01030084 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDHSS: PRRMI'1NO.
1.0060 S STELLING RD 01030064
OWNER'S NAME: APPLICATION SUB DATE
WAGNER LINA C ET AL 03/15/2001.
•PHONI:. SANITARY NO. . CONTROL NO.
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q � ARCHI'lhCr/GNGINIJIH: BUILDING PERM11INFO
❑ HLD EAXCI' PLUMB MUCH
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c 6 LICENSI[DCIIN'IRAC'IIII-1 DECLARATION .106 DCNGrIpt100
O z=o I bemnv m.111,dial Jere liecr.ea tiler proms;am olCharge 9 mnoreenemg
<r�Cm ,;h Section 9XXB of Division 3ol',he Hu.ine,ound Prof cu ions Crile.and my licep.
.x�_ mrodforeeandeaee. i /j/�� ``Jyr/ DEMOLITION
3 ek License Class Lie.a
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ARC}II�I'IiCI'S DBCI.ARANON
Ea S IunJcnl;umA nosy pl'rny(Intll M1e u.ad an Oublic reanJ.
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OWNER-BUILDER DECLARATION
='w 1 hemby nlGrnm that 1 am exempt liner the Contractor's License Law for she
rollowing nmwr.(Seaton 911.313,If I,,and Prolc,00ns Code:Any city ur,omn,
which requirespenoill m t b r.improse.dervolish.or repairy structure
prior to its .. IDI requires the applicant for such Permit l file a signedstaimment
,bathe is licensed p .ua t to the provisions,(if the Contractor's Ls,Law Chapter Sq. FL Floor Area Valuation
(coal b 'm Section 700(n or Division t t theB : I Professions Ctw e) $9500
or lien he it ex.n,d themlrant amt Iht ba...for the alleged Ise t pl on,Ar,6,1,fiu m
of Need mt 9031.5 by any applicant or a permit...hirci,me applicerf it,u civil penally
of nm nm,m man five hundred d.11.(,SOU). APN Number Occupancy Type
❑1.as owner ofine property,nr my employ«,widen wages as mdr.ole comper o0or. 35907003. 00
will do the work,and be amewee is not intended or offered Iia sale(Sec.](94.
1m.inc.s and Pndasxbrs Cotte:rhe Contractors Licctn,Law docs nor apply It,an Required Inspections
owner ifpropeny Who holds mM1npoot,It.mo..todwhodoes such work
hinewif NO ASSIGNED INSPECTIONS
or through his own employees.pnoided that such impro cinenrs arc not trimmed or
offered for.ale.IL however,the building or Impreemem is sold within one year of
tmplction,the toner builder will nave the burden of proving that he did not build or
❑I.a,owner ofIh p pent xs relycontractingwith I a licensed oacmtso%
Lmase theof t(S ]toe Business dProfession,Cal')Th C theme,
itt W J r apply I n th a once who built. p thio the
mJ 1 contracts such p 1 1. ilM1 , , 1.1 d p l m,hes
Cnnperrn.License law,
❑I um exanpt under Scc, .H N P C for Orris'm,00r
Owner Ute
WORKER'S .. Y
ORKER'S CUbtl'IiNS.\TION UGCLARA'I'ION
I heresy.Gun wider kodly n1'perjuryac,ofthefollowingdeclareion-
❑ 1 have and will maintain a Ccnificae of Consent to%elGirsum for Worker's
Congmansetion, ao provided for by Section 3701 of the Labor Code. for me
perlitrnmocc ot'the wo,k for which this permit is i.,li
❑1 have and will maintain Worker's Cnmpenwnion Insurance.us required by lection
3700 of the Inbar Cade.fol the ge,bernot,of the work for which this permit is
mem M1fy\' er ti umnce alter J Policy number are:
C: 'I'B B 1F BXBM19lUN Ilt(M WORKERS' -
)MPHNSATIONINSURANCE
1'ITi,section need not M campleed if the pen on is for one hundred Joflan
151018 ar less.)
I certify that In the 1adornuume of the work fur which this per nil is issued,1
.hall nor employ any perwm in any manner.n as to bacons,object the Workers'
Compensation laws of Califdmia.Date
Applicant
NOIICC'1'0 APPLICANTS If,otter;nuking this Ccnincum of Bxemp,ion,you should
he ...,nuh,,l tome Worked,Ca..ry,a winn...ockinns oI rhe labor Cnde,you alas,
Q Q ......
forthwith co.nply wlth ouch pmskinn.ar this permit shall be cinved revoked.
Z ` CONSI'RUCI]ON LENDING AGENCY
a ' f hemby anion Thar There is n emoraeion Icnding agrney for rhe performance
of the work b),which this penult is boiled(Scc 3097,Cie C,)
S A f.cndur's Nati
= Z lender's Address
V O I terrify that I have mad this appficmion and stale that the idowe information is
kt H corrwt.1 agree to cumply with all city and county on ioaneus and state lawn relating
Q V In huddle,norm udioo.and ha'ebyuutIt ornnewnertivesof this city to error uqm
rid tire o-
e ehovmerelonIf molerty In norcalnn parpowex.
L y (",I).,memrave.indemnify and keep harmless the City of Cupertino against
N liabilities,judgments.costs and expenses which may in any way acerae against and ,l
V Z City in comeetenee of the gmming of this Perot. 3 /✓'G/
APPLICANT ON ryPRS'rANDS AND WILL COMPLY WITH ALL NONPOIN'T '-d hill. Date
SOIINCP.REG II.Q'IONS ` Y'
nim ,�fnppi nk ' nr Date
Re-roofs
HALARD US AIATERIAI S DISCLOSURE
num,:;ppllcannnrto, aFmllaingal,np:nnlwmmmM1anefenanaminu>nmmedm Type of Roof
n..Jetin,d by the Cupertino Municipal Code.Chapter 9.12,rod Ih,Hrnhh and Safety
Cull.Section 255321.)]
0Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orFuture lie ding acupantuse eyuipmen�nrdes i<ewwhich If a roof is installed without first obtaining an inspection, I agree to remove
mit hvardous are emmate a is as Jetlned by the nay Area Air purl i,y Munagatnem
Di.trieli all new materials for inspection. Applicant understands and will comply with
❑Yes, 0 N all non-point source regulations.
1 have read the bazlnlum materials mynmeen a under Chapter M195 of the
Cali Luna Health&Safety Calc,Sean inn.255115,'_5533 and 25534.1 under rand that
i l'the huilding duos nal cun'adly Irk,n mmol,than it is it,rcxponsibi lily m oodty Ilio
w I of the nyuir<mm�nx I n1li nnul be nil prior to I...unue of a Ccnmcmc It
`
fairly. V �3 � / Signature of Applicant � Date
e — F
a amndtnri'Ilia e t )mat
ow AAll roof coverings to 6e Class "B"or better
OFFICE