00090025 CITY OF CUPERTINO -
.RUILDING DIVISION PERMIT CONTRACTOR INFORMATION: I ,
BUILDINGADDRMESS PERAIIr NO. .V
OWNER'S NAE r • APPLICATION SUB OAT 1;
20675 ACADIA CT 00090025
' PHONE , ` SANI PART NO CONTROL NO
HWA REGINA ET Al_' `09/07/2000
O O ARCHITEC'1'IENGINEER {pp'� {/�� • BUILDING I'll INFO
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t t. Y .. I I)G - ELf BC'1'. 1'LUO.+1B Mrl'JCIi
LICENSED CONTRACTOR'S DECLARATION e
z 5 H 5 l here's IB:m that I alit licensed under fCha ter 9 aontmcnein Job Description
Yn pnwl+IOn+o p
I—=C with Secumi 71X101 of llivtmnn3 of rho iliuincx xnJ l'n,le+win,L'uJe..tnd my hu'n+c r . .
SS In
OR Inrac unr cl 1 G
_
z N 6 'Lmen+e class ( Lar p •��n�l S •• '
1 .11 Connector
ad F ARCHITECT'S
se DECLARATION
g understand dagpanlieree9m SHAKE TO LIGHTWEIGHT TILE
p O LmmtccJ Prnfc++ional OWNER-BUILDER DECLARATON -
'�' 1 herchy allirm that I air ekempt train the Contractor's License Law lot the
C 3< following reason.(Section 701)5,BuanIts and Prold,,hm,Code Any city or coop •'
3 x O whmh on uire+a permit m nmctrun,alter.Imprme.den,nhth,armful,any mmore
t°ds� pntinoirt i++uence,al+o teywm+the epnc�em forsucM1pennmofileavgned,utamem
an.,he,,lsenwdpurwanuothcpmuaonsof thecinreene,License low(Chapter 9 Sq. Ft. Floor)ga Valuation _
(commencing.,an Section 7(X101 of Divi.ma 3 of the Ihnln�F and Prom,anons Coder -
or that he is escmpt therefrom and the base for the alleged caemptimV Any violation
of See unit 7011 5 by any applicant Ibr a permit subjects he inns ant to a civil penalty
„fnmmmcmmn live nnnercndolhtmisSOTn_ .. -APN•Number ��/ Occupancy Type -
O l.as owner of the prepeny,or my cmpinv ee+with wage+as their.olc compensation., ,� $'t .�a(JIa
.0I Jo the work,end the sT ,Otsrc is not tmendW or ntfened Can salt(Sec.7T1Lk - -- _ _ - - `,{Business and ptnression,CNe The Contractor's License[.at,docs not apply to an RegytrebInspections
owner of pmpery Who builds ar marrows thereon,and who dams such work himself (�
dr through his own employee, provided that+urn Improvement,are not Intended or A, 3265602 Jr. 00 `0
onered fill,Ire,If,hnwmer,tire building or Impmvclnem I,sold xnua one year of
oinple,nu.the owner-Hodder w'rl pine the nnnlen nl loo.mg that he dud inn build or
I mprme for p op oil of sale.)
305 — FRAME
❑Las owner of the pSeeity,oat c Business a d Praaing w Cade I The C commuction
industr to
eonwwm the does 7031.Evans„aril hole,+ton,code I The sesThetor+ 307 '— I NSI ILAT I Ohl
License u Jai toapply m an owner with property who builds ord too sin thereon. '
and sent, lLarlow Inr,ualt proieetx won a eomrnmomTlieen.ed nnl>wiltl to me 601. — ROOF TEAR OFF
Eliot Israelianse Lax , .. 602 — ROOF ir)Lywonl) NAIL . .
❑rum escmpt under See 'A&rclur ihls lctiinn
•Owner Date 603 — ROOF' BATTENS
WORKER'S COMPENSATION DECLARATION GOA — ROOF Ihd—PROGRESS
I hereby affimt under penalty of peeury one of the ful lox tng declaratiein
0 I have fruit wdI mnmmur.o Ceoow,ti,oI Can+anl in toll-Inwic Inr Wmkel's
Compensation, m Prnvmcd fn:.hy-SCLnon•1700 of the Labor Code, for The ,
performance of the send for which this permit is ,,old _
01 have and will maintain Worker's Compensation Insurance.u.required hy,l'ecuun -
37M of the Labor Code,for the performance of the work fonwhich this permit is -
issued My Worker'%Compensation Insurance comer and Policy number um:
.. Cain=• I Policy No .
/ CERTIFICATION 017 EXEMPTION FROM WORKERS', f,
COMIIIiNSA'l'ION INSURANCE ,
mr,serum need ism he complemd d the permit is for one hundred dollars -less I
o bight or 1 eerily thin In the performance of the x'ork for which this permit is issued,I • '
shall not mplay any pei,,,n In any anu nor m.n In IOLOOte'.blecl To the Woll 4
Compensmiun 1. 0 Calllornia.Dural +—'7—O('{ •e
NOTICE'IT)APPLICAN'T.11,vlter ling Nt+CcmOcme of Exemption,you should
become subject to the Workers Compensation provisions of the LtWr Code.you must -
Z 0 forthwith comply with such prmision+or this Permit shall be deemN revoked
F" I CONSTRUCT ION LENDING AfiEst '
ai rr^ I hereby nfllmt iM1,u them,s a cnn+wcllnn IcnJmg agency fur the perm,nonce
wa m sa,
r
,I The lk for which this pro i+iod(,Set.1097,Cie C r-
11 Q Lender's Nant•'
= z Lender's Address -
0 1 eeinfy dmt I hide mail the,application and late that the above Inlormaion u, -
F• correct.1 agree to comply with all city and county ordinances and state laws relating
Q to building conoost I,and henhyanhrnme represemntmes at this city In enter upon ..
� r� the aboveamntioncd p,,,,,Oy Innnsretlinn pu,pnse,
r` Q es,judgments,agree ts sass, anti tmly loin whi hnmayin Ian City o1 ison,a jai st so T q e7 -
W IlaMhu(We)ri as , abl mpcnscs cep h may in any way name.g•unn sod"
U z City in consequence of the gmnung of its permil. r '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON'POINT Issued REGHLATIO en _ y� Dale .,
,ISlgnatnre m nppheaneeanfra D:IIe - Re-roofs
HAZARD US NIX]'ERIALS DISCLOSURE
Will 01e a"]lane a r t:mire han If ing oecnpam.arm or hnudle hasomou,nau,ri Type of Roof', .
a,defined by due Cupertino Mumctpm Code.Chapter 9 12,and the Health and Safety '
Core,Secuon 25532mrP -
0 Yes ON. All roofs shall be inspected prior to any roofing material being installed:
Will the applicant or future htilJmgoccupam uwequipmeat or Jtrates which If a roof is installed without first obtaining an inspection, Iagree to remove
emit haurdou+...r mmam,nnnt+m refined by We Bay Area A,Quality Mvnngcment
Districn all new materials for inspection... Applicant understands and.will comply with
El Y., C"" all non-ppint source regulations:' -
1 have read the hound Iu.nc mis irytiircnsnt+under Chapter 095 01 the
Calif..,.Health St Safety Code,Sections 5505,25533 and 25534 1 understand that _
if the building dues not currently have a tenant,that uw by respomhloy,m noufynn,
occupant of the rcgmrcmem+which must be met prior to issuance of a Certificate of
/D"apa°c"' Signature of Applicarr ` Dater
�n�� `-� `. - . All roof coverings to be Class "B"or better
/ Owner or omhnrireJ egem _ Dam � g -
OFFICE