03100198 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAClbRINI.ORMATION '
BUILDING ADDRESS: PERMIT N0.0 310 019 8
19462 ROSEMARIE PL
R'S NAME: PERMIT LSSUE DATE
BLUE EDWIN AND GERTRUDE M T US 10/28/2003
NE: SANITARY NO. CONTROL NO.
ARCIUTEC MNGINEER: BUILDING PERMIT INFO
BCI ELECT PLUMB
MEDIA
O
+06 LICENSED CONTRACTOR'S DECLARATION
� F❑ I hereby affirm that I am 11CCnad ander inions of Chapter 9 aammneing !Ob Description
W with lion )orDi isiona orthc Basin rad Pmfcssinm Co.,and my license is
i._ mm11 ` Ciro . 73 fj y 4 REPAIR PORCH
Licence Clus Lic..
�e ate Contrctor. CONTRACTOR: WASHBURN CONSTUCTION
le lundersund my pins shall)be used�hlic records
1yU
0
mLicensed Pmfemional
s � OWNER-BUILDER DECLARATION
y I hereby al'Ban that 1 am exempt from me Contractor's License law for]be
00 following manners,(Section 703 1.3,Business and Professions Cade:Any city m mem,
which requires a Permit to construct,eller,improve,demolish,or repair any,arunure
.iy poor Or its issuance,alsu requires the applieemforsuch Permit to file a signed statement
that he is licensed purmamtnthe provision nrfire Commnor'sLicense Law(Chapter 9 Sq.Ft. Floor Area Val ua4s000.
`uh$ (commencing with Section 1000)of Division 3 of the Business and Prolamines Code)or
d ..
that he is exempt dramatic.and me basis for Ne alleged exemption.Any vlolalion of
Section 7031.5 by any apPlicanl for a permit subjects me applicant to a civil penally of
Out more man Ram hundred dollars(1500). Occupancy Type
Q 1,as owner of the property,or my employees with wages is Meir sole compensation,
will do the work,and me structure is not intended or offered for ale(Sec.]Md,Business
and Professions Code:The Contract Licmte law does not apply to an owner or Required Inspections
prepeny who builds or improvesthpeon,and who does such work himselforthrough his �I
Own employees,provided that such improvements see not intended oroffemd forsale.If, q
however,the building or improvement is sold within one year of completion,the owned ��
builder will pave the burden of promu
ving he did not build or improve for purpose of D
sale.). DECftQ I,as owner of the propany,am exclusively contracting wit licensed characters to C 2 2 sj0 p�
conswet the project(Sea 1044,Business and Professions Cade)The Contactors Li. G
can=Law does not apply to an owner of property,who builds or improves thereon,and
who contracts for such projects wim a contractor(s)licensed pursuant to the Convector's /
Law.
0 1for
1 am exempt under Sec. ,B&P C for this rtuon
Data
!C31)y1'1
WORKER'S COMPENSATION DECLARATION
I hereby griirm under Penalty of perjury ane of me fallowing decimations:
ve and will maintain a Cer ilicam of Conant to self-iasum for Worker's Compen-
as provided for by Section 3100 of the tabor Code.far the perfam once or me
or which this permit is issued.
ave and will maintain Workers Compensation Insurance,es re uircd by Section
f me labor Code,for the performance ofdre work for which oris permit is issued.
rkk 'r/,C mien elion Insoanen carrier and Policy number art:
Cartie¢rVERTHFICATE OF EKEM Polic OMWORKERS
COMPENSATIO INSURANCE
(This section Recd Rol he compound if the permit is I'monc hundred dollars(SIR))
less)
1 comfy mat in the performance of the work for which this permit is Ounce.I shall nos
employ any person in any manner an as to become sabjmuo the Worlums Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cenifcalo of Exemption,you should
became suhjeet to the Worked Compensation provisions of the Labor Code,you must
D forthwith comply with such provisions othis permitshallbedoomed avnked.
ti O CONSTRUCTION LENDING AGENCY
I hereby affirm that there its consuactina lending agency for me perfurmarec of
Ya the work for which this permit is issued(Sec.3091.Civ.C.)
Q Lenders Name
S z Lender's Address
Q 1 cent mat I have read this applicaion rad sure mal the above infomomma is
y U correct I ague to comply wim all city and county matim es and some laws relating e
0 V building coated pr,end hercM1yRuth ari Poe Wsentarives of oris city to enter upon the
L4 above. counted Proper for inspection which ms
y LL (We)agree ve, mainly and keep Mrmless the City of Criterion against
L4 inbilitin,judgm Wcoaua Li expenses may in anyway eccmc against sold City x
J z APPLICANT Urvc NthUIE`RSTA DSANDWILL OM L WITH ALL NON-POINT Issued by: Date v
SOURC RE TIONS.(
Re-roofs
HAZARDOUS
Sign rcaf ApplicaDatc
HAZARDOUS MATERIALSDISCLOSURE Type of Roof
Will me applicant or(marc building mcopant erore or handle haaNaus mamriel
e.defined by the Cupenina Municipa c.Chapter 9.13,end the Health and Safety
Stenion 35533(4)? All roofs shall be inspected prior to an roofing material being QYea ;No P P Y g g installed.
Will the applicant or future building occupam use equipment or devices which If a roof is installed without first obtaining an inspection,Lagree to remove
' aaardoes air contaminants as defined by me Bay Area Air Quality Management
t? all new materials for inspection.
QYcs
Ih Leadth tuuNnus areariab requiamenu under Chapkr5.93 ofthe Calif.,
Ria Hcal dr cryC ,Sccguru 25505.25533 it 35534.1 undcomnd thmif the holding
dtxs no c Iy m a ens,met it i y responsibility in notify the oocupnl of one
rcyuim tswhich ul mctporb nceofacmlfcateoloccupney. SignatureofApplicant Date
/Oka
Ownm ur mariaad age All roof coverings to be Class "B"or better r.