01050102 CI;rY OF CUPERTINO
BUILDING mvIS1ON PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22077 MC CLELLAN RD GB GROUP 01050102
OWNIi R'S NAME: APPidcNr oN SUB DATE
KETELS SUSAN E 8921 MURRAY AVE 05/09/2001,
PHONE: SANITARY NO. CONTROL NO.
a (800) 653-7172
BUILDING PERMIT INFO
nal ARCHITECrENGINIiER:
r o O HLIK ELECT PLUMB NIECE
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F� G I.IceNSen DICLARAHON anal of ChlOu Job Description
o_pp , u7 W)ol mm1en0"finnedumrr prov'ub,ns,i C.IrC it 9a„n,'I"cn,F
Ozy will,So,,
Ela 7lHlallol'DivinionJ nl thclluxinex,unit P�C �Je. ,➢IJItlY liccnw
xis i. nfunfnmearm"'"'y/���S r/(t/r REROOF / SIDING & TRIM:
z�6 Lifcnw Class—L- Lic.M
O i Dole cool
3 0 y ARCHIL PU'S DECIARATIIIN
1.C=O 1 ondcawnd rip'plans Isill ber used.,Public reauNx
ce
✓+Ir
m¢n o Licensed professional
c n nWNER-HUILDER DF.CLARAI'ION
6V1^ 1 hereby affirm Ito,I an esampn Iron the Coahcour x License Law for the
Iellowne,rcaxna f5ceti.nt 703 S,Huxinme nod Promseinnv Code:Any city or county
F O which mquires n purinil lu nmxtmch aper,improve.Jcnmli_sh,nr rcpair:ury slfnelum
aprior to its usuancc.also Capone,the applicant h,r such permino life a signed sutenicut
�a� hadheishcen.edpunaunl nthetoo,,insnnheamtme res License Law(Charier 9 Sq. Ft. Floor Area Valuation
(commencing dim Section 700(..of Division J of the Ilusinena and Profe..in.,Cala)
or that he i%exempt mempnttt and he bads for the dRged exemption.Any shboon $10294
of Section 7031.5 by any applicant for a pachat eobjects he wpplieanl Ina civil Oar ah)'
of not mom than Ilse hundred donut.(s5WL APN Number Occupancy Type
❑Le,owner ohne po,pert,nr my employers with wog„as their sale cnmpeavntlon, 35
71 71029. 00
will do the work,and the 4rWere is not intended or ollored for sale(Sec.7144,
n^xine,x and Pm@ssionx Cast.: I ho Conpan....Ll cta,a Law down not apply to an Required Inspections
or�
r of prol,eny Who build,or Ingro,,thrn,on.and who dors smb work hlnnOl'hrougn his o%it employee..provided that...It itttpr..vetnenle am ant intended nr 305 — FRAME
onimJ I,,,.sale.If.howmvr.the hnlldinflor itnpruvanmm is sold olhin to year of
,mpmtimt,me..doer-I,anaer will nava me broil proving stat he did nal builder � 307 — INSLII_RTION
im'mee mularrimw nr""'. 601. — ROOF TEAR OFF
❑I,as owner of properlY.nm excl—ody centrarttg with licensed contractors to 602 — ROOF PLYWOOD NAIL
Lm\wct the project(Sec.7(14,li-iness and Pmm%sinn%CNe:)The Contractor's
iana Line does n,tapply ria o rnl pmpeny whnbudd,nr impr,a.merenn. 603 — ROOF BATTENS
and who commas P ice with a ca';a;rt\I licensed punw:nn In the
cr.noact^rata '' 604 — ROOF IN—PROGRESS
❑Iall cion toe •,rat ,Hffi PC font
Own,"_ Date.
\vl C)MI'ENSATION Dr:CIARAI'ION�
1 hereby aflinn under penally of Perjury one of the following declarations:
• ❑ 1 have and will renhou n a Cea ifca,of Cnnwtn u,wlf-incur=for Worker's /�
Compensation, as provided for by Section 371X) of the Labor Code. for the LED
peno.of—of the work tn'o,which this pian,' iseued. FIIlIAk
❑1 have and will tnahuain Worker's Cotnitcnstnion Ill surun' ,a,required by se"ion
3700 of the Labnf Coda,I,, the pc.tor nancc of Ibc work for which Ilii,Ir,nit is DEC 0 6 2001
o,a,d.My
Woo,kkeee,,CC-ntyu},,u.,�u,,nti\nn Insurance comic,.,,,IPolicy r r numbee
Carrier.,�YJZG "ems Policy No.:�--LO I, ��
CEN 1'IFICATION O:EXEMPTION 1'HOM\vORKERS' U I LDI NG
COMPENSATION INSURANCE
(This mins need not Ire eontplemd if the permit is feature hundred dollars
IS 100)or less.)
1 Certify the In the put..... a al'tim work lir which his peanut I%iu,ued,1
'hall ora ain't...arty x
pcot
ratty n t ,.tem beentne.object to the Wnreard
Compcn.alon Laws of Cr....ife a R Dam
Applicant
N(rl'ICE TO APPLICASaT II:ate r making his Cenilicole of Exemption,you,hnulJ
beeomc subject In the Wmker.Cut n,atton provision%of the Label Code,you mod
Q O fnahwith comply wall such provisions or the,pfmtil shall be Jemtmd mvomd
FCONS'TRUCnO.N'LENDING AGENCY
I hereby affirm that ahem is a mmouctinn lending agency for the performance
of the work for which Ill, real in",sued(Sec.NN7.Clv.C.)
ALarder's None
5 z I.cnJcr'%Add—, t
U Q 1 canil'y trial I have mad this uPPlicaion and%tae t .w ora abtwe infnn....I n is
las tom., n ran.I agree to anttpl.will all Cray wait linen,orf .sac% cmc law.,«Iming
O U mbuildingconwmnioatm ,erebyaudei:epre.s• naives, ibis city mercer upon
the abn(We).,met.pm yfor'
F}" S fe-matio edser ,inJ rya. x ilesa th 'iry ofC iso against
V) liabilities,judgments, st% explain . naY in came again.,said
U z City in ronsequcncu the Frantin• t n. �w �/'
APPLICANT UNDO <SLWI Af (hIP 'ITH ALLC�����I,/'s/'/�p,}..0/%/•j�T Issued by:��— ��l'�4'c-'�' Date
SOURCEREGUI 1' )N I Dg L
Signtdureot'Apptcamtcm,tmc r 0 D(I/ 11 Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will ahaapp",ann..n tbmm had,ho,o,,^punt%on,..r trundle hadwou,owded Type of Roof
^,defined by the Cupenino Muictle alc.Chapmn9J2,ed the l ,illhand Safny
Cale. Yeo 255321,)7 :IN.
All roofs shall be inspected prior to any f g material being installed.
Will the."he tar faturc MNdin•occupant use equipumna or device which If a roof is install without f St n r n inspection. I agree to re Give
emit M1m.allom air nmmminano as J' J by nM1e Hay Tree An Duality Munagemem
all new materia for ins o tic' . ands and wit co ply with
all non-point: once ul•
thew ad he on, noun, nl%'are imotam,ander chap¢.ho5 of me
California H Ith k Lai Saint s 25505,2553)and 25534.1 mukra:ntd that
ifine buildgd,• not a u have Court J it isnty rcspunsibililY h,not ynhe LL//
occupant ah aqui i it h met prior m isutvme of o C ntf am of
Occ'M y' y ' Signatur f Applic•nt Date
Own all JT6 an
-h"eo All roof coverings to be Class `B"or better
OFFICE