01070048 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19852 PORTAL PL 01070048
TION SUB DATE
TAYLOR GAVER F AND MARGARET P 0712/2001
PHONE: SANITARY NO. CONTROL NO.
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n Ore O ARCHITECTENGINEER: BUILDING PER FINFO
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z LICF,NSEDCOIPnRACnderp DECLARATION Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
°_ria
in
ad OfDlvisionJofthcBustoesasanJPrnfesxiansCode,andmylicenm FIRE REPAIR.
a m y in full force ad effect.
zii:O i a 4iccn.e Cm. Lic.e
is u
are
�, 0.. Convacmr
77 ARCIIIT[CT'S DFCLAR TION
FH 1 understand my plans shall be used as public records
da fc
dp' Licensed Pmfessi...I
%ca OWNER-BUILDER DECLARATION
ad=' 1 hereby affirm that I am exempt from the Contmcmr's License Law for the p
I—z following mason.(Section 7031.5.Business and Professions Cale:Any city or county $28264
xF o which requires a permit to cenetmet,alter,improve,demolish,or repair any structure
ce
to
prior tots' e,al cam that applicant for such p maittolile a signed statement - — --
that he is licensed Potsdam to the provisions of the Contractors License Law(Chapter 9 r Valuation
(cont 'n8 'ithSect ]0001rDivismn3ofthcausntcssepdPmfrsstansCale) J `tris, pad*4�Ori�°f,�0;?tth,S.i„i_ +{1v, l
""bar he is esempt therefrom land the basis for the alleged eximptien.Any violation - - -
-of Section 7031.5 by any applieam fa a permit subjects the applicant to a civil penalty
.or not,norcthan rive nanarmaonar,(asBn)' 516paPN liYRWL BUILDIN I'' Occupancy Type
❑Lin, ,ohne propcnri nr my employees with wngesas their.anle compensation. l
ill do he lark and the stmcturc is not imandod or affieral for sale(Sec.7P : .
'Bu dProfessions Code�The Contractor-1 e Law does not applytan Required In pections
owner of property Who builds or improves thereon. d who chats such work himself
orthrough his own employors.provided that such' p t intended on - -
',offered fI If horoswer,the building or improvement issaid vvithin-one year ofcompletion,thicowner-larialar will have the burden of prov ng that h d'd not haildor ,
improve for pm,csa of ,), /�•/� / �k'.�///' D
❑I as owner of theppcnY m I rvelyraating with licensed contrawsbarra to
construct he police. Sec 7044 B i ess ad Professios Cock:) Due Contract
s
License Law loot not apply to an owner of a co ty who) Ids orimprovesnotation
to the /
.and who contacts License Law,
such pmje[6 with a contractors)licensed Pursuant m the _... _ _ .... .. _.. _. ..._ _. .
01 a.axes Liccnm Law. ,.
❑lam exempt under Sec. .B&PCfor this reason ns �
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affnn under pcnahy or perjury one of,the follovim,declarations:
❑ 1 have and will maioned a Cenificaie of Consent to self-insure for Worker's
Compensation, as provided for by Section 3700 of the Latter Code, for the
performance of the work far which this permit i,,,,.cd.
_ - ❑I have and will maintain Worker's Compensation rnsunhni.as required by Section
17 0e Lxbar CI
c,fur the performance of the wmk'ror whim this permit is
i ad.M,y'W_ke�r`s C_�pc t o Inxpra c end Po/l' y �(be9 ogre:
Carr "diyN
CERTIFICATIO FFXEM1IITION F150M,WORKERSi - s s. �•- - - - •- --
'Oh_ ENSATION INSURANCE(; _
rrbis section need not be completed if the peanut is for one hundred dollars
1 anifv ihm in the.perf ance'of:he work fur wh I th pc nls Lvsucd:I � � •-�-- �- - i � _• - -
shall not employ any Persian in any manner so as to become subject to the Worked
Coinpmolu n Laws of Collfomia.Dote
. Applicant .. _ .. .. .. _ _. . . _. _.
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should '
becamesubjectmtl.Worker's Compensation prd ioions fthe Labor Code,you must
Z
Q fonhwith comply witM1 such provisions onhis pem,it shall be deemed revoked.
of COVSere is a IDN LENDING AGENCY
Irkhereby,affirm than is there iss fear. inn lending agency for the performuntt
r of Lethe work for which tots pcmtit is issued(Sec.J09].Civ.C:I- j -
S Q Lender's Name -
= Z Leaddn Address i -
V
-C lcertify that l have mad this applicor ion and state that the above information is
Ist'F.. correct.1 agree to complyswith all city and county ordinances and state laws«lain,'
C) no buildinganstrunion,and hereby authorize representatives ofthis city to enter upon
�.rW the above-mentioned pmpcny for inspection purposes., I _
E-r
A. twe)agrcbmsavc,indemnify and kcephermless the City df Cupeninoagama'
_ tZ) liabilities,judgme is. -lasts and eapenws which may in any way oceme against said
U Z City in cuNT ' ca the gmmi 't armit.
APP
' ANT DER.NAND ND L COMPLY W1TH� .f.NON DINT Issued by: - Date
S R'CR L I(NS.. ... Y•
Sigwwm p t/Cm,vacmr Data. Re-roofs
o HAZARDOUS MATERIALS DISCL SURE
Will he.,,dicrriu or biturebuimiiad,ia'orhandlehaarden,m t I _ Type of Roof .. - - ... .
as defined by the Cupertino Municipal C N Chapter 9.12t and the Health and Safety
, -
Code'Sccton25532O ss •'•'1, '. ., r�s.; I
IOYc, ONO' Ia1tis , v.
._.All.roofsshall beinspected prior.to.any.roofing.material being.installed.____
Will the applicant or future building Occupant rite equipment or devices which: If a roof is installed without first obtaining an inspection, Frgree to remove
emN
chair hazaoes air contaminants as defined by the Bay Arca Air Quality Management
District all new materials for inspection. Applicant.understands and will comply with
Oye, : ON. all non-point source regulations. . .
I have read the hazard,.,materials requirements We,Chapter 6.95 of the
CaliforniaH b SuIet,Cade.Stations 25505.255J3oad25534.I enders.ndthat _
if the buil ' da. of currently M1ascamnant.thm it is my responsibility to notify the
f me r<y icemen 't be met pri,ir m i.asuance nf:Ceniticam of
°yap r' Signature of Applicant Date _
'o rut - D, All roof coverings to be Class "B” or better
OFFICE
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