01100093 (2) TY OF
CI
BUILDING DIVISION
PERMIT CONTRACTOR INFORMATION:
a BUILDINGADDRESS: PERMIT NO.
18675 LOREE AVE DAVID D. ENGER 01100093
OWNER'S NAME: APPLICATION SUR DATE
DAVID D. ENGER 18675 LOREE AVE 10/15/2001
PHONE: SANITARY NO. CONTROL NO.
OO ARCHITECDENGINEER: BUILDING PERMIT INFO
paHqGELECT PLUMB MECH
LJ L.'1
dad
LICENSED CONTRACTOR'S DECLARATION
i 11 o 1 tion 7 )of that Into licensed sinsis and
Profe of ns Cash.and mmccense Job Deseripti n
„C°, is ins«d°n]tuts)°r°ivixinn3nrmeau:in<asanaPr°rea.romeaee,.namyh«nxe REROOF.
Szoa Licens Cll lassavdc°"` uc.a T/O & INSTALL 20 YR. COMP. 2 " INSULATION
;3�y
Date. c°"'r°"°` 30 LB. DOUBLE FELT & 5 PLY 1/2" PLY.
ARCHITECTS DECLARATION
g < 1 understand my plans shall be used as public records
7 s.p O 4 ,nes�ee Profa"iwmd
I
°u
OWNER-BUILDER DECLARATION
m m fine n
S 1 hereby affirthat 1 aasempt from e Contioor's License Law for the
C?afollowing reasons.(Section 70315 Business and Preferrionnes Coda:Any city or county
E o which q Permit t' cont It p demolish, p y structure
6�m .prior to its -alsomqUiMS the applicantfor such Pe u' filaa siganot statement.
thm hlicensed
al 1 n. a i .nt to the Pin I the c tractor.L La (Chapter 9 S F[ F1oorArea . anon
Icom ncingwahSecton]r(IIBofDivxi n3nrtneBwryt�essarWProrq -onxcme) C"t,1'is L,,,qi',r" S.".I : . �,y�.. i t�.7 $38�bl
or that he is exempt therefrom and the baso for rhe alligdl ekemptoa.Any violation _ .
of S«tion 70313 by any oppliant fair permit subjects the°ppliam m a civil pnolty
of mm more man five handrail dollars(sere). 3 7�'fYA"61b�0 Occupancy Type
❑I.d ownerof . nd h.y.sertiemployeeswirewer .their sale,(S.,7044.
will ne alae work,and the worods: a is not core's Ll or License
for sale IS«. 1.son
Business and Professions Cade:The Cves towns,
,and w taw does not apply to an 305 - FRAME Required Inspections '
owner ofpropertyhis ow Who lofiles or improves thereon,and who Burs such work,intended
at �'
o through his awn employees. Wilding
that mer improvements are not meyew or 3 07 - INSULATION
o(fued for sale.If,howcvec the building«improvement is sold within one year of 6 01 - ROOF TEAR OFF '
completion.the owner-builder will have the Wrden of proving that he did of Wild or I
improve far purpose of sale.). 602 - ROOF PLYWOOD NAIL OCT 2 3--200
t` I 111. m
I.asowncrofthe Property.mexcluxivelycommctingwlmon
licensedeum
acnto 603 - ROOF BATTENS j '
., conswn the project(S«.70a4,Business and Rnfessinns Coaa)The Convenor's
License law doer not apply to an owner of property who Wdds or improves thereon. 604 - ROOF IN-PR GRE S S'
:\ aM who convects for such pmjenu with a contractor(.)licensed pursuant m the BUILDING
Commctors License
E]
l tares,
m es, B&P C for this renown
owne,�r
RKER COMPENSATION DECLARATION
0
I hereby eRrm under Penalty°I perjury rent of the following d«lamb°nr Q
❑ 1 have and will maintain a Certificate of Consent to self-insure for Worker's 2
Compensation, as provided for by Section 37011 of tW tabor Code, for the `rJ
performance or the work for whim this psrmil is isxud.
01 have and will maintain Worker's Com i:nution Insurance,as required by Section /�
3700 of the labor Care.for t pert ance fir the works for which this pnnnit is C
".
issued.My Workers C a
pen d 1 sennet career and Pol s'Y a Wr arc
Gainer lu , t( Policy No { e,) 1 :v Y•..it.., i r/2� dyx l•`i,1�.-: A �,
CERTIFICATION OF EXEMPTION FROM WORKERS
_COMPENSATION INSURANCE' I ,-..__ ..._._ _. .._.. _ .._. .___ .n,.•, ��1.._ _. .
(nit uniori octal tan be compined if the permit is for one hundred dollars
IS 100)or less.) ,
1 certify that in the performance of the work for which this Pemdt is issued,I
shall not employ any parson in any manner so as to become subject to the Worker
Compensation Laws of Calif«nie.Dam
Applicant
NOTICE TO APPLICANT If,after making this Cenificam of Exemption,you should
ZQ 0ebe subject to the Workers Compensation provisions of the labor Code,you must
comforthwith comply with such provisions or this parrot shall W deemed revoked.
F CONSTRUCTION LENDING AGENCY v '
a ' I hereby athnn on
mot there is a cstrummi lending tiger,for the performance
of me work for which this permit is issued(Sec.3097.Civ.C.)
(L'Q Landers Name
;; .z Lender's Address
V 0 1 certify that 1 have read this application and state that the a rove information is,
W [.i correct.I agree to comply with all city and county ordinances and state laws relating
Q V to Wilding construction,and hereby authorise ns,nowuniver of this city to cmrr,uptin,
the aWw-mentioned properly for inspection purposes.
y y
(We)agree to save,indemnify and keep harmless the City of Cupardno against'
fin liabilities,judgments,costs and expenses which may in any way accrue against said
V z City in con ua all th gm I mf this permit. ^ _
"—PPUeC YI�,J �Ti$�111jtA�NDDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 1 Date
/Signatureof lPh asi um nor - .' Dare. I r, Re-roofs
- .HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future building occupant store or handle hamrddus minimal i Type of Roof
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Core,Section 255326)] f -2.`;, tt ;• FA �. ..' fir:
0w" _All.roofs shall be inspected.p., rior.to any.roofing material being installed..
Will me-applicant'or future building occupant use equipment or devices whim If a roof is installed without first obtaining an inspection, P agree to remove
emit heurdons air conumim wtsdc d d by me Bay Area mnt
Air Quality Managee
District all new materials for inspection. Applicant understands and will comply with
❑Yes No all non-p nt source regulations.
I Awe road the husardous nowen.ls requirements under Cnepler 6.95 of the' e
California Health&Safny Cuda:Santora 25505,25533 and 25534.1 understand that
ifthc Wilding stmt curtentlY haveerenanL mat it is mY responsibilitYmnotify the /il/�� / - `Q— /�/
«cupam ems which must be ren prior m issuance of a Certificate of
.. C Occup. cy.
/O - /5—v/ Signature of Applicant Dale
waur or ooh cot .Dau All roof coverings to be Class"B" or better
OFFICE
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