01050088 CI TY OVISION O
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22885 MC CLELLAN RD GB GROUP 01050088
OWNER'S NAME: APPLICA'nON SUB DATE
ENGESERITER S95HVYN BND NANCY 8921 MURRAY AVE 05/09/2001
PHONE: SANITARY NO, CONTROL NO.
(800)653-7172 , ,
pBUILDING PERMIT INFO
ARCHITF.C'fIIiNGINEER: BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION Job Description
O Z In I hereby a1Rrm that 1 ora licensed under provisions of Chapter 9(commencing
with Sect ion 7000)of Di vis Infill l{uei a oarIPrn1eWrnsC d and, Ilcense
q IxlnmurorcalrmlolRc REROOF/SIRING', ONIQ'.RT,RIM
°�` License Cle" Lic.tt74� Q
°•O It u Data Contractor
C0 ri, ARCHmiCT'S DECLARATION
m g I understood my plans shall be used w public i
apoLicensed l'rof'sional
OWNERcitronDGR DE,I i I(lN ( i
I h by Million that 1 t" pt f d C L for the t
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following r (Section 7031.5,1{u:' J P :. Any yLL ountX
I] which require:a peat tt c .mutt Ir p J I h W e y tomo
3 Poort t r:uan...l rey ire.the opal tf h n I fl n � nten
ni-
that he licensed Pursuant thep Lofts fnte C(mlf sd& I ra S` Valuation
(commencing with Set 7011(1) f D 3 f the B 14M 44"'444
m mat he is exempt m refrom..d the b.x far the alleged ex•mpmon.A.,violation -- $10294
or Ser ion 7031.1 by any applicant liar a permit subjects the applicant m e civil penalty
of not more(him rive hundred outlets($500). - APN Number Occupancy Type
°I,as owner of the property,or my employees with wages as their sole compensation, 0
will do the work,and the sumaum,is not intended or offered for sale(See.70,14. Required Inspections
Business WallProfess ns Code:The Contractor's License Law does nm apply to nn q p
invite,of property Who builds or improves thereon,and who does such work himself
or through his own employe',provided that such imprm ems arc not mended or 305 — FRAME
offered far sole.If,however,the building or improv m- h sold within one year of 307 — INSULATTON
completion,the owner-builder will have @c handlef r Ing drat ha did not huild or
improve l'orpurpnveofs.la). 641 — ROOF-- TEAR OFC.
°l.asawner"nhep perry.. ch vel end, ng with licensed contractors to GGE//YYII-02 — RROOFJr PLYWOOD
YD�NAIL
construct the projec .B nes and P anions Code: The Contractor'
License Law does eC.y m a m ,. or improve,the 403 — ROOF BATTENS
and who ronml for such p n cis n racted,)hcemesi pus n I the
Contractors use Loe a r 604 — ROOF IN—PROGRESS
M am cxcit an try .B&P fillla
Owner
WO E CO PENSADONDP.CLARAN
I hereby affmn under Penalty of perjury one of the following declatutions: _
❑ 1 have and will maintain o Certificate of Consent to self-insure for Worker's
Compensation, its provided for by Section 37ln of the Labor Code, for the
performmucc of tha w,ak for which This permit is timed. .
D I have and will maintain Worker's Compensation Insurance,a required by Section
37M of the Labor Code,far the perfnmuram of the work for which this permit is
issued.My Wor7keerrr C m�pen/�t���m/Illsfff)ral and Policy number are
Carrier:' ////f�N OF LN EM]No: _
CERT I•CATION OF :lot icy o: 'R WORKERS'
COMPENSA'T'ION INSURANCE
pbis seaian need not be cnmpleed if the permit Is for one hundred dollars
.18100)or less.)
1 certify that in the performance of the work felt which this permit is issued,I
,hall not enrpluy any person in any Inman so as ,,beeome v.bjecl to the Wnrkent
Compensation Laws of California.Date
A,Iwarl
NOTICE TO APPLICANT:If,after mak'Ing this CertiOcam of Exemption,you should
Z become$object to the Worker,Compensation provision,of the Labor Code.you nntst -
p C forthwith comply with such provisions or this permitshall W deserted revoked.
z
,rte, fO CONSTRUCTION LENDING AGENCY
I hereby waffinahich this there is a issued(Sic. lending agency for the Ikrfnnnnnce
W Fn of the work Ibr which this permit is issued(Sec.3897,Civ.CJ
(z Lender's Na v
7 Z Lender's Addre Addrces
V C 1 certify that I have mad this application and state that a se information is
fz F. cored.1agreeg con m comply d h city and coo dinar s stem lows enter
upon O
Q (, tto he above mentioned
end for
amlhmry uta' esu is cope,, rupon /fes
the aho011a r'ee nt'. tem inspec t
flit QWi cs,judgrcolo s. is an nit dk nc sat• .h uperti " all
F+. h liabilities,judgment, nsrs an wrtsc' icha ay acerae uin said '
V z Chy in ttmxeyuane of the gnu uin f' per � � !/
�I
AP PLICANTU ERSTAN05 ILL IPI IT H AL IM Issued by..:) e- 11 N7p•�I�lil.P Date
SOURCE RE f,l. S. d� Y'
Sigmmmof Applican cant. are Re-roofs
HAZAR US MATERIALS Of 'LOSURE
Will the applicant or future building occupant store or handle hamNous material 'type of Roof
as defined by the Cupertino Municipal C, , hop¢,9,12,and m9 Health and Safety
Code,Seen 12553^-la)^ ,
E3 Yes All roofs shall be ins ected prior to n roofing material being installed.
wBlthelivill ntof lilt re pant use equ menrordeviceswhich If a roof is install with first t ing an inspection, 1 agree to remove
. emit banudnus air conmminaam a def ythe ay Art. it Quality Management
Dfsrrie7 all new materia for p t licant understands and will tom y with
°Y°` No all non-point sir reg s.
I hove road the h .00h . ell I in er, 1,under C "pier 6.95 of'the
C.1iftener[]cloth&Sa y e,Sct It S ..4.l lmdenF d at
if,he building does c envy I. a Lt at IS lny rexpnmibilitym ori the
cupant of the rc ems wh' ar m issuance of o C ti0 m f
°c`"pa"`y' a Signat e of ApplEadiff Date
Overerin mice s=at, All roof coverings to be Class "B"or better
OFFICE