02010053 OF
CI BUILDING DIIVIISIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS'. PERMIT NO,
22384 RIVERSIDE DR WM H FRY CONSTRUCTION C MPANY02010053
OWNER'S NAME: APPLICATION SUB DATE
JAY ANDERSON & DONNA POGGI 10351 SAN FERNANDO AVE 01/14/2002
PHONE: SANITARY NO. CONTROL NO.
4085935219 CUPERTINO CA 95014
O s Z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
OO BLDG ELECT PLUMBh1ECH
<�E INSTALL TEMP POWER POLE u u u u
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Z H= LICENSED CONTRACTOR'S DECLARATION Job Description
O Z_O 1 tion 7 affirm Ibm 1 am licensed tanner provisions of Chapter 9(commencing
FNH with Section7")of Division3ofmhc easiness and Professions Code,and my license
<yy� sin full force and efie
, m ce< License Lic.a SL075S
O a U Date - - Cmnrec oAeezrr L`1
u.fir ARCHITELT'5 DECLARATION
F,n w g 1 understand my plans shall be used as public mounds
roN
w C O O Licensed Professional
OWNER-BUILDER DECLARATION
cd a, I hereby affirm that 1 am exempt from the Commaor's License law for the
s-Z a following reason.(Section 7031.5.Business and Professions Code:Any city or county
E x O which requires a permit to construct,alter,improve,demolish.or repair any swcture
3 prior to its issuances also marinas the applicant for such permu
io file a signed statement
a. Ibuihe is licepped pursuant in)the Pmvsmna Of the Cnmracmr's License Law(Chapter 9 S Ft. Fluor-Area , , , ,, Valuation
(commencing with Secuon]000)of Division 3 of he Business and Professions Code) [ '•t C i (j..;>.q l .._ e. .�,:1�;�`;:
or that he is exempt IFcremom and the basis for the alleged.toremmm,Any violation
of Section 003 1.5 by any applicant for a permit subject the applicant to a civil penalty
of not mom than rive hundred dollars l55oo), APN Number Occupancy Type
❑I.as owner of the property.or my employees with wages as their sole compensation, _
will do the work,and the dourture is not intended or offered for sale(Sec ]044, -- - - - -Business and Professions Cwt The Contractor's License Law does not apply to as Required Inspections
owner of property Who Wilds or impowesthemom and who does such work himself
or through hs own emply s providedtht such improvements are not'intendedor.
off ml(o side IL-moover,the Inaddingor ouprovemintissmd within - y ar of "' _.. . _ _ _...completion.the owaser-thatilder willh due burden f provingthth did notWild or
improve for purpose fsale.). ..
❑I o iter f me Propcny am-exclusively imuding with I sed contractor;ro _ /J I.(.�. ............._ ._.. .._
-
construct the project(S ]Oa' Business d Profession,Coda)The Co tmemor's -
`
License Law does not apply to an owner of propeny who build or improves thereon
,wd.who,comorcus for.such projects with.a comrecmrfs)licensed pursuant to the. . .._ __...__..__.__ _ ... _ __ .. ....._ ..__ ... _ - _ ... .. ...... ..
El I am exam
License taw. . .. . .
O ..
❑lam exempt under Sec, � B&PCfor this rt .l •• • =' "
Owner . .. t Data
- WORKER'S COMPENSATION DECLARATION - r f
thereby affiwill munder pewhyofpe,ry Of
of sent in self-ingdedfor Wo �+
❑ 1 have and will mvided or by fccebf corm O m seLa or for Worker's
C'form inion.dm work for for by Section J]W Of the labor Code, for the
'perfortna c<of the work for which Nis permit is issuN.
F a d ill maintain Worker's Comp n atiInsuran required by Section
O�
]00 f the tabor Core,hii the Performance f the work for which'his pc.it is 57
issued�7MW kcr's Compensation Insurance and Policy number are
c x Policy N v�'14/I Zz'; •�� , . >. , ��%
CERTIFICATION OF EXEMPTION FROM'NORKERS" - `•I•-t ' t
•-, ION INSURANCE'•"'•. - ,_... _.___...._._._.
__. _.
... is sccmion nod nbe completed .. •.Permit is.. .for one hundred dollars .."_.. .. . . ._.. ......_.------ ..___. .
QT
ted if me -'
(I 100)or lass.) n •. . . :. -... .._ _ _
1 can(yah. tor pe form rice hhwork for wh h dis ct t' ca.l _ r s If CL• �, '
shall not employ any perwn m any mannerso as to account subject the Workers' s
Compensation sen Lows of California tae
NOTICEtTO APPLICANT.If,after masking .. _. . _.... .------
NOTICE
.__.
this Ccnifcaof the
Labor - -
become subjectocomply
the Worker'CLm ri or t od Prow isionsll be d Labor revok you most
� O 'fonhwi'h comply dish such provisions or this format shall be deemed revoked.
-Z -
.F,tiCONSTRUCT',ION LENDING AGENCY
f hereby oft r that dice is n est suuei on lending agency for the pert()olance
'Lithe work for which this permit is issued(Sec.3097.Cie C.I
a.Q •'Lender's Name"•. .._.. _. . .. . .. .. .
Z Lendcr's Address ' ,,,} I ', •iii.
,U Q
_ lc nthat d df lPPI t J r'm.'_haIr
theWinformation s
'correct.,l Beet comply early ri countyordinancesdstate laws
I b"Id g construction,and hereby authorizep i fver fth' city to pan
W h W e m m d
�A
p Pent far inspection on P ea
F y (W)zg n,to a d< nsz nJ Loop M1 y an the Cwy f c pert ai against
N
liabilities,J clumcc seas aaJing oftswh ch may'nanyway'acene against Ll��
U Z City in ronscquence of ihe'graming oft permit �+
D .API'LICAXTU:vDE�R�STN�NDSA.DD.WILICO)(PLY%t'ITH,11.LS6v: ],\T Issued by: Date
.. 'SoI':CF
Signature of ApplicanVConra '•:Date „ Re-rOOf$ /
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant is,futurebuildialtucemant sore o handle hazardous mm d l .Type of Roof .. .. .... _.. .......
eta defined by the Cuseasuato Municipal C de Chapter 9.13 and the Health and Safety )„ F •s, ,.
CLde Section 2551 607 O y "•` ".
C •. l „All roofs shall be inspected prior to any-roofing_material being Installed _
NiII the tppl cant future b king sec pant use equip t a 'ce5 which If a roof is installed without first obtaining an inspection, I agree to remove
s commitment,a.a acr Ah 'he Boy Ar A Quality Mang cm
p ib d t _ ,..r , all new IT for inspection. Applicant understands and will comply with
❑Yes _ ..
l :. _ _ all non-point source regulations.'
I ,
�_. I have read Me hazardous ma¢riaN requirements under Chapter 6,95 bf the
�California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if'he Wildinge rernwments othich must
be
sharps issuance
iatitymnmify -
oecupnm of t e requirem nts which mus{beta prior m issmnee ate Ccnifca¢of
ceLpancy Date
�/ cc�� J_�j� o Signature of Applicant
"' All roof coverings to be Class "B" or better
Owner or omhorized age ' •Dore
p OFFICE. — _