01030127 (2) CITYBUILDING DIIVISSIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
OWNIIR'S NAME: APPLICATION SUB DATE
1180 ELMSFORD DR ROYAL SERVICES 01030127
PHONE: SANITARY NO. CONTROL NO.
ARNEST. ,JAMES M AND JOAN 4396 NICKER CT 03/22/2001
ZZ ARCHITECUENGINEER: - BUILDING PERMIT INFO
s.a (831 ) 462-0539 C :
Uc LI Ecl' PLUMB MLE�cH
Z S N j LICENSED CON'I'RACIUR'S DECLARATION t lob DOSCrIpI1OO
0 Z— I hereby Whom that I am licensed under Provisions of Chapter 9(commencing
F=�� with Sermon PBp(p y'Ui�io oftbe Businea anA rmfcasium Gee,and mylicanx _
in full force.n eels
s6 LicenseFla�a['t—��•f Lic.p L
L V D'vlc J/y /_/ [I Cnntfveta _ '7�/�lD
a
o�U:Hjrirr's nECLARnTION
I undemmndmyplans bull be upublic records CHIMNEY REPAIR.
- `
�Y
ii w o p Licensed I'ndessiunnl
OWN[on exemDER DECLARATION
— I hrehy,(Beal that 1 1. exempt from the Cion, o Lieeme Law for me
Z6 billowing reason. emit17(DI.S,IlusBesand mprvedeiollcode:Any city carrummy .
O pwhichrim"requires a permit ne In Bel.impcion rove such
demolish,or repair any ahoamre
tpaJ3$ alt he islts cense prsa reyuithe movisiosofthnuoM1selors License Law
haptens)
mabin . with actio m theprovisionsiisi nnncemmusineslandPrLawonsCe,9 Sq. Ft. Floor Area Valuation(commencingthat hes exam t New Newborn
t]the ribs 3,tube Business and ion,Professions l Code)
or that io 7 exempt meefrom and the iters for the alleges exemption.Any violation
.f no, on7(1.3 LS of myapplicantnntfru a5lud. subjects the applicant toacivil penuhy Occupancy Type
.rotnone lnanBxcnundreddid unm(sslxa. APN Number "
❑1,u.uwnend the proPeny,car my employe,with wages ns Meir Line ntmpcnxuti.n. 1 901A
will d,the wore,and the structure i,not intended or orrered for sale(Sr,7(44, Required Inspections
Business and Profeesi.nz Code:'ITe Contramr's so Licenlaw does num apply cat an
r of property Who builds or improve thereon,and who does such work himself
none, his nrployvc,.,uwimd flew such impro emus I. not intended. 36209007. 00 .
offered for role If,however,the building or Improvement is sold within one year of ,
`nmmletidm,the ownenbuilder will have the burden.f proving that he did not build or
t.....mrparn. .fxnle" 101. — FOUNDATION
❑1.asmatter of the Pmpery.amexclusively contractingwith Beensedcontractors to 312 — CHIMNEY REBAR & STRAP'S
colonel Ibe project se,70oe
9,Business mW Pt, .. Comm
... .Codc:) the Conoas
censeI- mvmw[ apply t.must property fill budd,orimprovesmere.., 514 —;FINAL UBLIC WORKS
and who contracts for such pmjectx with a contrunmts)licensed pursuant to the
Cmam.mrs Liceec Low.
❑1 am nentpt under Sm. ,p&P C for this mason
Owner Urate ..t
WORKER'S COMPENSATION DF.CIARATION
I hereby alllnu omen pemdty of perjury one of the following declnrationn,
❑ I have and will maintain a Cerificale of Consent I,self come for Worker's
Cnmp.u,nion. a, pruvided for by Section 3900 of III, Labor Code, for the
Performance of the work for which this permit is issued.
❑1 have and will maintain Walker's Compensation lnsumnc.,as reunited by Section
3710 of the labor Code,for the pedommncs,of the work for which this permit is
.,sued.My Workers Compensation Insurance carrier and Policy number arc:
Currie. Policy No.:
CERTIFICATION OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(This section need not Ie completed if the pcnnit is for one frowned dollars
($W)or less.)
1 cvoify that in the performance of the work for which this pcnnit is barred,I
shill not employ any Not in any adurver so a%to become subject to the Worker'
C.mpen.ati.n Laws of Cdimml.Date
Applicant
NGTICBTO APPLICAN P If,after making this Certificate of Exemption,you should
becomesubject to the Worker's C...ifir anion provision,ul'the Lahnr Cadees
,yount
p Q (onhwith comply with such Provision or his permitshall be,deemed revok.6
4 CONSTRLIC'I'ION LENDING AGENCY
1 hereby affmt than there is,construction lending agency,for the performance
of the work for which this permit is issued(Sec.3007,Civ.C.) -
G Q Lender's Name
7 Under's Addri
C.) 0 1.rody Ibm 1 have lead alis applirallnn and.state but the above inlarmmi..I is
cored.1 agree to comply with all city and county orm...ees and sante laws relining '
p V t0 building construction,and hereby authorize representatives of this city cat enter upon
W the abnvuanentiomed pmpeny lie inxlwcti...put pmes. ..
E. A. (We)agree t.one.indemnify and keep harmless the City of Cupertino against
V) liabilities,jusho41111M
d expenses which may in any why acdu.againu[aid
6
Calm dm,""b" "tingof peAPPLICAUSANWILLCOMPLYWITH IssuedbofDy Date
gncal,pponRC-roofs
MATERIALS D15CLUS U
Will etc altpecatn m future looking mc.p:ud.rote u,hmnd.l—rad...annelid Type of Roof
as defined by the Cupertino Municipal Coda Choi and the Bel lib and Safety
Cal,Section 25532(,17
Dye[ ElNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicator future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
until huzonlous air contaminants a[defined by the Ray Area Air Qnalily Management
Df incl?r.[ ❑Na all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I'buve read the broads.,mntenild,residneurso,under Chapter 695 el the
California I leahb&Safety Coale,Stenion[25505,25533 and 25534,1 undersand that
it de handl ng doesnot cu Iy havcu tenant.II it is my mspnnuibiltry m noti fy the
..,an,.1 the a d,acu is hieh must M met prior t.issu:mm of a Cenificnte cal'
`)C(e `y Signature of Applicant Date
i)re All roof coverings to be Class "B" or better
OFFICE