01090103 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
11793 TRINITY SPRING CT 01090103
OWNER'S NAME: APPLICATION SUB DATE
BOWER KEITH D AND HELVIA B 09/24/2001
PHONE: SANITARY NO. CONTROL NO.
MOO ARCIIITECTIENGINEER: BUILDING PERMIT INFO
w{- B ELECT PLUMB MFCH
zJ a I hereby affiwEhat IOmnlicensed undo,pmOR S D ci m in'Chapter 9(commencing Job Description .
:i—�
v�C,m with Section 7000)of Division 3of the Business and Peofosions Code.and my license REROOF.
r ismtdlroaraawe ct. 217 TSHAKES, ADD MONIER CEDARHITE TILE .
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CI"S DEC RATI
1 undersmnd my plans shall be used as public reco ds
a
2 C 2 b 2001
3 a o o uraaed Pmresamnal
OWNER-BUILDER DECLARATION
I hereby affirm mat I am exempt from the Comr,u tor.Lianx Law for the
h
C?< following maven.(Section 7031.5.Business and Professions Ca :Any city m coon
f S o which xquim a perruh to conswm older.improve.d.crm ish.or repax oncy swan U I LDI
ud7 Caw -Priors 'ts calm rrquua the epphcmtfm ouch prmut to Bkxugnedataturc -.- - - __..-_..— - __ _____
mat nc sl d paRicamnnmeptoa:;ona of convectors License Law ram rt v S :Ft: Floef'Area ua[ion
(cote mag withSection7060)of Division 3 of me Bgsmesa and Prof ms Cod) f,'c,Ns'i i,_meq kil,i s.`ta •s:�... 1,_z E-10
or that he is exempt @emfmm and the ba.s for the elldgeJ ciGnyObn Any violation
of Stttion 903 LS by any applicant for a permit subjects the applicant to a civil penalty
or not moreman five hundred do][.(SSW), A um er Occupancy Type
°1,as owner of the property,m my employers with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.701,11
Businces and Professions Code:The Contractor's License Law docs not apply to an 307 - INSULAT lW ired Inspections"
owner of pmpmy Who builds or improves thucon,and who does such word,himself
orthrough
provided
or through his own employees.provcd mat such improvements ore not intended or 601 - ROOF TEAR OFF
Offered for sal..If,however me building or improvement is mid within orm year of ' ' -'-
completion,the owner-Wilder will have the burden of proving that he did not Wild or 602 - ROOF PLYWOOD NASI L'1 "• " "-
improvemrpurposeofsaled. 603 - ROOF BATTENS _
`ori,as 6waefur the propeFry.am exclusively contracting with linens'mvtrachrs to .. 604 - ROOF IN-PROGRESS _. :"��J: - - .; t'7' -
conswct the projttt fstt.706x.Buair.ane Profeteions Como The Contort n's i 1,
License law does not appy to an owner of proprey who Wads or improves thereon. ..
and who convects for such projects with.a contractor(s)licensed pursuant to the
Contractors License Low.
°I am exempt under Seca '.B&P C for this mann : > t?-�•';tF 'il
Owner Date
_ - WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty mf perjury one mfthe fuluwing declarations:
' � ❑ 1 have and will maintain it Certificate Of Consent ro self-insure for Worker's
Compeniation, as provided for by section 37W of the labor Code, for the
_ perfotmaiice of the work for which this permit is issued.
I have and will mainum Workers Compensation Insurance,as po uired by Semon
3711(1 of the Lnhor Code,for the performance of thc work for wham this permit is
- issued My rkcr'sc pc r 'I sumrc arrl - dPoI 'nu bar are
agiyi 9ml 37
1," CERTIFICATION OF E EMPTION FROM.WORKERS';
(This seciion need nmin'completed!ON INSURANCE ..., -... ._. .,- ..- ..-....__.�_._ _... . .....
COMPENSATION .
' it the permits for one hundred dollen
(S1W)or less.)
sI'enfythat in Chemin my nurof the amid,forwinch th pc t issued, r;s n1 . [. `!'I(,
shall not employ any Person m my ma ss to bwome sub3cn to rhe Workers
Comicnsaiion Laws_Califomie.Date m
Applicant _:. . •.. 1 . . .- -
NOTICE TO APPLICANT:If,after making this Cmilicate of Exempdov,you shouki
Obecome subject to the Worker's Compensation previsions of the Labor Code,you must
forthwith comply with such provisions or this pewit shall be domed revoked. ,
V]_,, nt" CONSTRUCTION LENDING AGENCY
1 hereby affirm duct ttln6t is a consduciim lending agency for the Nifowantt
Woe . of the work for which this permit is issued(Sec.3090,Civ.C.)
'�-0 lender's Name . ..-._ ...u..', . -.... ... -. . .. _
5%z Lenders Address '
unify that I have read this application ruralvete mat the alvve inf tion is
W E:y corneae 1.gree to comply with ell city and county ordinances and state laws minting
V to Wilding conswnibn.and hereby authonu represcounnes ofthi,city to enter upon
the above-mentioned property,for inspection purposes.
��..s.s :L. (We)ngrcnd save,indemnify and keep harmlussrhe City of Cupertino against
liabilities,judgments,costs and exprnxs which may in any,way accrue against said
V rzr City in consequence of the granting of this pewit.
APPLICANT UNDERSTANDS CPYfV OMPLY WjiH ALL ljg4 �fi7DJ Issued by: Date
SOURCANT UN ERSH T / y•
Signature.of ApphcmUContmctor'; - Date Re-roofs `
,.,
HAZARDOUS M TERIALS DISCLOSURE
Wdl Ur applicant m to.building occupant Gore or hiscula haaaAtus rtwaial Type of Roof
as defined by the Cupertino Mn p 1 Code C r hapter 9.12 and the Health and safety 1 {sl a '1 Y t ,
Cod-Sect n255331a1 W t, s y.l Q + .�•. l '. t 3'.': f,.1' !.! 4 !.
°Y'' lam`'°•':(; . . _._ All roofs shall be inspected prior-to,any roofing material being installed. . - -
Willtheapplicantorfumre Wilding occupant use equipment or devices which If a roof is in§talle'd'without first obtaining an inspectioli,Ilagree to remove
emit hazardous air contaminants es defncE Fy the Bay Arca Air Quality Management
District+vex all new materials for inspection.. Applicant understands and will comply with.
° all non-point source regulations.
1 have ad the hie a' ms materials requtremems ander Chapter 6.95 of the
Califomie Hm1th&Safety Cmc,Sections25505,25533 and 25534.1 undersmndthat
if me building does not currently have a tenant.that it is my responsibility to notify the
o8c pant of rhe u In. wM1i h must be cp..ortoissuance of a Cmi icme of
°" pa y Signature of ApplicaRf Date
9
" ownaorautham=ed.gyr. - rData
,e All roof coverings to be Class"B"or better
OFFICE