01080014 CI of D nG DIIVIISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
23646 OAK VALLEY RD. KIRK MANSFIELD 01080014
AhOWNER'S NAME: APPLICATION SUB DATE
KIRK MANSFIELD 08/03/2001
PHONE: SANITARY NO. CONTROL NO.
l
q Q zO ARCHITECTIENGINEGR: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
a0�+ LJ LJ IJ C_I
i= LICENSED CONTRACTOR'S DECLARATION Job Description
Z
O m= 1 handy affirm that 1 am licensed under provisions of Chapter 9(commencing
„Ftli withSerfun]DuornfDivision3otlheBadnassandProfnslon,Coda,andmylicense TRELLIS/PATIO COVER OVER CEMENT PATIO.
ce my is in full force and eRcct.
at,,s¢ Littnec Class Lic.p
Oc D Dae Contractor
to a.u.I- ARCHITECT'S DECLARATION
u O 5 1 understand my plans.bull W used as public records
o ¢p O Licensed Professional
Its OWNER-BUILDER DECLARATION
1 hereby infirm 0m I am exempt four the Coamnor's License Law for the
F'i following reason.(Section 7031.5.Business and Profe.iions Code:Any city or county
$2500
¢ wrier requires n ,m Conntmct,rater,in,
<Sp
ael-
q permit improve,demolish,permits Frerepairsig any rnament
n5` pre , ¢. requiresthapplicant( such 1 fire signed ,anent . ...._.._ __ ..
b",he . l Ip . t I( [ho C(ranactioA Liccow 1 IChapter9 OI' e}I. . V81Uation...
(commentingwithSecton]UUO)nfDivsun3attheBusine ndProle.iamaCoaki ( t 34�8`)"o2$ . (S0, ,. `fl;`' ;
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 703L5 by any applicant fora permit subjects the applicvm Io a civil penalty
of not more than five hundred dollars(5500L 516ACN]�yRkeL BUILDIN Occupancy Type
❑h as owner of the property,or my employees with wages as their sole compensation•
will do the work,-and the nrostom is not intended or offered for sale(Sec.7044. Required Inspections
Business and Professions Code:The Contractor'.License Law does not apply to an tl "
owner r of property Who builds or improves thereon,and wno does such work himself
orr through his own employee,.provided that such iis,sol ve not one,year or
offered for c le.IL however,the Wilding - improvement is sold within one f - - - - "' '" --' '_ .. ... .._ ._ •,_ _.. _._. - -...__...
I completion,the owner-builder will have the buren of proving That he did not year
in
improve for pntpmsa of,me.).
/�1t(L as owner of the p(See.7 am ca sines.a contracting with denud contractors to
.cryarum,M1e project(Sec.]BW,Business and Professions Code:)The Conuac,or's
Li,
no,Law does not apply to an owner of property who builds in improves thereon.
and.who contracts for such.projects with a comosions! licensed pursuant,o the. .. _..... ... .... _ .. ..._. .. __..
Cnmmcmr's License Law.
❑lam�e/aem�prl uv�nd-e�r Sec.
:�— " B,&PCf lis reason
owneDare ' �Y
't WORKER'S COMPENSATION DEgCARATIC NN
} Ihereby affirm under,penalty of perjury one of the following declarations:
V� O 1 have and will mainuid is Cenifeme of Common to ulf.insure for Worker's
_ Compensation, as provided for by Section 37M of the Labor Code for the
perfon emir,of the work for which this pefmil is issued. , . V
❑1 have and will maintain Worker's Compensation h%morm,as required by Section O
37M of the Labor CWc,for,he perfmmznm of the work for which his permit is /
issued.My Workers Compensation Insurance carrier and Policy number arc:
Cihner` f l i .'.:Policy No t1
CERTIFICATION OF EXEMPTION FROM WORKERS',' - "' - s - - "
` . . COMPENSATION INSURANCEr ...... .. ..... ................. ......... _ _ _... _ ___
Mist ecuon need not be completed of,hc permi,is for one hundred dollars
IS100)orlu s.! ,
'.1 certify that In In,perfnfmative of Ibe wok Icor wM1icn this permit i.issued,I
&hull not employ any person in any manner so alto become subject in the workers
Cdinpcnsmion Lawn i,f Calltmnia.Uac
"NOTICE TO APPLICANT:IL tater diking thin Catiticac of Exemption.you shouldt '
dccomdsubjm,o Ne Workcrz Compenzhtion provisiore of the lahor CWe,you moa
Q O lonhwithcomplyw hh such provisions or Ihis permit shall he dcemcdrevoked. _
z ^ `r•• CONSTRUCTION LENDING AGENCYr,rht
9 I herebyaffirm Ihat them is a construction lending agency for Ne performance
per
� Addres hlchthis mi,is i.sued(Sec.3(19].Civ.C.),
0.. Lendar's Name LenJa -
U 1 verify,rat I have martins application and nma ohm the above information is
I.. t.,, correct.I agree to comply with all city and county ordinaome and state lawn relating
;O [) ,o building conamction.'and hereby,authorize representatives of this city to enter upon
} f� ndre b t ed notion,p ty f ,' :Pea ...... -
p, (Wa) g , indemnify and keep harmless the City of Cupertino against f�
rp firbililles. ingrier,cost,and asTon-v which ria,in anY way arcerture against said
U Z Cry inconsequence ofah ing of this lre rat - ✓
^ +APPLICANTUNDERSTA\DS AND WILL COMPLYWITH AL9LNON-POINT Issued by: Date
SOURCE'REGULATIONS. y'
'Signature of ApplicantlCon,raimr "" Date _ , Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will he Itindienot in future banding recupon,amc'mn dl houmomemumnal Type of Roof .. .. .- ..— . . ... .
as defined by the CupertinoM pal Cod Chapter 9.12, d,h Health lth aid Safcry .���. _
C de Serf n 255)2(0) , y I . ,_1 . .-
P
.
ore (n'n' P t All roofs.shall be ins p c[ed.p ior_to any.roofing material.being installed.- ...
Wi1l,he applicant orfuture building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,•I'agree tli.reinove
emit hvarJons air containi enn as defined by the Bay Area Air Quality Management
DistricL,' ` all new materials for inspection. Applicant understands and will comply with
ova. No all non-points ree regulations.
s I lave read the hazardous materials requirements under Chapter 6.95m,he
California Health&Safety Cods.Solt...25505.25533 and 25534.1 ImdcraznJ that
:if the building does not cnremly have v tenant.that i,is my re.ponsibility to notify the ,. D
occupant of the requir mems which nwst be met prior m issuance of a Cenifcae of
°"a ' onature of Ap nt_ e
Owner or aan,ariecd agant .. ,, D e All roof co rings to be Class "B" or better
... OFFICE - - . . ...