01080117 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22780 MERCEDES RD WULFF ROBERT S AND NANCY J01080117
OWNER'S NAME: APPLICATION SUB DATE
WULFF ROBERT S AND NANCY J 08/23/2001
PHONE: SANITARY NO. CONTROL NO.
I '
GOO ARCHITECT/ENGINEER: BUILDING PERMIT INFO
U BLDG ELECT PLUMB MECH
1_J U
6
II-- LICENSED CONTRACTOR'S DECLARATION
{iLZz It. Job Description
,aC� with Sec11ore rudmf Division3af the Business and Professions Cade.and my license FURI�R�
iv in full Tow[aid cWn.
¢ u Liana Class Lic.p
o n Dme Contractor
3 u G ARCHITECT'S DECLARATION JUN 10 2002
V,� 1 undemmnd my plans shall be used a%public records
iyaC LiccnsNProf[ssional - BUILDING
OWNER-BUILDER DECLARATION
w^ I hereby nffrm that I airs exempt from the Contractor's License Law her the
1=2 a fallowing mason.(Section 7031.5.Business and Professions Cale:Any city or county $1200
2 e which rtq rts a perm t, ....du t Ira - pro demolish.or reps r any voracious,
a 3 s -pit
it)t.issuance,al eq - dueapplicantf r. h permit In file.signed smcmcm _ — ____ _
mh snwChapler9 c ; . nValuation
na o¢Pmfcssiots code) i'13 4'22 s '.e aett(o m ngwmh sect 7W )ofD"vi3 theBsin
,
or that he is exempt thcichoma and the basis far the alleged exem,r an.Any violation
of Secuun 70L.1 by any appl'Irant two peman,objecia the applicant mast penally- p7t,.�ys,s•.
of not more than for hundred dollars(SSW). .301APN TCC7L• S PLUMB IN Occupancy Type
01,as owner of the progeny,or my employees with wages as their sole compensation. _
will do the'%ork:wd'the someone is not intended or offered for sale(Sec.9flaa:' - -
Bhsiness acid Professions Code:The Contractor's License Law docs not apply to an 304 - ROUGH EJFR92l EBILctions"
uwmr of property Who builds or improves thereon,and who Jms Busch work himself
505 - FINAL ELECTRICAL
or
it— his axn employees.provided that such improvements art not intended or
ul7ema f tial[.if,how[vcr,the wading or improvement is said within one year of 507 — FINAL PLUMBING
completion,the owneawildr,will have the buNofen proving Nat he did raw build w
impmsc for paryoa x(.10. 508 - FINAL MECHANICAL
Jen I,as owner of the ptape,rt,ran esclusivcly contracting with licensed contractors to '—
cansruct the prise[,(Sec.70,14,Business and prnfimaio"s Code:)The Carearc ar's
License Law docs not apply m an more,of pm,dy who wilds or improves thsrom, "
- and who contracts for such projects with.a corrosions)lharrord.punout to he
.. Co slaw. .._. ..... . . .. .... _..... ..
_ Cont ow"
Limn
_ OIu a tpuuntl rScc. .B&PF fw,hinrta .f'1' i s. I-:, FPI
Daic..
WORT ER pMPENSATION DECLARATION
I•M1ereby._a_under enahy of perjury one o(Nc following declarations.
0 1 hove"and will moiinthinCenifcmc of Conserv m sof-insure for Worker's
Compensation, as provided
or
by Section 3]00 of the labor Cade, for the
per[o..a of the work for which this p nor is issuW.l„
❑I have and x'ill maintain Worker's Congeni'ation Insurance.-as regbireJ by Section
3700 of the Labor Codd,for the Performance of the work for which this Permit is
issued.My Worker's Cnmpenwti,m Insurance cuaier and Policy mmnba arc: nom• _ _ _
Camp 0 , h} t ..tu IpolcY No. ', •- ... 0 IPI l
f CERTIFICATION OFEXEMPTION FROM WORKERIS! - ` l 1 ' _1 ) �Y,�.a' a �Il s•
_.� COMPENSATION INSURANCE ----- ..... _... ._. .. .__. .
`_.
ffli,,ictonncd not he"conplcad if the permit fw one hundred dollars 1!
151001 orkssd - '
Ilcenlfy that in theperf mime fthc rok forwhithth .it is i,w[d,I _{ _•.I "-t 'l, ol`1/ � • ' t- -
shall n tplay,any person to any manner w as to becore subject to the Workers
Compensation Laws of California.Date
Applicant . . _ .. ... _ .
NOTICE TO APPLICANT:,If.after making this Cenilicme-rat Ekemption.you should •^ •t"
beEoe subject the Wo
rkers Compensation provisionss of,he labor Cade,you mu
z Omloath,th comply-with such previsions or this pemit shall the decmed revoked.
y
lr d•u..
` "" gICONSTRUCTION LENDING AGENCY" '
a ' "1 hereby u(limi that there is a amstrvwion kndind agency for the perfotma.a
of the work fnr'which this pwmii isiskaed'ttlw 3097,Civ.C.)
gL. Lender's Name - _ .. . . ... _.. ._.
o.z Linder'9 Addresva.. .. . : .. a ' Ise.
U0 eenify that 1 have read this application and anile Nm the above information is '
CL cit t 1 6 t comply with II city and county rd' nces and state laws rely ng
O V toWilding construction,add heathy authorze representatives of the city to enter upon
the w , map pen r apt keep
parpan �.
,(y (Wc) g ass do uI,a keeph I 0.City of Cupcmn"ogans
Vi liab bdgl cm, t d pen h ch m y anyway acerae against said
U_ City m quence f the gra ing of permit.. .
APPLIC UNr ST V! 'ANI V LCOMPLY WITHAL NON INT
SOURC FOUL oN. ^I; �j 23 26 o Issued by: Date ��Z
Signature.f AFlicgni/Conlinnon Re-roofs
- .,:HA9ARDOUS MAT ALS DISCLOSURE '
. n W II the tip(kart w future w(ding pat tore w Faradic h,;aatdatrs maternal Type of Roof,
asJf dby th Co,,emm M- palCh pre 9.12.and N<HealNand Safety L� Ys .),V •I s `sU1 :v'r
Cade Section 25531(.)? a I ail
'i Dyes, No ._. All roofs shall.be inspected priocto,any.roofing material-being.installed..,-
'; Will the applicant or future wilding occupant use equipment or devices which If a roof isiITsttilled'Without first obtainingan"inspection,�I'agree to'i'emove
emit hassNous air connotations as defined by the Bay Area Air Quality Management ,
Dist", - all new,materials for inspection. Applicant understands_and will comply with
/� °Y + all non-point source regulations.,
I'
I ha a mad the do a ora.,matenitis 2egwmmcros under Chopar 695 of the
alifirnia HeelN&Safety Ctde;Sections 25505:25533 and 25534.I understand that
dins'n v not moreml haec ti nho n;Nn it is my bit,mibility to notify the "-
mMiilof,
f the requir c ,nun homer prior to isx Yntt of Cenifinm of
=' p"Y It.' - ``� 23 •top Signature of Applicant Date
�= All roof coverings to be Class "B"or,better
t
Y' tb 3cd og . Data
g
�i - ! OFFICE ._