01070077 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
981 MILLER AV 01070077
OWNER'S NAME: APPLICATION SUB DATE
YURTIN IVAN W AND SHIRLEY A 07/18/2001
PHONE: SANITARY NO. CONTROL NO,
ARCHITECI'rE.NGINEER: BUILDING PERMR INFO
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Z S n Z LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm vi I am ohelicensed under provisions of Chapter.and(commencing
°r„e° with5enion7W01nfDivision3nllhcBusinessand ProfcnsinnsC^de.anJmylicense REPLACE MAIN BREAKER.
m Y I is in full force end elfelt. -?`9U 7—/Z +1 p C
E.rc a Lic CIm, C-1 O Lie.a �'I FINALE
IG ID
O i O Done Commnor G
vai 3 w -k ARCHITECT'S DECLARATION
G='O; '�1 anT rciand,.y tons shall be used as public record,
w 25� J U L 2 5 20 01
o Licen ,Pmfessinnal
°'°• OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Convenor's License Law for the
F Z¢ following mason,(Section 7031.5,Business and Prate„Ions Code:Any city or county ��_ QDI NG
E=O which opiuim,o permit to can.tiun,altar,improve,demolish,or repair any nounme
W m prwwts ante.alsoreq tM1 ppltcanr roc.urh pemntt fl 'geed wmmens.
'"athes� Pstdpu"Wo"odep_ donsonheConvanurL,maaw(Cbapter9 f,� II�nsor,p,�ea';•, 1 Valuation
(co m n, 'i�h Scn '!0001 f Divis:on3 of the Buhnc tld Plofe cions Code) �'{)y.;�j 3'r6 ,L�'YtsyU 17_,/Sy
or that he
it cxcirs Imr,"om`am,Ibe basis fnr the alleged uam'dou k y vlulndon {
-cif Smion 103 Ls by any applicant for a pemtil mbjec..she aPPlicanrm a civil pemhy
m no,mommas Five hundred call...(5500). 304 ALN kt#§H ELECTRI Ater, . ,... Occupancy"type
ml,as owner of the property,or my employees with wages as their sole compensation C301 -
-will do thc'w.,k;and the swcttm,is at intended"or'offered'far sale'ISec:7Go.-
Busirao;end Prnfelosms Code:The Camranor's License Law does not apply m an 505 - FINAL ELRCM1W(J Jiettions
owner of pmpeny Who Wilds W improves thereon,and who does such work himself
or through his own cmpluY<esprovided that improvements mpvcmts e not intended or _ -, ____
-dfliord"f it tele:If,however,the bg or tsuch pro uddin - t n sold within cine rear of — '` - - .,_ . . ._. ..
(C .,
completion,the owmerbuilder will lave the burden m proving that he did not build or
improve for purpose of salol, `
L m owner fiche property, 4,exclusively a d Poifting with licensed contractorsto
,',
] onswa the w oris n(Sec.7to1a,Business and property
who
Codor I heimp.ves artan,
License Law does not apply to si owner h propertY who )thre or improves thereon,
dna who License Low.ch-prolttts with.a.cam.xm(x)lircnscd purwanem the
Compactor's xtr License bow. ..
❑lam exempt under Sec., '„ Io- ,.B&PCfonhis reason I I♦ `U IIt ':•P
(Tuner Inme
WORKER'S COMPENSATION DECLARATION
I hereby affirm under,Penalty of pdrjury(me of the.fthwing dcclamtionsr
❑ I have and will mcdoufn'.Ccnificate of Conseni'iio sdGinsurc for woAdn
Compionadon. as Provided for by Section 3700 of dm Labor Cole.-for the
perfomlance of the work for which this Permit is issued,
- - ❑1 ham and will iaintain Workers Compensation Insurance,as reyuircd by Section
3700 of the Labor Code.for the performance of the work for Which this permit is
issued.My Workaes Contamination n
ination Insurance carrier and Policyumtier am:”
.a. ._ -.. _
Ca - IY k.l iia PnLyN.
CERTIFICATION OF.EXEMPTION FROM.WORKERSI a
K. '` a '• .0 a ",+ ,. a.✓';�4ui l/I� I
. COMPENSATION INSURANCE":_ .._ _ . _ -,_. _. __ . .--. ___.._ ._____ ..__._-____ _.._.. _.— _ _. -----_
a
(This section need not be completed if the permit in for one hundred dollars
., I cenif that in the mance of the WWI
wi fore. is .mit is issued.l' 7. s',sr•;"'
. s Y Pcrfo R 1 i+• I ... ..
'xh ll not eiploy any P< n any ma r o as toboc a subject to sbc Wo kers
'C us gt.yyrtr�w C I f is Daae��
NOTICE I10 P IC I.alter making druiCerlitmancot Exemption,you,h uld
Z I
0 O forth th comply with ouch p P
_ P
1 Pen ode.You
neco ri subject thew k 'C m t n
.. yoked
o t us
previsions tsn.n la dee a
i y s'f Pun." "CONSTRUCTION LCNUING AGENCY
7 1 hereby affirm that N :s a con w t lendyf forte
a peHom t
.. Leine work for wh ch thn permis¢ sued(See J09r.Civ Ca
f] endrr's - -
�;.L Lenaer's;ABllrcic ' `s' I:•I';'x ,l• r a l ` if,
I-. •. 1 trinity that 1 have read this application and spite that the above iWomatian is
Ls. L [onat,I agrte m comply wilM1 vl(cin'.and countsWilirmnces and state laws mining
Mlilding eanemeliJu,:hJ lcreb'hutbon'rA reprt¢nuuva ufthiccily In.non upon
ithe abavo-nrentinncd propeity tar inspeninn pe,po...._
Q. (We)agree m save.indemnity and keep harmless the City of Cupertino:igaimt
sr V1 liabilities,judgments,costs and expenses which may in any way accme against said,
V Z C ty coaseq encc f the granting of ih ppeesmu
(APPLICANT UNDERSTANDS AND VILL CON WITH ALL NON:POINT Issued by:
Date
OU fE RF J ATIIO S !I j f• y� -�O�
-Sr ona.rAPPMAMALWIractor unit— Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
- Ithedpphc t.,.future Wildi.g.cutpoessmic.,handle hvudousaerials.—...Type of Roof - �� - -'-- • `/ �-� /1 � 1 '
as defined by the Cupsourni Municipal Code,
t ❑Yes" -s.. . -.. b Nn-:s: Cl hapt.e.r`9.1K2and the Health and Safety sr h .Cole..5eniog255J3(a)b rC.R:
t„1
o installed._
All roofs shall be inspected prior to any,roofing
materia]beino __.
Will the applicant or fatfaturc building ccp I use equipment ardsvices which If a roof is installed without first obtaining an inspection; 1 agree lo.remove
amltM1 b c a t: sdf defter] Bay Ann.A Gould,Mana,cuum
Duret all new materials for inspection. Applicant understands and will comply with
,t I , ❑nn all non-point source regulations.
I have read the haaardims more nls,equueme nn I ndei Chup¢r 6.95 0!the
Celif.rda Health&Safety Code.Sections 25505.25573 and 25534.1 underhand hat, ..
ifdmbuiIdin6 dxs not curtcn0y have3 sena. mat it ii ymspon.ibilitymnotifymct
:occupaM of the iequirtmeniv which mow bo met In to issuance of a Certificate of,
Signature of Applicant Date
se agent - _ 7 o All roof coverings to be Class "B'• or better
or OFFICE
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