01050100 CITY OF CUI'ECONTRACTOR INFORMATION:
BUILDING DIVISION
stou PERMIT
BUILOINUADDI ESS: PI!ItMITNO.
22069 MC CLELLAN RD GB GROUP 01050100
OWNER'S NAhIF,: APPLICATION SUR DI
ADAMS GEORGE B 8921. MURRAY- AVE 05/09/2001
PHONE SANITARYNO, CON'IROLNO.
(800)653-7172
❑s Z ARCHITIicmiNGI HER: BUILDING PERMIT INFO
O❑O NLUG17.1.1.(7 PLUMB MECH
�` IJ I=1 I_1 I_i
4 uCRnsuDCONTRAcnderpDIicn%ofCON Job Description
O Z_ 1 hereby170 Minn that 1 n 3licenced under pnr'i,inns or n,Cod.9lcommenese
win+Seen n,It 7axn ornivi,ion3or me Rnsloca%ard rror%mm%cam, mmrhanae
a'oJ i,in fillba,cand eR t. del REROOF/ SIDING & TRIM.
J
—05rC z�S License Clan hie,M
3 a F Date % _ Contmcror
L = nlgan'll:cr's Decl.nlennon'
C— 1 orders Illy plans%hall be used as public records
o o Llecnsel rrofe',wmd
OWNER BUILDER UIiCLAItAIION
I hereby alliin dots I an,exempt firm the CnntracaW,].is...c how for 0e
F•Z Q following reawa(Section 703L5.lmmess and Proleaioin Cale Any city ur-comay `
Z o
I,hich requires a psanst ill consumer.dier.implove,demolish. repair an,a cmre
as i ct m prior( is a, 4 re:th (til t f such pem+lu fl g d-,at emrnt
m:In lir:dpun tt the provisitacalns c 1 , r License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(vo s I,[,S", 70ag r�wl g +fthef k,v dI tmaromn Cock.) $10294
rr Ilett he Is clamps theira s an I she ilea,It,,she nllegcd"vorpeon.Any viamion
of Sectio 7031.5 by any applicant fora Permit w:bjem%the applicam at a civil pewlty
of not mote tnaIl Five bumhed dollar.S500l. APN Number Occupancy Type
❑Lavowncrofthe property.orn+ycmploycc.with wages a,stheir wdeentopen.arnn. � 35713027. 00
will do the work,and Inc,nuilnrc I,% +n(mlm+ded o,ore rod nt,,alc(S".7344. Required Inspections
Hl'tor s send Prnl'es,innx Code:The Con.mcso",Lian,n Law dna not apply(oi 9 P
owncrof propctY will,builds or imIthereon.and who doe%such work himself 305 — FRAME
or thrnagh his as,is empdyas.provided that such improvement,use not intended or
offered for sale.If,however the molding or improvement is sold within one yea of 307 — INSULATION
completion,the ownerbui Wer will have the madal of proving that he did not candor
in:provemt,
for „male). 601. — ROOF. TEAR OFF
❑La.owacronIt,noducrty.all,c.cwsaely cmtrutimg was hcenwd c,nInto,a(^ 602 — ROOF PLYWOOD INA.TI_
ionswa the project(Sm..7f44.Its it sand In.. sinm Cude:)ne Comranm:
meIl.e l/d., ofgl
W11III)IS"Ar[ON
. property who nudmmia+pmvcs mereor. 603 — ROOF BATTENS
and whokIcontaamgs)licensed pntauant a,thecmrne _ 604 — P.00F TN—F'ROGP,ESS
, .It&I' Inc -
wenn
Owner_ .��
1 DECLARATI
I nereny affirm sad,,penally of perjuryone of Inc following dcelarations 1 N A L E D
❑ I have and will mal am Is Calfi,:(o of Cun.en w sell'-loure ler Worker,
Congwnvatim. as provided for by Section 37a) of the Labor Code. for the
peHotnanee of she work for which lhi,permis is issued. NOV 0 8 2001
❑1 have and will muinlain Worker's Cnmpcnsation Insurance,as requirad by Section
3700 of the Labor Cudc,for the pcdo...mIr of the veld lot which shl%pemtil is
i,sned M/y Workck,Cmn stiohoulaaacto..,a)n.1111',..m....bar�ro / BUILDING
Cumer.:j /—�/ I
CERI'11•ICAI'ION OP h%IeMrr10N FROM WORKERS'
COMPENSAg'ION INSURANCE
('nil,svOion need not be colupicard if OIe per nni(Ix till one hundred dollnm
SI(XI)or leas.)
I cenify that in flue performana of the work an which this permi(i%issued.I
shall not employ any person in any stunner so as u,become subject to the Worker
Coone...no.Law,of California,Vase
Applicant
Not WE 10 AI'I'LICANI`I IIL aller making(h Ia Ccdlliram of Itesquinn,you should
Mcome subject a,she worker',Cnmpematiem provision.
afire LarCode.you nett
U 0 forthwith comply with such provisions or this permit shall be deemed mvuked.
Z
E• ^ CONSTRUCIII)N LENDING AGENCY
a yI hescot affirm that there I,;, aa,ru,aam sta, 309th ng agmmy Ibr the Isrrnnnuncx
of the r,was kN fur which(his Ism+is in Iaw,cJ(Sas 3I97.Civ.Cd
1 Q bander',Name
.L Isndvr',nddreu
U C 1 cenifyathus 1 Wore read this apps jail inn and%title that the alm c inli,rmatina i%
Ifs [r e, cct.1 aree m l, if,eo,,dy wall all city and ey diranecs and,tate laws relating
O U It,mndd'n"con,lmeaon•cad Ill ynomod, repr cnmdvesonhla city metier
she uho(We)st...%., for it Pur Y
a (N'elagramnm InJ• d 1 chi m. .. (he way
against
fin City I. .,iudsmnnl%. at,. d e vet am way sec sin%t sono
U Z City in amncquenee d NID t nil.
^ APPLICANT UND STAND WI COb1PLY WITH PLL '0 -P INT Issued by. . Dille 15�: e/'
SOURCE RF,GU 'I' �S(
Signature or II II radslo — b to Re-roofs
HA%ARDOUS MATERIALS DISCLOSUR.
Will the applicant or future buildln acupaIn enc or his Is hvnNos material Type of Roof
as denned by me Cupertino nmmcin;d.�+dc.cnapmr v,12.an the sevum and Safety
Coda.Scudo„2.9532(Io'r
❑Ye. .LI No All roofs shall be inspected prior to any to( lig material being installed.
WiHmeappreamorfamrebaidm occupant use equipment or devices which If a roof is installed w' hoot first btaini a spection, I agree to remove
emit Is... lair nmmninams je de' dby the HuY res Air Quality Management
District?ve> No all new materials f ms an ndersamds and will c rep with
all non-Point sou e r I a[i
1 have mad t IiawNous req, e urns under Ch,,ser 695 of she
California Hcalsh& metyC IS 550 .255)3a _5534.1 un enppa that
Hthe nuilofthedo, nm Intl a nam +m" ry l....c hili,(I fearsthe
«capma of the q ' mete Ic n t prior m iv,aaocc nf: c limnshe
°iaopuney / Signature Applicant Date
here,or orl,sd ager 7`— - )O k All roof coverings to be Class`B"or better
OFFICE