00090167 1-NER'S
TY OF CUPERTINO
nuu.ntNG DIVISION PERMIT CONTRACTOR INFORMATION: -
ING ADDRESS: - • PERMI'1'NO.
0o .`NAME + APPLICATION SUB DNU!
E' 10397 AMISTAD CTWESTERN REGION ,ROOF 4111TARY NOtD019 04 "TI.No.
C c Z ARCHITECT/EN
5off�V 231 N 12TH•ST -- n1bc, rrY1�6 u`��@0eMI:cB '
y= LICENSED CONTRACTOR S DECLARATION, (408) 360-911 'lob,Descri titin
O Z—O 1 hereby M that 1 am licensed I p ro or Chaps 96ommedc ng p -,
FvF wthS tin7lNNq fD'vsonl o(ths Bu Ile feisinns Cmde,nnJ ny l'cenw
6�— Ill fall Raid I r1� �/ ,f
arc�5 License I' J Lic.N' 10
e.3 ad V Date a Co.,NClnf_ f /A/
{ 1 ARCHITE(T'SDECLARA ION VV
C 5 I unaernlnnd to,duns..hall hat uwd as public records - s
DO Licensed professional - s - .•
word OWNER.BUILDERDECLARATioN OVERLAY SHAKES W'/ FIBER 'FOIL INSULATIO
I barely affion dett l on,c,abon,fread he C 1 ct :License 1 f r the
ba fel g S I' 70.1513 . and Prol. ' C Any ly any l ILE ,
O
which ablonares a permit to construct. Imo,improve,derrejam. p y mb CI re - ^
poor to itsi Iso requires the applicant fsuch parent l rile a.ged-t nt
that he illicersad 11 tsar n shat ,sect r-I enY La (en pt a S' FL Floor Area Valuation
(Commencing with Salon 7")of Division 3 of the BusinessN Prefees ons Code) q'
I ur that he is d.ould fit"I sI,and the basis for the alleged exemption.Any violation -
eISection 7031.5 by anyapplitanl for a permit whjec"the applicant In acid(dually - APN Number .
„r tm moa than E.a nanerca amnm aSOIA' Occupancy Type '
01 a f thep p y. y npl Y tb dg. :the I mperecum, '•
ill the k and the structure t intended(a Iffeadd fill at,within
7044,
Bun anti professionsil se Th Contractor's 1 1 does not alelf m.11
Required InspectioTns
owner y, h Id. improvesthereon, tl M1 J h work himself mM1 ,h his Ie ya,p a lead th t p met n ,neeI,,
offered for Sala If,however,the hu . or improvement's.that w min I,.,year of
.$4100
m ia-I 1.1 will L.d 4e bincnolo (het he dnuI hold
improve fin pmrsoc d1.see.).
' +
- - 34.24501.0. 00 .
01.as owner of the property,am exclusively contracting with licensed contractors or
construct theproject IS ]IH. li n I f r f %i s C def The Contractor's
Lh,e 1 1 :notapply an owner(if property wh laultIs a dipmve%thermal,
and who contractsfor such Projects will,a cultist licensed pastoral to the 305 — 'FRAME .
Cannonade°1.ansa Lax. - '
O l am mean,under Sec. 14&P C for thisrca.dn. _ 307 INSULATION
Owner Dale " 601 . ,- ROOF ,TEAR. OFF
WORKER COMPENSATION DECLARATION 602 — ROOF PLYWOOD NAIL
I hereby affirm tinder penalty of perjury one of the following deelnfmum,:
603 — ROOF BATTENS
I hate and will IndouninCer(ificald ol Col,cat 1) f for Worker's 1 - -
Compensation. as pn 'Jed for by Section 31011 of dic Labor Code, for the 604 — ROOF IN—PROG ESS. ,
performance f the work for which this promit is I'.ued
1, I I daun; Worker Counivadoli lroead,a.asrelented byS e -
- 771111 f(he Idmor Code.lor the parlormance olliffic auck fill which this permit,s
issuW 5 CZoope .ei In.wm enr'anJ P�ol�l/y,�l Ler agrc:
Corr �`-4—. PolicyN .', 16y•✓ J { t
CI1t❑IBCAI ION OI EXEMPTIO PROM WORKI,RS
COMPENSMIONINSURANCE - - -
(This Icrion sad non be completed if the permit is for one hundred dollars
is
Ny or le".)
1 cenify that in the recommitted of the uu k for which this permit is issued,1
:shall not employ any person in any m r so as to become wbjwt m the Workers -
Comp rvabon latws of Culifisfur Damn '
APPI'cad,
NOTICPTOAPLICANI IIB Ik' gth:tanfifi,alcul E.c......r.you fibalJ
Z necome.objectI the WorkersC pemarinapresident,of theL bm Crude.you mud '
Q O forth nh comply with>uch pavilions or this perms final lie deemed rcmked. _
y ti CONSTRIICIION LENDING AGENCY . s„ ^
I hereby affirm Inns there is a ennstruction landing agency I'm me perhardea ed
of the work fit which this per-mil is i.wcd(Sec.3097,Civ.C.) - -
y O lender's Name
z Lender',Address
RI real l y that l have read this application had had that the above inrornolion,,
p. comrea. o
1 agree ,comply with all city and county ordinances and stare haws helaling -
C) V Id building consrunion,and thereby authorize zeprcsenlanives of this city,enter upon
W
did.1 e n t d foolven,Ra i n,crflod purposes.- t .
W (W) I&Ice(6 so%c, indamin11ybuild keep hal aless the C'Iy ol Cpa glnnl
W liahil tie j Ag nems,costs d espenrs which tidy in any way acerae lig 'est said
U z City in comdquence of Ne gaming or this permit. r„ J
APPLICANT UNDERSTANDysyrtTT�(VILL COMP}jY WITH ALL ryyp 1N/p (� 'Dille �G
SOURCE REGULATIC �/Y / {r ni oat ISSIICd b V e I�/7�tiVG r
Signature nll3pplicant/CnntraDOUS i��L DmcL= -Re-roofs '-
HAZAkDOUS MATERIALS DISCLOSURE '
.Willy(he Catarin,rmure building baccurcla,
0store,9.12.handle harildlabd me, Type of Roof - '•
as de.Sed Section
ltic Cupertino Municipal Cnde.ChTyner 9.12,and the Heullb xnA Safety
Csvle,Secdon?5532(,0'!
L1Y`° All roofs shall be inspected prior to any roofing material being installed.
Wiumean IC Iorfuture biddingoccupant use ttlulpmentordeviecswhich If a roof is installed without first obtaining an in action, I agree to remove '
tu ,znnlous all conuuninuW asdclincJ by the illy Area.Air Qtdlity Management 6s p. 6 i
italic, all new materials for inspection..Applicant understands and will comply with
all non-point source regulations. -
I h ad the h ard t Ind. y t nt. d Chapl 595 nf,ih
Cdtf ' IIuld &Sardl,C I S :2550525533 11534.1 I Pmrllal
If thebildingl not currently have tenant,thtit my s 'bllyR tifyah - - C• C ,
ccupam f the rc m 1whichmasa M o n priono -na ce f C n'fcam f X /
Oaup n y. /
Signature ofAp Icant - "Date
Owtal araathor d e sad - - All roof coverings to be Class "B" or better - '