02020111 (2) CITY OF CUPERTINO - -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: ,
BUILDING ADDRESS: PERMIT NO,
21448 KRZICH PL ADVANCED ROOFING TECHNI UES 02020111
OWNER'S NAME: APPLICATION SUB DATE
BETTY TRURO 15272 STRATFORD DR 02/28/2002
PHONE: SANITARY NO. CONTROL NO.
(408) 261-9663
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
HF BLDG ELECT PLUMB MECH
y
" h therebyoffirmEhat[amONTRlicensed
under
PDECnsofChARATIaper9(commencing Job Description
?yrw with Section]0)0)ofDivision3oftheBooressundProfic. o,Code.and dr,hc,me SKY LIGHT INSTALLATION.
Cx-s-3 ,on rmlfnme and et.
:rewa octose cmx.. e— I.ie.x
nate con ..
3 a vl-i ARCHITECT'S DECLARATION
O 1 tmderstnntl my F Iw�,V ��
°= plans sbn11 be used ns public recmds
3as $ Licensed Prnlesximtnl MAR 1 1 2002
o
OWNER-BUILDER DECLARATION
1 hereby uffimm that 11. exempt from the Cessions Co License Law for the
followF z a which ng reason.permiS�vt 1 ]mos. t,alter,and improve.
demolish,
cmc:Any city or county
re $3 5 0 0
E?O which termites perm t to crossuuct alter,nmprme demobsh or repair any structure .`
w ..,pct t t ' ce.elm on,toms the applicant for such Femurs fl a signed statement. - 121
a z3DY66 ,•t i v ?'y;i x' - - - - ---
- that S d pursuant to the provisions of the Contractor L Ise (Chapter 9
f<,�♦♦�sT.R �Q pr Qct 100
(co c gwth Sectmn]0001 ofUvmonJohhe Busmc agdP f iov Cme)' `,` L u�i/-'�,U
or rhm he ns exempt thcrtfmm and the baso for N<a118gcd oiemptg�B.My vinlmnon
ofSection 703I:S by any applicant for a permit subjects the applicant to a civil penalty p, ��C Occupancy Type
.of not room than five hundred dollars($500). 101-PN "r8 NDATION 1 '
❑L as owner of the property,or my employees with wages as their sol,compensaion,
will do the work;and the suracture is not intended or offered for sale(See 7044.* 103 - UFER Required Inspections
'Business and Professions Cate:The Contractor's License Law docs not apply to an i
owner of property,Who Wilds or improves thereon.and who does such work himself
or through his own employees.provided that such improvements arc not intended or ,- - 104 - REBAR___-_-.
off ted for sett.IL however the bedding or m,rov,hnmm is sold within one year or
completion,the a%her-Wilder will have the harden of proving that he did not Wild or 105 - ANCHOR BOLTS
impr..oRe"urpn.eofsale.). 106 - SEWER & WATER
�. ❑I mowher of
tutee progeny,ora culaueyco troth with licensed The Conmarrsm 202 - UNDERFLOOR PLUMBINGLicense
cit the does
ho(See ](oW,Bus mess and Professions Cme)The Commnoh
' License Law finesnrtopPlytoanownern(property wonbuilJsorimpmsesshereon,i 203 - UNDERFLOOR MECHANICAL
L. ? _I -and who contracts for sueh.projects with a.contmctor(s).licensed.pursuantm the. ....... ........... .. ..___._.... _.___.. _..
2 04
hmmnnrs license Lpw.... _... -... ..._... UNDERFLOOR FRAME
❑l am exempt under Sea' _,B&P C for this mason 205 - UNDERFLOOR INSULATION
owner` -' " Bate 301 - ROUGH PLUMBING
WORK);B-S COMPENSATION DECLARATION
302 - TUB & OR SHOWER
1 hereby a0trm under[stwhy of perjury one of the following declarations: 3 03 - ROUGH MECHANICAL
2•❑ 1 have and will maintain a Certificate'of Consent to selbinsure for Worker's
Compensation, as provided for by Section 37M or me Labor Cash, for the 304 - ROUGH ELECTRICAL.
Performance none work for which this permit is issued.. 305 - FRAME
❑1 have and will inuimiain Workers Qmipms lion Insurance,as required by Section 306 - HOLDOWNS
3700 of the Libor Cma,for the performance of the work for h h this permit Is 3 O 7 INSULATION
issued'Mykey
W 's Co. 'at an 1 sum ice cam e d Policyrc number a
s,-
CN : , o1icyN .. :-368.` SHEETPOCK," ,
i CERTIFICATION OFEXEMPTION MOM WORKERS. { kr t' t '43(O9't-s'EXTERTOR''LATH,
COMPENSATION INSURANCE - - _
... .. - - .. ._ .. ..... ._. .. .,.... .__...--.,..
'''Cibi's'iceiion Weed not be completed if the permit is for one hundred dollars 31O_ -?NTERIOR--LATH..-_ .,_�..`,--.i'.:: "--' -------'-`
tt100)or less.)„ 311 - SCRATCH COAT ;
L` _. .. . . .. ", -'NAI' -.._. -
1 ten fy tb t is the p,rfo'rmonce of th ork for which th goon is issued,1 313 -_ROOFL
shall'not employ any,person in any manner so as to becom bjecI to the Workers' 5 01 - FINAL ELECTRICAL' ENERGY
Co opens t In of Calf Date'
Appheant ENERGY __. - ...
NOTICL TOAPPLICAN,If,ilfternaddr,mis ClenificticofEseroptumn,cm should,
z liecome subjecttothe Workers Compensation ptnsafthelnbaCdayoumust 503 - FINAL MECHANICAL 'ENERGY
mann
nsnmply won suchp awns or Permit sna- - cam oked. ... 504...-._ FINAL..BUILDING ENERGY,
CONSTRUCTION LENDING AGENCY
F' � IM1archy aRrtm that there a a consltdc0o lending agency for rhe performance 505 - FINAL ELECTRICAL - .
a.> of tb k f titch th n t .sue (Sec 309],Civ:C) 11,
p ,
uemd rvame 50.6. =._GA$...TEST
p LevdasAddes 507 - FINAL PLUMBING .
U 0 508 - FINAL MECHANICAL
I certify that 1 have and this application and orate anc the above imfomn eion g
I*+ E. 'ebeeet.I agree to comply with all city sena crntmy ordinances and stem Taws rdmmg' 509 - FINAL GRADE
0.0 m building constriction,mid hereby authorize representatives ofthis city to enter upon
W me abn.e-meneaneg prop ry ter inxp ainr,mp,r, 510 - FINAL PLANNING
6- fWe)5gree manse:indemnify and keep harmless th<City of Cupertino agamn L/
lin Inabilities.' mems,costa and expenses which may in any way accrve against said 514 - F INA P I C WORKS
U z City i meq ante of the griming of this permit "
'APP.CANT :NDERSTANDS'AN TLLC MPLY WITH AIL NON.POINT" Issued by: �_ Z
S
RCE
'ULATIO'S.'"' %/ y Dale
'y Z 7—�
Slinirtho,a'Applicant2ant fir t Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE' ( ' . ''•'•
d. " WilYlm applicaht orfuture building occupant store or handle hLardous material, Type Of.R00f. ........- „
as defined by theCupertino Municipal Cipal Code Chapter 9.12.and the Health and Safety
Code-$�eY n 25SJ21q i �( 1 L .- n.. o '[ ; G I y :i'1.'t
I All roofs shall be inspected prior to,any roofing material being.Installed. _
W 11 the app tonin future building nc upanI use equipment odevices which If a roof Is installed without first obtaining an inspection,I agree to remove
em t hazardous air contaminants as defined by the Bay Area At Quality Management
Distract' understands and will comply with
a new materials or inspection. Applicant
all non-point source regulations..
1 hu e'ocadihe ot,4dous materials rcqu rcmems mule Chapter 695of the
California
c p t yf tlt s>� hh h P Y responsibility notify .. a .... _... .... .-. ... . _ .. .__Cal f ail IM&Sal ty Code.Sections 25505 25533 d 25534 1 understand that
fthelhu snot cu7ndyh mountthat ti res o sblit-to
q est b t 't n,a..ce of Cenide to of
O
?-tl Signature_of Applicant Date _
Morum,aamon=ea ng Y Date. All roof coverings to be Class"B" or better
OFFICE . .. __ -._ _. ....._ .. . .n .. ... ... ... . . - .. ...