01100143 (2) CITY OF CUPERTINO
j BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21421 ELM CT PETERSEN-DEAN INC 01100143
OWNER'S NAME: APPLICATION SUB DATE
MACLIN GEORGE F AND NORMA J 7980 ENTERPRISE DR 10/26/2001
PHONE:
(510) 494-9982 SANITARY NO, CONTROL NO.
O 0 O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
kC Ivi 8L ELECT PLUMB MECH
8 y i LICENSED CONTRACTOR'S DECLARATION lob Descri ti n
5 Z ❑ 1 hereby aRnn that I am licensed under provisions of CIaMor,9 Onmmencing p
me withSeclion]fNq)ao�fDcisv,ision3oftheBusinessandPtofessionsCwle,endmylicense REROOF.
�y5 ,an Poll force and(..; J
oau Lice"x L.LClzss _ t ID ua.« T/O SHKr RESHEET 1/2 "CDXr
i3 u'~ Dair i
ale C A�kCH1TECT'S DECLARATIi ADD 40YR. GAF COMP. SHINGLES .
2to
I undementl my plans shall be used as public records
a�O 9 I-menxd Professmnol
k oro 2 OWNER-BUILDER DECLARATION
m—m I hereby affirm that 1 am exempt from the Contmcl License Law for the
C?Q
fullrovirg reasior.(Section 7031.5,Business and Profeasions Code Any city or county
❑
which requires a permit to construct. lter,improve,demob h o p r any suucmrt
m pit t t ane 1 req the applicant for Myth Perrot m file signed st,emem- .__ . ._. _._ _ __.... .__.., _ —_._.
y _ _.W ..._.__.__. ._._
.....__
that
bribittlictimatel patmostrilt the priadsions of the Contractorv Licinne Is (Chapter 9
m meg tgse t a rD'v a on a the all geb «e iory Ac�de) CID' , (;�S9: r- r" a r,; lzaMIN 1.�'al1J:- 1 $1-04�ation
or S the is 31 i5 b therefrom anJ the basis for the ch,th a¢tempt on Any l violationpenalty of Section]031:5 by any applicant for a permit subjects the applicant m e civil penalty '
ofnet'..Illnfimhandled doll.,($500). 362'aWPblil6n.1148 r"'.,'r•" Occupancy Type
❑I;as owner of the pmpeny,or my employees with wages as their sole compensation,
will`do the work,and the structure is not intended or offered for sale(Sec.7044,
'Busineis e 'Profe
ndssions Cade:Thc Coinmcmr's License Law does not apply to an 305 - FRAME Required Inspection§10-roP r,:,;1
owner of pmlval Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements are not intended or 307 - INSULATION
offered for sale.If however,the b ilding or improvement is sold within one year of - - "-'
dmple ion,the owner bueder will have the burden of proving that he did not build or 6 01 - -ROOF TEAR OFF
npnceforpurpoxafsale.). 602 - ROOF PLYWOOD NAIL
e DI as owner of the pro fairly,am a x clusively contorting with licemand I eonotion to ._ . 603 .-ROOF` BATTENS._._._.r._.._
Lonstruct the pro3ecr(Sec.7044,Business end Professions Code.)The Contmemr's
icense Law does not apply'.a. .net who builds or improves thereon, 604 - ROOF IN-PROGRESSa:.Dr. -L-Ili r,
_and0 1 h t is fo h ps ns with is cot ror(s).licensed pursuant to the .. . .___.._ _ r�—
Contractor
ont t s c
lop not
SeciB&PCfonhis reason tr"d N4 `s r4m'� I
_ Ownei' Dam _ uo L�
WORKER'S COMPENSATION DECLARATION
1 hDEC 0 2001
ereby aRmi under peiupy of pe jory;onla
e ndl following declarations: C
❑ I have and will 'maintain a Ceaiman of Consent to self-insure for Worker's
.3 Compensation, as mweieed for by Section 37M of the Labor Code, fm the BUILDING
perfornal afthe wmi forwdch this Remit is isaued. .
�pf,��i h i d II trio t W ke a-Compe S t Insurance,as required by Section
/J)00 of the labor CWe f the pMRrmarice of th ork f which thisperm tis
is's d W lon's Co prow a l7aurancec carrier,end PolicynuImlb c
Carne f ra Poky TIONFR 7��Y 7 y� _ ..r >• y.+. _ _I _ '
i,cpbyiP AT
OF EXEMPTION PRpM WORKERS'l i. f $ F1 r�E�. azo - e p?',1(v;} kjt�h.
:�_ COMPENSATION INSUPeR�NCE. _...... --
' ' (This senan neednotbe'comleiee if the t is for one handled dollars `t•"" 'i•' i 'i' i.�t•. (J..CL{ ❑ -1 t,(Iti.
(110f)or less) '
carry yahot in the performance hhfwhich the permit is uschad,1 _,Ci.l!' "I' :'i�t.Vi4 b'"• _
shell m
not employ ink person n any ' n r so as t become bat to theWork is'
Compensation Lawsof California,Dale,' • i
Applicant ... .. ..... .,.... .
'
O
NOTICE TO APPLAhe Cerfr t of Exemption.you
should
ihould
CZ became subject the W Corrt n prov stopof Lab CoeYou Forthwithmust comply h such
P Provisions othis pe ,tshall be deemed revoked.
I
I,,,•i„i
Vaa FQ _ CONSONLENUINGAG,.ENCY
> rem that themysa imiao1agency f.nJ he pcffbn`i:
n_ne
ofthew owhihs 's suet IS 307;Ci.C)
Lentl Nam
Lend¢ Arbon
rb s
i,
...,..,. i;_, ..
W bum y agreenfilly that 1 have read this city
and on and state tnat the above information labor, '
E., ea.r agree tr comply with all lot and county ordinances and state laws relating -
V the Mom-ancring aarmado,aid fiereinspection rtommsematives of this city to enter upon
y_W 0e b e) t oriindo inspection p p s
(W) get a droit fy and keephannl s the City of Cupertinoagainst
Fr Vi liab i 1 1 dg ms is u d xp n es h h m y in any way scame against said
V City in consequence of dsi granting ofthisp t -'
APPLICANT UNDER$t ND WILL CO YWITHIALLpNo�01 T '
SOURCE REGULATIONS 17
Issued by: Date
Sign nue of ApphcH Z
' HA,ARDOU A.ERIALSDISCLOSURE ' ° `"! Re-000f$
p p mate al Type of Roof
Ntl Silt the ppl ant err boom butt n aril ant sin r Bandl hazallou
as defined by N 53 mit M ici o W Chapter 9 12 rid the Health rid Safety
Code Sect 25532(¢) '- - r rs#^ tlI' '� 'S 1 w t a
N1
❑Yes ySfd Nti,6 '�Sg . I t°1 s ''i.•.} x 1> � i'i 'L tilt {) 1].
All.roofs shall.be inspected poor to any roofing material being Installed. _
will the applioce t Pomre bu,ld'ng sopa t equip t p devices which If a roof is installed without first obtaining an inspection 'I'agree to�feinove
emit 1:2 ardo m ants es def d by th B y Are.A Qu I ty Manag m m
District? - all new materials for inspection Applicant understands and will tom I with
❑mal�,. ❑ o.'.. " p.y_
* - ) _ all non-point source regulations
1 h ,'read the hazardouej mai rials requnements under Chapter 695'6(the
Califomin Health&'Sefery Code,Secu6ns 25505;25533 and 25534,.1 understand that
m t hich mu ew t th t it responsibility to blify the
r Occu t f N t currentlyhave a ssu rice of a C ',fcete'of
i t c u n does no
v g Kv 're p m t r r `p Signature of�plicant Date
P
P Y '
own antno :ed Da All roof coverings to be Class"B" or,better
OFFICE