07100072 CITY OF CUPFRTINO t �� , � T ' ° �
BUILDIM1vtiIVIS1CN �E1�1ruT ������Q�` ���������� '
; :: >:: __..._
;
PERMIT NO.
BUfLDING ADDRESS:
18590 RALYA CT CO F:OOFING 07100072 •
PERMIT ISSUE DATE
OWNER'S NAME: ,
MARGARET JONES 1901 OL?) MID
SANITARY NO. CONTROL NO.
NE: � `� `�
(650) 96��-7663
BUILDING PERMIT INFO
ARCHITEGT/ENGINEER: BLDG ELECT PLUMB MECH
� 0 � �
i p o LICENSED CONTRACTOR'S DECLARATION IOU DCSCilptl0❑
� v� I hcrcby afGrm that I am liccnscd undcr provisions o[ Chaptcr 9(commencing
; Z� wim Scction 7ooU) oC Divisian 3 of ihc Businrss and Profcssians Codc, and my liccnsc is RE — R 0 0 F 4 P LY TAR & GRAVE L 2 2 S Q.
�� y in full Corce and eCfec� 7 �
��? Licensc Cla, ._ Lic. k
p Datc ConuacWr
: F' W ^ ARCHITECTS DECLARA N
7 p ,�
c e 1 undcrswnd my plans shall Uc uscd az public rccorcis
)aV
' u. y Liccnsed Pmfcssional
' y � OWNER-BUILDER DECLARATION
I hcrcby alTirm that 1 am cxcmpt Crom thc Contractor's Liccnsc Law Cor thc
� p o [ollawing r'ason. (Sccuon 7031.5, Busincss and Profcssions Ca1c: Any ciry or county
�$�i which rcquires a permit to cnnswct, altcr, improvc, dcmoiish, ar repair any swcture
�' N prior ui iLt issuancc, also rcquircs thc applican� for such permit to filc a signcd sialcmcn�
s 2 p �at hc is liccnscd pursuant lo thc provisions of thc Conuactor's Liccnsc Law (Chaptcr 9 � q. Ft. Floor Area Va uation
u t- �(commcncing wi�h Section 7000) of Division 3 of �hc Busincss and Profcssions Codc) or $ 8 6 2 5
��., that he is exempt tMercfrom and the basis Cor Ne allcgcd exemplion. Any violation ot
Section 7031.5 by any applicant Cor a permit subjects ihe applicant to a civil penalty oC 3 7 5 2 5 01 "� : � Number Oeeupaney Type
not more than fivc hundred dollars (5500).
� 1, as owner o[ tfie propeny, ar my cmployces with wages u the'v solc compensation,
wiildoihcwock.andUiesuuctureisnotintendedorof[eredforsate(Sec. Required Inspections
and Professions Code: The Conuacwrs Licw�ce Law does not apply to an owner of
propeny who builds or improves thercon, and wha does such work himsel[ar through his
own employccs, providcd that such improvemen�e sre noc imm�ded ar ofCered Cor sala 1f,
however, the building or improvement is sold within one year of comptetion, the owner-
buildec will have the burden o[ proving t6at he did na build ar improve for purpose of
salc.).
❑ I, as owner of the propeny. am uclusively contncting with Iittnsed conuacwrs w
construct the projen (Sec. 7044. Business and ProCessions Code:) The Conaacwr�s Li-
ccnse Caw docs not apply to an owncr of propeny who builds ar improvrs �hneon, and ,
who contrac�s tor such projecL� with a wn�ractor(s) Iicensed pursuam to ihe Contnetor's
License I.aw.
❑ I am ucmpt under Sec. , B dc P C(or this rcason
Owner Date _.. _
WORKER'S COMPENSAT[ON DECLARAI'ION
1 hereby affirta under penalty of perjury one of the following declantions:
❑ 1 hs.�e and will mainuin a Certifica�e of Conscnt to sel(-insure fw Workefs Compen-
sation, u provided far by Section 3700 of [he Labor Code, for �he pedortnance ot the
work for which Nis pertnit is issucd.
❑ I havc and will maimain Workers Compensation Insurance, az rcyui¢d by Section .
)700 0( the Labor Code. Cor the performance of �he work for which Nis permit is issued.
My Worke�s Compensado lnsu articr and Poliry number arc:
Carrier. _�} �t u n r' Poi�cy tao.: 5?t— (� 0 6<< a`S � U 7
CERTIFICATE OF FJCEMPIION FROM WORKERS'
COMPENSATION [NSURANCE
(fhis secuon necd not bc campletcd if the pertnit is for onc hundmA doUars (S I00)
or Icss.)
I ceni(y Ihat in thc perfortnancc af thc wark for which �his pertnit u istucd. ( shall not
employ any person in any manncr so as to bccomc subjcct ta the Workcrs' Canpcnsation
Laws of Cali(omia. Datc
Applicam
NOTICE TO APPLICANT: If, aftcr makin� this Ccni�ca�c of FaccmpGon, yau should
become subjcct ta U�c Workcr's Compcnsation provisions of the Lalwr Codc, you must
� O foMwith comply with such pravisions or this permit shall bc dccmcd mrokcd.
z "" CONSTRUCTION LENDING AGENCY
F r �-�. I hereby affirm U�at there is a consuucuon Icnding agency tbr the perfwmance uf
(� � thc work fur which this permit is issucd (Sec. 3097, Civ. C.) ,
W A Lendcr's Namc
� � L.ender's Address
J � I ccrtifY ihat 1 havc rcad this applicuion and statc that ihc above informauun is
w ►-" cortcct. 1 agrce to comply wiih all city and county oniinances and sute laws ¢lating to
� U building conswction, and hcicby authome represcnutivcs of ihis city to cmcr u�n thc
� W abovc-mcnaoncd property for inspcction purEwses.
� (Wc) agree to save, indcmnify and kecp harmless the City of Cupcnino against
H � liabilitiu, judgmenu, cos�s and expenses which may in any way accroc against said City
V,'� in conuquencc aC thc granting af this permit. ��— �
� APPLICANT UNDERSTANDS AND W]LL COMPLY WITH ALL NON-POINT Issued by: Date � `� c�7
SOUR GULA NS. �_�
/��'�. �Ti�71�i� �� � D � � �� � Re-roofs
Sign re a Appl�ant/Conuactor �a� T of R�of
HAZARDOUS MA7'ERIALS D[SCLOSURE YPe
Wi11 thc applicant or futurc building occupan[ storc o� handlc harardous matcrial
az defincd by the Cupertino Municipal Codc. Chap�cr 9.IZ. and the Hcalth and Sa[cty
co� Section 25532(a)? � All roofs ::hall be inspected prior to any roofing material being installed.
❑ Ycs Li n� .
�11 tho applicant or futurc building occupant usc cyuipmcnt or dcviccs which
If a roof i:; installed without first obtaining an inspection, I agree to remove
cmit haiardous air contaminan�s as dcfincd 6y �he Bay Area Air Qualiry Managcmcnt all new m�terials for inspection.
Dcstricc?
� y� Q�Nu
I havc mad the hvardcws matcrials reyuircmcnt� uncicr Chaptcr 6.95 o(ihc Cali(or-
nia Hcalth & Safcry Cadc. Scctions 25505, 25533 and 25534.1 undcrstand that if the building
docs nat curtently havc a tcnan4 Ihat it is my responsibility w notil'y �he occupant af the
rcquire cn�s wnich mus� be mei pdor to issuancc o1' a CcrtiGcam o�Occupu�cy. SlgilBtUI'C Of APP� IC8T1� Date
� � 1� � All roof coverings to be Class "B" or better
Owncr or au�horiaed agcnt T— g� -