02100093 CITY OF CUPF,RTINO �'"' a
BUILDING DIVISION PERMIT CONTRACTO•�' R INFORMATION:
IdmLB A 1511ksN WOLFE RD PIRMrrN(02100093
dl+'�ARIS ROEBUCK AND CO APPLIcA'l'lirOy/ I'li"' 2002
PHONE. SANITARY NO. CONTROL NO.
ARCHIILCrfENGINEER: BUILDING PERM]TINTO
BLDG ELECT PLUMB MEC11
WOO LICENSED CONTRACTOR'S DECLARAI]ON
u p 1 hereby arfirm that 1 am I sca enact wisnis,..f Chapter 9 fenmmencing DEMO (1ST FL. )Job Description
�7Hwith section 7000)x1 Dm ion T.,"he nuxin�WProfossinns Ct Je.t emy Bans is
m(alltures. "`"` 7zo 963 FINALED
z 0222 lLiiccan'se Cl. to 11
F-�� f/lff /r ARCHITECTSID 1r^ATIaN / IVZ3, NC
1 undcrstanJ my plans shall be used as public records DEC 0 9 2002
up6O
w3 � Licensed Professional
=�5 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Comenctnr's License Law for the
w BUILDII GI s o 0
carno o following reason.(Section 731 s,Business and Professions Code:Any city or county
e of m E� which requires a permit to construct,alter,improve,demolish,or repair any stmcture
poor to its issuance.also requires the applicant l iumch permit to file usigned statement 'yam'
that he is licensed pursuant to the provisions oflbe Cadlmomrk License law(Chapter9 —try 3.0 0A109 Valuation
a'in (commencing with Section 7000)(if Division 3 of the Business and Professions Cmic)nr
y 3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of A Occupancy Type
not more than five hundred dollars(SWB.
I,as owner of the property,or my employees with wages n their sole compensation,
will do the work.and the Shecture is not intended or offered lot sale(Sec.7044,Business
and Professions Cute:The Conuscmfs Lacers Law does not apply to an owner of Required Inspections
property who holds nr improves thereon,and who doessuch work himself or through his
ovion employees,provided that such improvements are not intended or offeree for sale.If.
however,the building or improvement is sold within mm year of completion,the owner
builder will hard the burden of proving that he did not Wild or improve for purpose of
sale I
❑1,as owner of the property,am cachasively contracting with licensed contractors to
construct the pmjem(Sec.7W,Business and Profession Code:)The Contractors Li-
cense law dons not apply to an owner of property who Wilds or improves thcmon,and
who contracts for such projects with a contractrais)licensed pursuance Ne Contractor's
License Law,
❑ I am exempt under See .B&P C for this reason
Date
WORKER'S COMPENSATION DECLARATION
I hereby Non under penally of perjury one of the following declaration:
❑1 have and will maintain a Cci ilicatc o(Consem to self-insure far WmImr.%Competr
cation,as provided for by Section 370(1 of the Labor Code,for to Performance of she
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Retain
3701 of Ne Iator Qx(e,for the performance of tee work for which this permil is issued.
My Worker'aa Compensation Insurance carrier and Policy number art:
t:.orie,,�1�✓���>b CVc•Y Por Nt .G✓V 4B on 693
`W;� CF.RTIrEEMPr10N WORKERS'
COM PENSA'1'ION I NSURANCE
(This section rated not be completed if the permit is Inn one hundred dollars 1$100)
rot less)
1 certify that in the performance of the work for which this Permit is Tweed,I shall not
employ any Persian in any manner so as to become subject o the Worker'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICAT:IL alcor making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O O fonhwi th comply with such provisions nn this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
[r .�+ Iherehy offirm Nm titre is asoma,,nal lending agency for the perlormanceof
7 the work fur which this rermil is issued(Sce.3007.Civ.C.)
nLender's Name
z Isneer's Addragmet / •��
V Q 1 meaty that 1 have read this application and state that the above Wourrution is U ��
0U buildingcoureeatio,plyand with
yaucity and represeounty ntatives
anti statelaws ntr upon the V amovengcotioned ooantl forchyauLloriterposes, moves of this dty menmr urym the
} L[1 abnvr(Wa)agree
propertysave for im indemnify
an keep ha
(We)agree tu cast,indemnify and keep harmless the City of Cupertino d City
Uh inconiequenc of Benrstsangat this expenses which may many way uccruc againstxaiJOty
C.) z A APPLICANT
of UNDERSTANDS
of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITII ALL NON POINT Issued by: Date
SOURCE REGULA�TI�Oys,
a(��'��akz�� /e/' a Re-roofs
nmure of ApplivenUComraelor Loyale
HAZARDOUS MATERIALS DISCLOSURE ✓✓✓ Type Of Roof
Will the applicant or future building accepant rare or handle hareNous material
as Jcfirod by the Cupertino Municipal GWc,Chapter 9,11,and the Health anti Safety
dr.Secood2553xarr All roofs shall be inspected prior to any roofing material being installed.
E]Yea [}No
Will the applicant or future building aeupaut use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit haterdums air contaminants as Jclired by the Bay Area Air Quality Management all new materials for inspection.
Distinct'
❑Yes M°
I have mad the her arJnusmaterials requirements under ChapmrR 95 of the Calder-
nil health&Safety Cad,Sectinns25505.25533 and 25534.1 untkrsunJ BaUf the building
doe not curtmly have u mnam,that it is my rexlxiesibiiny a,entity the tKcupYal of the
req�immend,which must Wmet prior VpaneeofaCertmcateofacpancy.�% SignatureofApp]icant Dale
QZO /!�'la2 �� °?__ All roof coverings to be Class "B" or better
04,ora.therild agent Datc