02120029 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUIb DR3 .: RD DR PERMITNp2120029
OWRIBBSON ROBERT T AND OPAL B TRU APPLICATTTSfl"01f/1002
HONE: SANITARY NO. CONTROL NO.
ARCHITBCfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�ppLICENSED CONTRACTOR'$DEC
hereby nffirmthat lamlicen dunJerprnvrsions provisions of nrChaphapmr9(commencing REPLACE WINDO[><S�bQe�l�nFIT/
wish Scminn]IXX17 of Division 7 of Js Busincu and Prnfcuinns Ctdc,and my liccne is
as mmBforce and effect. 2 EGRESS WINDOWS @SLEEPING RM
Licnnse Class Lie.#
oza: Dale Contractor
RyQ8 As shall Wuse DECLARATION FIN A LC®
C 2 I undcrsmnd my plans shall M used as public records V F4 G
KOdU
r,Of Livened Pnrlcasimal
=0� OWNER.BUILDER DECLARATION JAN 7 2003
ne <n I hereby affirm that 1 am exempt from the Contractor's License Law for the
i ❑O following reason.(Stewart 7031.5,Business and Profcssinns Code:Any city or county
a�S which requires a Permit to construct,alter.improve,demolish,or repair any structure $8000
FZ< prior in its issuance,also requires the applicant fm such Permit to file a signed statement
ss thmheislicensedponu alhithepmvisimunrtheContractor'sLicensel:xis Chaprer9 Sq. Ft. Floor Area Valuation
a~$ (commencing with Section 700)ofDivision Jofthe Business and Professions Ctde7or 36207002 . 00
�— that he is exempt therefrom and the basis far the alleged exemption.Any violation of
Section 7031.5 byanyapplicant for a Pamir Subjects the applicant macivil penalty of APN Number Occupancy Type
not more Nen five hundred dallats(5500). 101 — FOUNDATION
❑I.as owner of the property,or my employees with wag..their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.70aul Business 1:82 EIIER9
and Profcssinns Code:The Contactors License Law does nut apply to an owner of 103 - UFER Required Inspections
prnpeny who builds orimprnvcs thereon,and who doessuch work himself ser Nmugh his
own employees,provided that such improvements are not intended or offered for sale.If. 104 — REBAR
however.the building or improvement is sold within one year of completion.the owner. lOS — ANCHOR BOLTS
builder will have the burden of proving Nn he did not build or improve fur purpose of
c0c) 106 - SEWER & WATER
tgtrt'1,as owner of the pmpeny,am evelitawly amtmctng with licensed contractors t" 202 - UNDERFLOOR PLUMBING
Gnnswct the project(Sec.7fW<,Business and Professions Cnde)The ConVaaor's Li�
scon,lswdoesnotapplytoanownerofpropertywhoWildsorimproveslhemon.and 203 - UNDERFLOOR MECHANICAL
who contacts for such projects with a conuacmr(s)licensed pursuant to the Contractor's
License Law. 204 - UNDERFLOOR FRAME
❑ 1onexempt under Sem. B&P C for this mua" 205 - UNDERFLOOR INSULATION
o,V r �/�/L I E8S6N Date(y q/e 2 301 - ROUGH PLUMBING
WORKERSJ
'COMPENSATIGNDXARATION 302 - TUB & R SHOWER
m
I hereby offuunder penaltyn(perjury soca emllowingdeclerations: 303 - ROUGH MECHANICAL
✓/ ❑ IhaveandwillmaintainaCenificateofConsemmsel4irmumforWorkehCampes. 3O4 — ROUGH ELECTRICAL
sobas 00 a., provided far by Section 77of the labra Cada for the performance of the
work for which thispemeitisissued. 305 - FRAME
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3 06 - HOLDOWNS
7710 of lie Libor Code,for the performance of Ne work for which this petmit is issued.
Mywarkeracampmetanm:manacourtand Policy nature,mrs: 307 - INSULATION
Carver: PolicyNw: 308 - SHEETROCK
CERTIFICATE OP KKFM PHON FROM WORKERS'
COMPENSATION INSURANCE 309 - EXTERIOR LATH
(Thissection need notMcompleted ifthe permitisforonehundrcddollars(5110) 310 - INTERIOR LATH
orfess.) 311 - SCRATCH COAT
1 cenify(hot in the Performance of the work for which this Permit is issued,I shall not 313 - ROOF NAIL
employ any person in any rryTnnerst�s�heco a_him mNo Wnrkits'Compensation
LawsnrcaufarniyDsmL - G 501 - FINAL ELECTRICAL ENERGY
Appl'ran !/ '1l
No . 0AP�LICANT:If.after making this CenificamafExcmption,you should 502 - FINAL PLUMBING ENERGY
Mea bjectmtheWnrkersCompensation provisions ofthe Layout Code.you must 503 - FINAL MECHANICAL ENERGY
Z fort itb complypre
with such visionM s or this deemed revoked.
O 504 - FINAL BUILDING ENERGY
CONSTRUCTION LENDING AGENCY
[-t .N. I Wony which thi that there isaconstruction 097,Clending agency for the pctl'urmance ill 505 - FINAL ELECTRICAL
cL > theLe work for which this permit is issued(See,3097,Civ.C.) 506 - GAS TEST
vg p Lendcr'sAd 507 - FINAL PLUMBING qf/
0 builder's Address V
Uo 1 cenify Nat I have read this application and site Out the above information is -508 - FINAL MECHANICAL
w [~ cnnectlagree tncomply with all city and county ordinances and state lawsrebring ln 5 FINAL GRADE
Wabove-menneuuctioaand herchyauthonp rpoesentstives of this city to cnmr upon the
above-mentioned Properly for inspection Purposes. 1O — FIN I G
(We)agree to save,indemnify and keep harmless the City of Cupertino against
F' V) liabilities,judgments,costs and expenses which may in any way memc against said City ,rj N L WORKS
V in bis Norio
APPLICANT eUNDERSTANDS of the granting of tAND WILL COMPLY Willes ALL NON-POINT Issued by: Date
SOURCE RE ATIONS, y
TTeel d. ^ /-�9-0 Re-roofs
Sure of App1c um/CnmIracum Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant nr future building occupant store or handle havaNnus m turned
as deGncd by the Ci promo Municipal Code,Chapter 9.12,and the[health and Safety
CuJc,Scam,25532(a)? All roofs shall be inspected prior to an roofing material beim
pies Ip}rvn P P Y g g installed.
Will site applicant or future building occupant use equipment or devices whish If a roof is installed without first obtaining an inspection, I agree to remove
ran hazardous aircomaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yrs KNo
I have sod the hasaNnus materials requirements trot@r Chapter 6.95 of the Califnr-
niu Health 5 Safety Cede.Sections 25505.25533 and 25534.1 understand Nat if the building
does not cuncmly have a moral.thm it is my respami fifty to madly the tccupent of 0c
myuiremcn hichmaslhcmctptnnnissu caraeet9fieamnraerpaney. Signature of Applicant Date
weer ar alt orivuJ agent oath LZ All roof coverings to be Class "B"or better