Suviot 7s S,act,
Business and Pmfecoubi Cuda:Any city...lcounty
so which 1 r itto1 1 rn p' lir w,rw ,
at
i 3 pr , r 1 Ih PSI ,f 'I I s 'A.aae,cur
— mall, ,tcensedp—rammmeprvsoa.ofchat Ck arra„ I. 1 (Chapw,9 Sq. Ft. Floor Area Valuation
(commeneing with ScE i 7(0X11 of Division 3 of Ise BLLdaCs and profession,,Cole)
or that he is exempt therefrom and the basis far the alleged exrmpdam.Any violation $10294
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of but name than five handled dotars($500y APN Number Occupancy Type
01,av owner antic progeny,or my employees with wages as their sole con,pen.alion. 3571 3010. 00
will do nae work,and fim mr,Yabe is nut intended or..term for,ale(Sec.7144.
Business and Pml'emlom Loar:'rhe Contractor's Liss¢Law does at apply to an Required Inspections
r or pmpefy Who builds or improv,Ieercon,:nal wbn does such wad haboulf
�;,ihrougb his own mnpleyeesprevidal mar lime'...pro rre,ms are nm iniemlm or 305 — FRAME
ofe,ed for sale.IL a^..ever.IIs building o,ilnpnwamcal is sold within one year of 307 — INSULATION
mmlelion,the owner.batder will have the burden of prosing that he did not build or
improve fmp^rsea,of.di 601. — ROOF TEAR OFF
01.as owner of the fps n ' 1 I cams.,ing x;m lieenscd oanlmelnR n. 602 — ROOF PLYWOOD NAIL
mamct//Ipl
T J rN n and Pa) cions CWeq TTe CommmnrsLicensepn ywnawammimpranesthere""' 603 — ROOF BRTTENS
Ind whoni r cummelnr(cmacl,l604 — ROOF IN—PROGRESS
❑Ismo ' _ _Owncr _ am I 'S 'OM1 iNSA'I'IOR UHCLARA
• T hereby affirtn under penally of penury one of the l illower,declaration
0 I have and rill maintain a Cenlficate ou,¢If
f Consent -imm, for Worker'sCompensation, as provided for by Section 3710 of the lalwr Code, for the
p,•dnrnanre of the work far which Isis permit i.1,sued.
01 have and will Imlimaw Wa,k,Yx Crnnpemallan hu,n:mea,as"tulles!by Serbian 1 N A LE D
3701 of Iha Lnhor C,111, 'a me perlbnnwwe al Ill'wk ur whmpm
b this nnil i.
I...ed.51y Wnrkds Comp•n lavalliere earnNo:!!(, st�all(IPolley tuner,arc'. p I -
Camie[A, 1 11) L%EMPI'IONTR!),liWO K85' NOV O 8 2001
COMPENSATION INSURANCE
mis,eef ion need not be completed if the permit is for one hundred dollars
(EIBUILDING
WImle")
I certify Ilnn in the perfurnmnce of the work ka whi,h this permit is issued,I
shall nor e^Iploy uny per .lir,
my a I to as x,Nem.. n
subject )the Wmkerk
Colupenxatme larwx of CWiWrnia.Dare
Appllc^m
NGFICE TO API'LICAN'I':IL of ref nmkmg this Certilie:ne of Eumption,you should
become subject the Worker's compensation provi.aons of the Lal or Cmc y^a mu.a
Q Omttfonhwim comply with such provision,or this permit but]lie Jeemm revokeJ.
FCONSTRUCTION LENDING AGENCY
1 hereby nRmm that there is a comau ri..n lending agency for the performance
W of the work for which This perms is i...ed(Sec.30K)7,Civ.CJ
0 Lender's Name
z Leader's Add,ev,
correct.1 ecrify Ilial I Inwe rend rhls Ilppl'nddomm amt um 0 ¢ahnve infnrnuuinn is
f7. U 1 gt,rcc v..In, is.y with all city and co m onl n and acity laws eluting
Q V n, idoNngronium, n,um cony au "ran cs of this city mother upon
he uMwe-memree,I v IY for - i',:
Ell "I nnfy n Wane nate way trace,
i her
laid t�y,Q/)
!b liabilities.judgnarm n I in lid ex h Eh - in any way acct ^ aina said
f) z City in comeyaene dthc grafi an ` ../{{C//� /�.� �j
APPLICANT UN iRSTAN . II r PLY WITH. M1ryI ISSICd by: J—� ryv0 �- v Date
SOURCE REG .AT ((/
slgnaramm oma/0"i rrar Daa Re-roofs
IIALARDOUS MATERIALS DISCLOSURE
Will teaandicamorrrumemudding ree"Nalnm,emhandleharaNnusbrataid 'type of Roof .
as defined by the Cn senlno Municipa vie.Chapter 9.12.^lid me Hcalm unit Safety
Cade.Socon d255321x)!
Dyes All roofs shall be inspected prr to any roof naterial being installed.
Will the uppticamor furore Wild" rupanlm e9mpment ar device,xmrn If a roof is installed withou Irst o ispection, 1 agree to rem ve
emit havallous it vml:uninanu a,def by c Ila •ma Air Quality Management
cif Cres all new materials for ins ctio A 3derstanWwillwith
Di" oyes all non-point source re la ' ns.
uvcream he Imusl awl' Is as, x^eon Ander Chapwr 19 0 lime
C: rualu Hcall S ,x2551 ,2553155]4.1 wA• ' lid phutthe blding , rt Il .� ml ory mxpans11,111 n nilymc
ofIem n ,ail la film m,..came ar e rc eaSignature of cant
owners h need' est Dan 'ATI roof coverings to be Class "B" or better
OFFICE