01050139 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMII'N0.
19361 PHIL LN. 01050139
OWNER'S NAME; APPLICATION SUR DATE.
JOHN THELEN 05/1.6/2001
PHONE. SANI'LARY NO CONTROL NO.
OKZ ARCHI'I ECT/ENGINEER: BUILDING PHRM1'I INFO
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_ .GC 1 ELECT 1'= M[C
I I_I r1 I-11
yz LIatCENSEDCONTRACT'OR'SDECLARATION Job Descrlp
Z ❑
0O 1 hereby"Iron m1 ata licea..d.nder prnvl in 1,of Cluiprnr,9(annmmaeing
°yf�W won Section 70017ofD.,.,i.a3ofhe Buninerts and Prom,,ior,Code,andnty license
in mu once ant]effect.�C.a Linctus Cl:t,% Lie.# REROOF. / COMP.
D DnIC DECL.r
3 ARCHITIiCrS IlEC1.ANAP1(lN
I undcn.md my plan%%ball be used an public accord, / 4
r
z p Licensed Prom,,iorml /
a'E:o OWNER-BUHMR DECLARATION ( �1
I hereby affirm that 1 am exempt from the Connector License Luw,for the 4 `/
rzafollowing fitamidme.dosioro Cats Anycity or county O
f s O which requirc%a permit Io rnm,the alter,improve,dcmoli,I file
repair any%trucmre
prdbe islcensedeursu acclaim,the the Contractor
miccow,aw(Chatgned enl
died be pursuant robe pnmi.nnm none the m inw.%indP Law(Chapter Sy. FL Floor Area Valuation
(commencing w I'rg with Section 7010)of e basis
3.d the Business and ion,An n i Code)
nr that he i,exempt t from and the basis forubj alleged cwiorat I.Any violation
of Section 7831 any:tpplicam fimapcmtit whjeas the opplicam maervil penalty
e
APN Number Occu ane
of not mo an rvc hundred Jnllun(SS(Mq. P Y YP
aso,su,ofthe property,army employees withwager.as their sole conflemation. r e
wil J"the work,and the structure i,net intended or offered for.cele(Sec.7(W, _
Businos and Profes%ion%Cute:The Contractor's License law does nor apply to an Required Inspections
orr of property Who builds or improves hereon and who doc%such work himself
through his own employee%.provided that such improvements are ant intended.r 305 — FRAME
.faired rid If.If.however,ncc building a,improvemmit is sold within one year of
completion.thewarmoWilder will have the burden ofpmving that he did not build or 307 — INSULATION
improve for pmpow ofualc Jf
❑1,m owner of the progeny,am exclusively d Prom mg with t Thcontractors Currto
601 — ROOF TEAR OFF
.nnmtmepm�ject(see.7w4,Ra%inn%%ago vrnreasmn%enJeoT�eanttaemrs 602 — ROOF PLYWOOD NAIL
License law does ant apply to an wner of property who W ills p
or imroves thereon,
and w ontmen for such pmjoectn with a contractor(„licensed pursuant to the 603 — ROOF BATTENS
c°atm% rsu"nww"' 604 — ROOF Jhl—PROGRESS
Ow am mnpORKCC POum
E1'SATIONI �� OIo r hca%on
wrehy affirm under penalty of perjury one of the bJhaving declarations:
I have and will maintain a Cenircate of Consent to snit-insure for Worker s
Compensation, as provided for by Section 3701 of the LaNn Code, for the
pe m,m%nce of the work for which his permit i,i...ed.
❑1 have and will maintain Worker's Compensation lusum me,as rcquireJ by Section
3701 of the Ial,ur Code,for the performance of the mark for which this permit is
issued.My Workers Compensation Imumuce carrier and Policy number on:
Cortise Policy Nn:
CERTIFICATION OP ME MMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars
(b I W)or less.J
1 certify that in the performance of the work for which this pemJt is issued I
shall not employ any person in any manner so as to become subject to the Workers'
Cnmpemation lawsof Carf.min.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Caemption,you should
Wrene subject to the Worker',Cour,owtion pro morsof the labor Code.you muni
O 2 Ibrtln%nh comply with such provisions or this permit%hall W deemed revoked.
? UG CONSTRUCPION LENDING AGENCY
a > 1 hereby affirm that here is a construction lending agency for he performance
of the work for wh;ch this Kmait is%sued(Sec 3097,Civ,C.)
6. Q lender's Name
5 z tender's Address
U O 1 certify that 1 bout read this PPI radon and%tate that the above information is
Cis F., correct.1 agree in comply with all city and county ordinances and scam laws relating
O U mM1u ildingcoronetion.and hereby authorize repew lativev of this city it)enter spot
he ub.vo-mmelloned property tar in%peNon plopows
(We)agree m eve,inJanunify and keep harmless the City.1 Castilian against
lip liabilities,Judgments,cos„end .epensc,which navy in ung way accme aquina mid
U Z Chy In cnnayuence.f the Brun ng ud thus Penna.
APPLICANT UNDERSTANDS ND W�Mfl` I IAI N(L POINT Issued by: Date
URCF.REGULATIONS.
11
Sismmtrenr Appl'mant/ ,mac"—r Dam Re-roofs
HA ARU US MATERIALS IJISCLOSURH '
W,II the.pprcan .Iia renudaingrecup t.rouen hamnc haondn...rnmerial Type of R of
ns defined by he Capital u M nicipal Cute.Chapter 0.12.nn I me Health and Sudety
Coda,Section 25532(al'1
❑Ye% El No All roofs shall be inspected prior to any roofing material being installed.
WJlthe appl'avmnrmtnrebtrddimgouemntmuwcyotipmemordr,jo.swhich If if roof is installed without first obtaining an inspection, 1 agree to remove
emit mns s
hurdnir ccrounin ad,as dere
fined by the Huy A "Air Vtrd;ty Munugemmat
.;nese all new materials for inspection. Applicant understands and will comply with
DYm 0N all non-point source regulations.
I hme real me hu.ardn.x nmmriuls,Clintmoons under Cltaptm(105 of he
Cnl'domiu[{calm�S+mty Cnde.Section,25505,2,55931 125534,1 u.id,,,tund Ilial
if lbs bu'ddlny dn1 11 aIndy have a ten:ent that 111%n ay re sp...bitty to not E'y the
l of alts rce to
ou whiun mewl h m t yu"a,.I'n Cuniliarnu of
ii rNm 111an.y. / Signature of Applicant Date
t,mnnnra. gem Dan All roof coverings to be Class "B" or better
OFFICE