00120035 CITY OF CUPERTINO' - s`f''
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING AD M -" PBRMITNO. n
1 c1'5 ARCfHONY- PL L.INDY ROOFING ( Q. .l'IV k101.c710s5
OWNERS NAME' - '^ "' APPLICAI ION SUB DATE ^
b.IENG SAM S, ;E'7 Al" - '' S:a"A - HARVARD DR
PHONE:" • , !,. SANITARY NO. CON'I'SOL NO.
QP0B3'r'69--025 ' .
O- ZO AR CHITF.C'f/F.NOINIiF.It - BUILDING PERMIT'INTO
C
w HLDG ELECT PLUMB ' MECH
H ti m
LICENSED CONTRACT OR'S UI CI ARAT'ION J IOD
Job DCSCrI
Q y,y� wIherchY'Rrn lM1tl I' ed unl p ,P . .
ith Seeunn7W0 ofDs of WeH
p�atmi J u the:anJ Pr fes,i :Code, nd m t license ,
a I:icn r n r nnn� I` L' l� 'SHAKE TOr ASPHALT
3 w m Dm iJ ediamener
- -
Iy 0" r ARCIII fECT'S DECLARATION ' ,t
-�aj I I 't Jny pia ':h'llh 'adasPublic nl.
Licensed Professional s
ce OWNER BUILDER DECLARATION
2, 1h by ff thea 1 - pt f' t Contractor's 1 f Lie
I" 4 toll g (S t 78315 B d P f..I C 1 A ity ounty ,"5 -
.c S❑ which factor c a t n p demolish, eP'tr.nny structure ,.. .
z Poor runs 1 W :Ih pili tt 'n fl s, I statement
m main T : Ipursuant I thep f the Contractors LLaw Chap
tart Sq: Ft. Floor Area • Valnation
Icmm� gwth Swt 711011) dDvtx 3 fm B . dP f:' oJe7
or'he'he 1,escaum fifienctroad' d the basis let l ll g J riwarrion A y vmlation - "• - ` ' �- - $16400
of Sernion 7o315hy ran, pl l' IrnraPe t: bjiappl' tt ivil penalty
of t tore man fine h 1 d d llrs(s5w) APN Number Occupancy Type
`°1 fin r P nr r ply :In g.a.m 1 31i 2l 2076. 00 ,- -
JI do IM1 k 1 the loom :nor onlicandecl or dhd f (Sri.7Cs,
Btu e.. a 1 Pont Code The Connector's License Law does himlie,Inan Required Inspections
.moof p pay Who build,in on,firve,fiarriour, ad who does iaich wc,k himself
o,mogh his rwn wtply ' n.,triedt t ..hi p I I lector 305_ - FRAME
offered I:r sale If,however,the building or improvemedla withim ote yean or - 30 i — S hlSIJLp T I ON
.
complel on the c,ser ,hold,, ll have the b lco of i mei smut be did Dol hulas
iogrmva far Torro,00f,we.). - _ - , - 601 = ROOF TEAR OFF.
°i.as owner ofthel p Ir. exclusively connecting withlicensed cmadraren,fi.
con.I 602 - ROOF PLYWOOD, P.If171._
ftire p I I(S 7W4 B ore I Professions ss Or6f Th C t t ¢
.Lei I I I pplyt fp inIv I b Id. p to y 603 — ROOF BATTENS • .
and who contracts for h Projects with mrfsl licensed p n n t the
Commences604 - ROOF •IN—PROGRESS '
El axen jcnderSc ,❑&PClor this hie,
Owner Data - ..
WORKERS COMPENSATION DECLARATION
I himethy affiner radialM by flip tyane of line followin,d l
� ❑ 1have and will mannam it Cedificatic ofC Il selt-houre For Worker s'
. Comp t provided f by Section 3700 if the Labor Code, for the - -
performance oft work bar h h this jecomit is suied. {/Q
ElI Almodern' Worker',C p mrnl y - dby Section r _"�/ '
3700 f tireLuh Cid f tl p f Ih f k t h This Perm t is a 0,
emd My Wiaker s Conalocescrion lainarroo,aner and Policy
�number
�y4 -.ILS
Policy N 11lLi�i����3 -
I2TIF TION Or CKCMI'T ION FRO- ORK:RS'
COMPENSATION INSURANCE -
' (Thos section neer)not lie mmplemd if the permit is lar ,a,hundriol dollars - • ^ "
• (SIIXBnr I""") '
I cerff,,Ihn inth torkarramea ofm k bar whicht prn'I's tsar. I -
_ ,hall tat employ any p r. m n
any oa nx m hero do wbj,cl to the Workers r - !
Coup I'. n Law,or California
ia,Date .-
Applicant I
,;'
NOTICE 1-OAPo'he Winked"
Compensation
olL Labor Code
becdma,ubjetlto the Workers,kronsmthis przwtetnml be defined Cnde, t most
z of
Yn .
Q Ibnhwnh comply with anch pmvtstons nr this Ircrmit shall be defined revoked.I -
r
F - CONSere Is a ION LENDING NDING ACCNCYy + x'
11 ff hereby that th ,t i nloneing agency for the lgrfnnnancc - ^ •'
W
of the work fill which thilf,real's slued(See 3097,Cb.C.) -
Q' Lent .Name
V . .
l eanif Ihtn l have rend @,t il:ation. smte thm tl' above i turn... _ ^
., r m n ' n ,.
C F correct.I agree in mmisly d ffihe all city aandudience
County e d fico,s and stale laws enter
upon _ -I
(„) the aioinycounme idn,undherr o,Ntiou rairienmtive,ntlhis airy to amerupon -t "
�„I W me eho(We)o''ma",lnopease,ltyfun for In,and
p mons. - It -
p.l (We)agmom,ava in ndexpennek which may
waycCureni,inn aid '
I� Ration Ob n P:ct`f d expenses wh h sy in any way tgninxt aid - • r"
V
City in T of thegranting f his p 1 1
APPLICANT UNDERSTANDS AND WILL COM7LY WITH I AI L NON-POINT Date'�
SOURCE REGULATIONS ' � Issued � � �'•
Signaime of Applicnm/Conmaclnr Data - Re-roofs -
HAZARDOUS MATERIALS DISCLOSURE' s
Will me apedrat or future handing oecapom stme or handle na,.atvon,'6lamial - Type of Root'
ax AetincJ by❑m Cupertino Municipol Cnde,Chnpmr 9.12,anJ❑m Heahh and Safety
Cedq'Science,255J21n1P - -
❑Y b" All roofs shall be inspected prior to any roofing material being installed.
Will the-pu t or fartmeb ding ce,mment ave enrealical or device, hien If a roof is installed withourfirst obtainingan ins ection;I agree to remove
mill d contamn' tsasdefinedbythByAreaAQaltyMagervat P g
Di,Ir I all new materials for inspection. Applicant understands and will comply with
°v °N r all non,point source regulations.
1 have d!he fi,adline,malmills almodulat,order Corner 6,95 if the
hrl
CaliforniaHealth s Safety Code,S 255115 2553]and, aro I d t l m t t
'fthe h lift e t nwhi t be mat t riniou hltyt ify me //`I•�' / `�
ccupam f the require ems which nuxYhe fuel prim w ssI e of a CuI rwm of
- a - ,- Signature of Applicant* Date _
DwnerorauthorArlracer ,,,� � • �a,e ,. - � ^ All�roof coverings to be Class "B"or better'-�•• ee-
OFFICE
1�1 is
x- .