01070063 CITY DIIVISSIIONNO
BUILDING CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22650 SAN JUAN RD 01070063
OWNER'S NAME: APPLIC TION.jUB DATE
SECKSTROM GORDON AND NELLIE 0 2001
PHONE: SANITARY NO, CONTROL NO,
n oc O ARCHITEC MNGINEER: BUILDING PERMIT INFO
w❑ BLDG ELECT PLUMB MECH
<.aq CI L_..I LJ CI
�v=Ni= LICENSED CONTRACTOR'S DECLARATION Job Description
�i-,� I hereby affirm that l am license!under provisions of Chapter 9(commencing 125 AMP SERVICE
ad with with Section 7000)of Division 3 ofthe Businessand Pmfessions Cade,andmyli«nu
axe pfereeande8eet. �p FINALE®
z a a License Class t /C Lic,a %o762L
s�3 d Date ' Co. q
O g I u�Jers'{,Jam)p1ARChaII be used s Public merodsa. JUL N O 20 01
ce
"�Y
a S p C Licensed Professional
OWNER-BUILDER DECLARATION
:�+ m I hereby affirm that I am uanpt from he Commetor's License Law far the �1 1I1 J']�A�r
following mann.(Section oUlS,tlminevs and Prefensiune Code.Any eiry or county V gyyl%Q
-2❑ which ationes a permit to mn.amct.,Iter,imp,ouc,dcon lisp,or mpuo anysInn add.
i 3 m ..prior
to it,isuartce,also requires the appiwaol for such pemduo file a d'ami amement
(co M1e intron Witpufuann7 the pm Division
the the Business and
Prlawmr,Cmr9 ...3 -Qg T.tOGqor,A�a„,. A , .O Valuation
(rthat he is exempt
Seaion71K1and the basis
or the
eleged iernd Pmfessions Cale( i .t s , ,,.,,V ,r5.�.,r\,L,11�.k ;
or that he is 31.5 bt therefrom and the basis for the alleged ppfica ioe.a ci violation '”
-of Sarion 7031.5 by any applicant for a permit subjects the applicanuo a evil penalty
mfmw mem than Eve hundred aeuara IasoB1' 3 04ARN�c ELECTRIAL'':;I •o Occupancy Type
01.as owner of dm properly or my employees with wages as their sole compensation, 501 - FINAL ELECTR AL ENERGY _
--Businesll do rhe-wotk, ad the Code: is not intendContractor
i or offered nor ansa(spay to an 50 5 - FINAL ELIi�Q'2Rd factions "
'owner of and propery Who
ilde:The Commcmro License o d does
su not apply m an
owner his own
Who Wilds or improves Thereon,and who does such work himself t
cr through his own employees. budded that such impmit R sol are not microbial or _ .,. _. _ •.— ......-
"u6nipld for sale.If,however.builde then have t e i den ofpmv n sola within doe Year o/
oprove far the owner-builder will have the burden of proving that he did not build or
improve for purpose of sale.).
_
01.as owner of live D.,,Iy.am exclusively......fin,with licensed cont metorem .,. .. :
construct the project(Sm.7644.Business and Professions Cade.Time Comractwl I , s•'
i. License Law does not apply to an owner of property who Wilds or improves thereon.
and who contract,for such projects with a contractogs).licemed pursuant to the
Contractors License law.
❑lam n,empt under Sec. ,Bffi PC far this mown
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have amiwi It maintain a Cenificam of Consent to self insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code for the
performintt of the work for which this permit is imued...
O 1 have tied will maintain Worker'a Compensation Insurance,as required by Smeion
37M of the Laher evade,for the performance of the work for which this permit is
issued My W k t C is ( I wmnce cancer ins Pol c number am
C .._ .. c�5�G8a l --
'Policy be.:
' 3jI1Tl:RA C
C .. .
�
r CERTIF„I�C-A_ IW,ORE
COMPENSATIONINSURANCE " , L t • s -,s-
,
(This¢«ion Beed has be cmmd ifpldthe aero,is for one hundred dollar, ` 'l: r `..' s
(5100)or leu.) 1
centfy that in the pr<
eRermanof the work for which this peorno'i is issued.ll
shall nor employ any person in any manner so as to become subject to the Workers'
cminpensadmn Ladsor GJlfonin. Dare
s s
Applicant,
_... __ __. .__._1___...__ . . ..... _
NOTICE ad ml to im APPLICANT.If.after making this Crnons te at he
Labor o de you auto '
Z bcchwithcjmly the Workers Cmnpenolnnprnv if provisionsfthe Luber Code,you must
Q O fenhwith comply with such provisions or this permit shall be declared revoked.
the work forxhichth it STRUss ION LENc. _ .._. .. ._ .. .___... ._ _ . -- ._ ...
E...^s _„ tf' CONSTRUCTIONLctionNGAGENCY 1 —.
Ya - 'n lending,CA for the perfmnrmnce
.. Lf' pc 3097.Ci,C1
....=L Q Lcnd N ne
------
;;.Z
Z ..
Under,Add s - .,:t l
U � 1 minty that I have read this application and nam that the above mformaion in
laaF.. correct.1
.� OW'a �SOPUyCRICGEAagree
utcomply
with all city and county
o
'J'
ante. and..r./t laws
�' .rdval',g
toWilding commission.and h rebyr Nar arepresentatives ofth' city to ter upon
the above mentioned
progcnyf inspection purposes,
Fh twit Olt , "d m fy and h IeofCalrontioul,amw
Vliabilities.pog .,c dapvmov,Which on, nanyway accim,agmen.saidU.Z Citthe gamin permit.
PoN NDISTANDS ILI.COMPLY WITHALLNON-POINT
Issued by: DateEGO[ ONS..
Slgnato of ppheantlComrum Doc Re-roofs
HAZARD US MATERIALS DISCLOSURL Type
—
the airylicant or(mart Wilding occupant store or handle hazardous matenal T C Of Roof
ns defined by.the Cupertino Cost,
Code.Chapter 9.12,and the Health and Safety .v ,I ",•l,'•
CSection 255321.1:' ' �, ,par; ; , f's i 'a i' ��+•'.
-O Yes .t.V O No, , I
'a ^' •-• ,All roofs shall.be inspected.prior to.any.roofing.material,being installed..
wdi me.apr,licamwfumrc bottoms menapam rise equipment or data,which If a roof is installed Without first obtaining a{finspection, Pagree to ferlove
emit harardmis air mommimms as defined by the Bay Arca Air Quality Munagemenl
Or...tO ❑Nm - all new materials for-inspection. Applicant,understands and will comply with
all no urce regulations: -
,1 have read the hazardous maen.1,im.iremenu under Chapter 6.95 of the
Cal turgid.Heanli&Safety Code.Scansions 25505,25533 and 25534.1 unaecaand that
:f the building dors not cuncgtly have a tenant.that it is my responsibility to notify the .. 7
Occupancy.
occupant of the rcqubements which most be met prior to issuance of a Cenificam of
, ..
Signatu of ApplicaX Date
" f o nate aamo reaage t Da All roof coverings to be Class "B" or better
..t '" -