04060069 CITY OF CUPERTINO
BUILDING DIVISION PERMIT X'ON
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BUILDING ADDRESS: WM H FRY CONSTRUCTION COMPffl4fTNO04060069
22790 MERCEDER RD
OWNER'S NAME: PERMIT ISSUE DAM
Ahh, 'DAVE RUSSELL 10351 SAN FERNANDO AVE 06/07/2004
E: SANITARY NO. CONTROL NO.
(408) 996-8173
ARCHITECT'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Mat I an licensed under previsions of Chapter 9(commencing Job Des
w Section701100ol'D
it flow 4.4 aficc�smn 3 ofthe Business slid PromssfimsCom.end my he...1. Clip ALED
M95 raccles. Lm.1 52,, '7 9 3- DECK REPLACEMENT
z a _`�"`_ —Commem"'51 V 11As' C�,4 SFP 13 2004
i ARCHn"ECT'S DECLARATION
I understand my plans mail ho used as public records
Licensed PrOmmi...I OWN R-BUILDER DECLARATION
I harchy, fliou the[IE.camels from the Contractor's License Law for the BUILDING
0 0 following moson.(section 7031.5,Business and Professions Code:Any city or county
which requirset a pernitoo Construct.atter.improve,donnish,or repair my structure S12750
pn.,to its ismance.alsomquirestloo applicant forsuch pumnittofilc asigned snamment
that he I,licensed dr.provi,ims of the Contractor's License Law(Chapter 9 Sq. Ft.Floor Area Valuation
(commencing with Section 7")of Division 3 of the Business and Professions Code)or
ERE that he us exempt therefrom and the hase for the alleged eximption.Aoy violation of
Section 7031.5 by Any applicant for 4 Permit Subjects me Ppficam 1. civil ..try of 3 QIRZZ"er 0 0 Occupancy T�pe
.or more man five hundred dollars($500).
0 1,a owner offlue,property,or my employees with wages an theirsolecompandadon,
will do the vmekmd the summure is not intanded.r.mead Waste(So,.7W.Basis.,
.it Preficalmis Code;The Commoner's License Low dean art apply in a.owner of Required Inspections
prelparty who builds orimpiroves demon,and who doessuch work himseffor through his
awn employees.provided that such improvements are not intandlad unroffered formic.If.
however,the building or improvement is sold within one you ofcompleflon.the nowar-
Wilder will have due burden of proving that he did not build or improve for purpose of
sale).
C]1,as Owner of the property,am CaClUsivaly Contracting With fiCCumd Constructions to
construct ths project(Sec.70,1,4,Business and Poficann.ma Coute:)The Combustion's Li.
Cause Law don not apply in an aswer of property who Wilds or improws daemon,ad
who contracts for such forrijecia with a comeactor(s)licensed pumuam in the Contractor's
License Law
r-I I arn camopt under Sec. B&P C for this matin
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WORKER'S COMPENSATION DECLARATION
I Wrathy affirm under penalty of perjury orte of ft following decimations:
have and will maintain.Cenficam of Consent 1.self-lam.for We*.,'.Classes.
sation,as provided for by Section 37M of the Labor Code,for the performance of me
we
work for which this permit is!wood.
F❑1 1 have and will maintain Warker's Compensation Insormcc,as required by Section
3700 of the Labor Code,for me purforemarec of the work for which this Permit is issued.
My W.,kat's C.milemalkne Insurance Carrier and Policy number a.:
C.7 110 cy NO .32--
'Q R
.P,/"L CECRTIF*IOFEXEM N F RKEG�
C At
O'PHNSAT(ON INSURANCE
(This auction need not tsccompleted if the parch 13 for one hundred dollars($1(I0)
or mars.)
I certify that in the performance of me work for which this Permit is issued,I shall not
employ any pormin in any runner se as W become subject to the Worked'Comiscossfirm
Law of California.Date
Appl�.C.d
NOTICE TO APPLICANT.If.after making this Cerfificat,of Exemption,you should
become subject w the Workers Compensation provisions of me Labor Code,you must
z forthwith comply with such porwisdons or mice Permit shall In deemed revoked.
z 0
51 CONSTRUCTION LENDING AGENCY
I hereby affirre that them is a Construction lending agency for too Performance of
the work(Or which thin Permit is Issued(Sec.30137.Civ.CA
Limm,'a Name
z Lcoida,.Add.
U0 I certify that I have land this application and stata that the show information is
0. P Comet.I agree to comply with all City old County Ordinances and mile laws misting to
0 U building construction,and hereby autionner MPMCnMLiM Of this City to enter upon the
above-mentioned Property for impaction purposes.
(we)agree to cave,indemnify and keep harmless ft City of Cupertino against
CA liabilities judgmans,costs and expenscs which may in my way accrue against mid City
U Z in COneaqWrCC Of the Standing Of this permit.
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
URCE�REG�ILATIONS
SxZ�'e" 7e,;:� �— \,--'(9/1 O�' Re-roofs
Ignature ol'ApplicanuContric, Data,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will do,applicant or future building occulpantston,orhandio humdous material
m defined by the Cupertino MunicipalChapter 9.12,and the Health slid Safety
Sgtio25532(ay?
.
0' All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hasaminue air contaminants ra&F,.Cd by the Bay A.Ail Quality Mmegmim, all new materials for inspection.
0 Yes
I have mail the hateardous materials requirements under Chapter 6.95 of the Califon
ata Heald g,Sidet,Codc.Sect..25505,B533 and 255N.I understand the if the holding
does not currently have a tenant.that it ins my responsibility w notify the occuper,of the
rcyuimmcnts which dun be met priormissuaucafa Ccrufmam of uvnLy.j Signature of Applicant Date
77Kier or anthorind agent tr-W All roof coverings to be Class"B"or better