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03120036 (4) CITY OF COPERTINO BUILDING DIVISION PERMIT :r� � '� '' 'A"CTUNa x+q.,c .4 - BPERMIT NO. BURDING ADDRESS: WM H FRY CONSTRUCTION COMP Y 03120036 PERMU ISSUE DATE 3R'S NAME: !PHONE: SANITARYt2/0 OL NO. ARCHITECf/ENOINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 Loo LICENSED CONTRACTORS DECLARATION Job Description m 1 hereby ciliumshe,I me licensed under provisions of Chapter 9(commencing with3ectim70IK))ofD!Num3ofthcBusinwandPnefessimeSCode,And mylicenmis nn m p �< tom0foreeandsitcr. �2,7PS REPLACE WINDOW & DOORS f��lb'�.LH© z License Class Lic.g n Dam /7-G— Coalrector ✓M 14 FRy of Lrz ARCHITECTS DECLARATION Ky I underused my plana shall he used as public records OCT 1 2004 �n Sat, Licensed Po4asio tnal 3 OWNER-BUILDER DECLARATION 1 hereby esTrm Nat I am exempt from use Commuter License Law for the �lVl�t�®�pyAN o, fig g following memo.(Science 703 1.5,Business and Prolessions Cade:Any cityor county P G ftp $ which requires a Permit to enomucn.slur,improve,demolish,or toped,any structure NZ 2 prier m its issuance,also mquires,he ermines,rorsuch permit to file a signed statement VaIU hon that he is licensed pursuant to provialomaf me Comracmr'sUrone law(Chapmr9 Sq.Ft.Floor Area $ (commencing with Section 7000)of Division 3 of the Busimusand Rorcesi...Come)., Met he Is exempt therefrom and the beau for the,alleged exemption.Any violation of Section 7031.5 by a"applicant for a permit subjects On applicant m•Civil penalty of 3 5V1U)b*$Qr0 0 Occupancy Type not mom than five hundred dollars($50% ❑1,an owner of the property,or my employ=with wages as their sole compensation, will do Ne work and the mumen is not intended oroRemd rental.(Sec.70".Business ns Required Inspections and Professions Cade:The Comember's Liam Law item not apply to an owner of q P property who bu ilds or im proves invented.and who does such work himsel f m through his ownemployces.provided Nat such improvements me nolimmnded molfered forsale.if, however,Ne building or improvement is sold within one yen,of completion,Ne owner- builder will have its burden of proving Nat he did nes build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed convacum to construct,he project(Sec.704,Business and Professions Code:)The Conuacmts U- cone,Law does no,apply to an owner of property who builds or improves Maroon.ad, who convent for such pmjeou with a contrsetorts)licensed pursuant to the Convatorl License Law. - am exempt under See. .B k P C for thismason er Date -.J WORKER'S COMPENSATION DECLARATION 1 hereby alrmrm under penalty of perjury mm of the following declarations: ❑Ihave and will mainumaCemficamof Consentleself-MmenferWorkergComPen- sation,as Provided for by Section 3700 of the tabor Code,for Ne performance of me wets for which this permit is issued. 0 1 have and will maintain Worker's Compensation Insumnca,ss required by Section 3700 of Ne tabor Code.for to performance of Ne work for which this permit is issued. My ker's Campmentlon lnsu,ance canucand Poll lumber am: C. �2at Policy 7o gl Q((2x72. CERTIFICATE OF EXEMPTIONF OMWORKERS' COMPENSATION INSURANCE (Thuaectioo need not ha completed true permit Isforone h utdreddellso,($100) or lmsJ T certify Nat in me performance of the work for which Nis permit is issued,l shall out - employ any person in any manner m as to become subject to Me Workers'Compensation Laws of California.Dau Applicant NOTICE TO APPLICANT:IL after making this Cenifmcam of Exemption.you should become subject m she Worker's Compensation provisions of she Labor Code,you must Q 0 foMwu t comply with such proNians or this permit shall he deemed reveked. „z,i N CONSTRUCTION LENDING AGENCY [--m Ihereby a(O,m Nat mem iiacentvucnon lending aganry for Ne Perfuronce of ai 7 Ne..,it for which this permit is issued(Sec.3097,Cih,C.) QLemdm'.Name S 7 z building Adtl^•• / V Q I certify that 1 have mad this application and sum that the above information Is D,f~' correct I agree m comply with all city and county ordinances and surd laws relating m QfJ abovemgennswctiro and hereby forinmmhodmrepresenutives of this city to corer upon tite W ahovc(We) re to ertyan.for inspection seep CL ha (We) gree m save.indemnify and keep harmless Ne City of Cupertino against it fa'j] mubilin do tie me Me granting uind expansion which may in anyway acrnuagainst send City D V be do of UNDERSTANDS ingot Nis per mit. 2 APPLICANT UNDERSTANDS AND WILL COMPLY WITHTLL NON-POINT Issued by: Date R% GULT0ys-L/�_- /2-8-05 Re-roofs Signa,um oJ'Applicant/Ce'stractor Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupanutow or handle h mudous mamritl efned by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety e.Sued..25532(.)7 r�Ne All roofs shall be inspected prior to any roofing material being installed. -0 ❑Ye Will me applieanl or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit haxotmus air comeminems a defined by me Bay Ama Air Quality Management all new materials for inspection. Diuricl? f [3 yes �(u I be.mad mels ardour materials requirements under Clybpmr 6.95 of the Califon a Heal"SafetyCose,Secdow 25505,25533 mW 25534.1 on dmuilthe Willing not curamiy have a union.Nat it is my rcepansihility,to n t the aeupont of Ne quire, which mostto tprio�rioissenuccofaCcnifca ofOceupancg Signature of Applicant Date � Owner ser auNodmd egm, Dam All roof coverings to be Class"B"or better