00080047CITY OF CUPERTINO
BUILDING DIVISION PERMIT
861 ROSE BLOSSOM DR
OWNER'S NAME:
LICENSED CONn oiCr0R'S DECLARATION
I hereby afire that 1 iso licensed under provisions of Chapter 9 (commencing
with Section '1000)ofDivision 3 of the Business and Pfofeasions, Code, to licomeis
in full freer aha cf
LhNIXLie. #
Da¢ Cmn.cwr
ARCHrfELTS DELT.ARATIO!
I understand my plans shall be used as public raarda
ucemea Professional
OWNER -BUILDER DECLARATION
I hereby oRml that 1 am exempt from she Contractees License taw for the
following reason. (section 703 I.S. Business aha Profesaions Code: Any city or county
which requires a omot to construct. alcor, improve, isoultaf. in regain MY avecmre
prim to its issuance, also requires the applicant for such permit to file asigned augment
that he ix licensed pusuanu. the provisions of toe Conbaice. License Law (Chapter 9
(commencing with Section 7000) of Division 3 ofile Business and PmBasions Code) a
Out he is exempt therefrom aha the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for it porous bj.,, the applicant to a civil penalty of
nm more Nan five hundred dollars ($500).
L as ownerk, and
prapeny. or mY employees with wages r Neo Sole compensation,
will do Nework, andtheeo Cmuisnot intended or offeredfm We (Sec. ad, own,
and property
who
Cade: The C es din m License law alma naw apply tom owner of
property who builds or improves Nsuch improvements and who does such work himself or througM1
his own employeese pmvMm that tech oldw art not intended m offered for
tele. IL however the building ur improvement is hold within nese yevof completion, the
owner-tankler will have the burden of proving that he did not build or improve for pur-
pose ar,
❑ st a owner of the progeny. outexclusivelysieand contracting witCod ) licensed c ntreacmn i.
construct the project (Seeapply
7066, weer ors and ny who ore Code:) The es floadm'e and come faro docs not apply je an with
owner of properly who builds m improve Como#. and
who ase Law. for such projeca with omnmaogq licensed purtuent w the Conwdoes
License law.
❑ 1 am exempt under Sm. . B A P C fa Nis reason
Owner Dag
WORKER'S COMPENSATION DECLARATION
1 hereby arm under penalty of perp, We of the following declarations:
❑ I have and will maintain a Certificate of Conserv to telt-in om for workers Compen-
sation, as provided for by Section 3700 of the labor Cade, for the perfonnsme (ifIbe
k fm which fl permit is iaemd.
1 love end will maintain Wnrte a Compensation Insurance, u required by Section
700 of rhe laWrssode, fm the performea<of the wmk fm which Nis peemil is isaucd.
My Wmkga%el�tio/TrtyuJampcerria aha PoIicYPyglkr/irC(yg 7�4 4
CERTIFICATE OF EXEMPTION FROM WORRIERS'
COMPENSATION INSURANCE
(Ori. satins nad nm bacampleted ifthe permit u for. hundgd alalia# ($100)
on Rsa.)
1 certify that in the performance of the work for which this pemdl is issluq I shall
nes employ any person in any manna m as to became wbjmt to the wmmrs'Compon-
sation laws of California. Date
Apphicant
NOTICE TO APPLICANT: If. after malting this Cemfi,,Mc of Exemption, you should
become subject to the Wortres Compensation provisions of the labor Cade, you most
fothwith comply with such provisions in this permit shall W deemed revoked.
CONSTRUCr1ON LENDING AGENCY
I hereby offno Nat Nem is a consmsetion lending agency forthe perNersonce of
the work for which Nia permit is issued (Sec. 3090, Ci, C.)
I<nder's Address
1 certify that 1 hove read this application and aloe that the above information is
conal. I agree to comply with all city and county mdinsnces andarae laws dating m
building concoction, and hereby outlander mWesenwtivea of this city to enter upon the
above-mentioned propery for inspection purposes.
(We) .gree w one. indemnify and kap hamless the City of Cupertino against
habiblies.pit,ments, costs and expenses which may in any way seems against said City
in consequence of the granting of this permit,
APPLICANT AND 111.1 LOMI9.V Will] ALA, N(1N-I SOUR
Signalof Appli<.nVC Intent Dag
HA ARDOUS MATERIALS DISCLOSURE
Will the applicant to future Wilding necupem store or handle har ndaus material
an &fired by the Cupertino Municipal Code. Chapter 9.12, ad the Health and Safely
Cade, Section 25532(a17
❑Yes MW27
Will the applicant or future Wilding mcupat use equipment or devices which
emit haardous air contaminants as defined by the Bay Arca An Quality Management
DoWo 7
O Yes
1 have on, the ha oodws mamela requiremrnt, under Chapter 6.95 of the Cali.
fame Health d Safaty Code, Smirm 25505. M533 aha 25536.1 undm if the
Wddingdo havealenen Ilw it is my respmnsibilily te selif m lent
of Ne uwhit monba m m issuance of a Cannes. ry'
W
Owner or authorized gent Dae
SANITARY NO. APPLICATION gUBMITTAL DAT
0G 080047
�dVQ �k Jr NIC CONTROL#
Wog \ %5145 ❑ 08/07/2000
S10> wo BOLDING PERMIT INFO "'' " 3
Job Description
SHAKES — RESHEET 1/2 CDX —30# FELT/31
Sq. Ft. Floor Area
305
— FRAME
307
— INSULATION
601
— ROOF TEAR OFF
602
— ROOF PLYWOOD NAIL
603
— ROOF BATTENS
604
— ROOF IN—PROGRESS
Re -roofs
Type of Roof
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
understa ds and will comply with all non point so rce regulations.
�jC 7 pO
Signature of Applic nt Date
OFFICE
All roof coverings to be Class `B" or better