01100122 CITYBUILDING DPERTONNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
7576 PEACH BLOSSOM DR 01100122
OWNER'S NAME: APPLICATION SUB DATE
BRUCE S . LEE 10/23/2001
PHONE: SANITARY NO. CONTROL NO.
O O ARCHITEC TNGINEER: BUILDING PERMIT INFO
iC BLDG ELECT PLUMB MECH
W T.1 O L=J L=1
=wi i LICENSED CONTRACTOR'S DECLARATION Job Description
J z v-C 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing REROOF . P
m t,w with Scxion9000)of Divisimn3 nf1ha Businessand Professions Cale,andmylin,me
in full forte nal crit t
ii«nreclasr 9 Lica G1 L T/0 WOOD SHAKE, INSTALL DURALITE VILLA.
O er.w U Dam �_ Contractor
5 LL Ori: ARCHITECT'5 DECLARATION
1 understand my plans shall he used as public records
u3T-
2 y O O Licensed Professional
OWNER-BUILDER DECLARATION
:2 o, 1 hereby affirm that 1 am exempt from the Contractor's License Law for the y
t?< following reason.(Section 703L. .Business and Professions Cale:Any city wcounty
E o which requires a permit m conswa,ulcer,improve,demolish,or repair any structure
�j m _%orroiu%iamance,also requires the applicant for such permit m rile a signed statement-
that h5is,licensed pusium,to fhf pilocklms of the Commetor's License Law(Chapter 9 p g�� S Ft.3,Flo Area ,• I, . Valuation
(commencing with Section 9000)of Division 3 of the Bp;ipess inp Professions Code) a',{;IN TRtiL'gk A is\t l lt\.�I A 11x�.
or that Kc ia'ex<mpt dicicfmm•and the basis for the allddgetl de of tjl d.Any violationIrrlll r
nn
of Seemn 9031.5 by any applicant for a permit wbjects the ap,li.act a civil penalty
of not more than fee hundred delta.MOB). APN Number . Occupancy Type
❑1,as owner of the property,or my employees wish wages as their sole compensation,
will mocha work,and ns Code:
is not mtenaca or offered amp apply to a, 3 0 7 - INSULAT 304bired Inspections' "
'Business and work,
and the
Code:The is Contractor's License Law dor not apply tom "
Owner of progeny Who builds or improves them on,and who docs such work himself 6.01 - ROOF TEAR OFF
or through his own employees.provided that such improvements art not intended or
arcered for sale.If,however,the building or improvement is sold within one year of " -' 602 - ROOF PLYWOOD NAI L lT. ^` '
ionipletion,the owner-Wildrr will have the burden ving of prothat be did not build nr
mprove for purp6m of sale.), 603 - ROOF BATTENS
"o i.a,mweerothe p:mpenY.a -exclusively cantraitwith licensed eonu:cor:m. .. 604 - - ROOF IN-PROGRESS . _ ._„ ."-er't
- = consumer the project(Sec.7144.Business and Professions Ced,:)The Contractor's „
License Low docs nm apply to an owner of property who builds or improves thereon,
.m T end who coormcta.(al with a ennhacmm licensed t m.the .._. .._". ...
such projects ' (s) pursuan
Commnor's Liccnsc Lew, m ,
. j ✓ .' ❑Iamexcmptundcr Scc. � 4 .8'&P C for this reason
Own . Date
WORKERS COMPENSATION DECLARATION
1 hereby M.under penalty,of perjury nim mf the following declarations: 11\G.A 1_E
❑ 1 have and will maintain a'Ccninci¢of Consent to self-insrs,for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the NOV 01 2001
performance of the wwk,(ar which this l¢rtnit is issued. .
,:�� II hal- ll Taint Wo ke 'C peer nr. o" ObY Sector
_- ] of the LaborCode,for the pstforniance Of the k for
which this permit is
issued MY,W, r/k aiCo pe satlo,l sure ce ismer and Polcy,-tuber rc,. •„- BUILDII\G--r-r-- - --- --.. --
”' e} ST'. Id; ,i. rpaircy Na '• 14d} !S-6'-Ll ` ,(�1..6{)e•. txi,''1�iiZ�q-(qtr,.
U CERTIFICAT NOF EXEMPTION FROM WOFROM KE t z z s I
;NSATION INSURANCE: - _._ -. ._.. -_-
K
COMPE _
('ITrs'section heed not tie enmpleied i(the permit is(or ane hundred dollars 11'.\
is BID)or less.)
"• ;1 certify that in the in any
of the work foe which tbiject to ii a issrkers
shall not employ Laws
operson Cm any madnegso'ns to become subject m the Workers'
Compbnsition Inws of Celifomie.Dere
Applicant
'NOTICE TOAin the NT.r'sC.OecoIf.after o. .png rCminr.msof h Lobel ian.you uhould
most
Serious,subjen m the Worker's visimxror tion provisions of the deemed
Caere,,you must
� O forthwith comply with such prmisimns or this permit shell be deemed revoked.
JCONSTRUCION LENDING'AGENCY;"
I hereby aRrin that Vert is conswction lending age noY for die peifotmen«'
of Ne work for which thii permit is issued Ser.309],Civ.CJ
Lender s Name'
D}O Lender's Address r.••1•.• . - . ..
ret 1crify that 1 ha ad this opplict Institute that theM infmsture.is
fs.,.E. comet 1 g to comply with all city and a iy dinarre d state laws relating
0.0 to Wilding construciion,and hereby authorize mpreSentatoms ofthrsCty to enter Upon
,,, W the above-mentioned property for inspection purposes.,. A
Uly el. ag ee m sa a ndemnipe and kc p harmless the Cly or Cupertino against
W lion tesjdueoix,, a dexpenses ti M1 y'n any y c againstsaid
U.�7y City neon equenc)Iof thANDSANDWI L t
RAPPLICANTOURCE''RE N)tt$1'ANDSANDWILLC. I .. ITHALL ONP INT'• Issued by: Date /0--23-0/
Lo A 3 set
signature orApphcan✓comra<mr- ,� .'. ,, —� noam Re-roofs
HAZARDOUS MA IALS DISCLOSURE
'-' Wtlllbdpplicant Wfture building occpant store or.bondlehawNous material Type of Roof -
as defined by tho Cupe,.irm Municipal Code Chapter 9.12,and the Health and Safety ..• -• T •` b J '•'e'•."•'s' x •' ` - I - - .
code section 25532rq (.n. •.,iH 3;p. t•t.`•r - IC `. b: - .. F f-.!, ' ..
❑Yeas•'•-^'r .,,;;�'l+a;il' , ar_% -". -_All roofs shall be.inspected.prior to.any-roofing materialbeing installed.-_ ...
Will the applicant f t b'Id g p t sc cqu pmcmo de tees which If a roof is itistalltjd'without first obtaining an inspection,'I'agree'to remove
'mit hazardous air ccunaminams as defined by the Bay Arcs Air Qutility Management
Dism<9 all new materials for inspection. Applicant understands and will comply withD.
_
°Ya p all n -pojnt source regulations.,
dl`0/L n•.:.r.r .
Ithe e rc d the h zeNous mmenals rtgmrtmems under Ch pier 695'6(the
Calirmni.H lth&Safery Code SoLme,25505 25537 and 25534 1 understand the
ifthe building dnotcnernlyh m tthtt yrcp b'Ity to tify,tho 1c>
oceupkm of h r irements which must be r m is
met priosuance of a Certificate of
u
_ _.l 0 13 O 1 _ Signature o Applica Date
ownerwaumod3ed agenr'm wte,., All roof coverings to be Class "B"or'better
i •�'" . �.dJ.�: a . OFFICE -