01040126 CITY OUCUPERTINO 2
nuti O NG DIV SIOr PERMIT CONTRACTOR]INFORMATION n .
BUILDING ADDRESS: e PfiRMII NO. -
OWNER'S NAME: APPLICATION SUB DATE - -
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PHONE: CAREBS BEI 'I. 1=AP-191' SANITARY NO. CONI'ROLNO
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- BUILDING PERMIT INFO
O O ARCHITELTIENCINEER: - -
L. ' ' - .:BLDG • ELECT, PLUMB' MECH
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Z ,ICI NSI ll CUN I RACIOR S DECLARATION .. Job DeSGr] tiona s'nZ ` II hY'ff fotI J J p tCbp, 9( b - v p v.
s, w,IS I 7nNE fD 3rfthe B IP t :Cd dnyli •.
4 t o Cleo,ander i 3 L a S +�-� �'' "+ ).
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Dal e„trnetrr RE=ROOF_ .
w RCHITECf S DECI ARATID
1unperson1 ypl h'rb d pbh' rs rd: , ,4 A s _ e • J
tau p O Lice d Pr I '. nal - , ♦ •.
S m OWNER BUILDER DECLARATION
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u7 1 h hl off that 1 son uset , fin,C r I . LaaanW Law f the -
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followingreason (Section 7031S.Business and Prolusswas Cod Any city or county
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which a,uiu,,aP t le construct. It P e,deardish,or repairany sh' Ire
opri t t '. 4 :Ih ppli If cl pc tl, Il a.'g I ,mnen • • _ .
a3=
that licensed prt I he n t l 11"C"alort'ars,License Law(Chapter9 - Sq. Ft. FloorArea. " _ . Valuation -
(comnmu',gwith Secfot]Boot of llivis;nn9 rr the Pt do and Profes�rns Crde7
or that he Is exelapl Ihcrefmm and the basis bathe alleged exciaptioa Any violation _ - -
ofSeclit7P319bynY'PPItf Prmli:bjmB iheappl cammacrv'I penalty n ... -
rrnmmrrem,nrvo-h ndredauham<&sIn) APN Number s :Occupancy pe ,
❑1 - n property, ) PI Y ''d b P t . ' L
will d IM1 work,
I thestructure ,
reended I e fl J f -I IS ](WJ .t—
n,: d 1 r : n d rn c t t I 1 "d Work
hit,an egmred'Inspections -
nwncrofproperty hhisow 'i l Id. I ,I d' d h tehpolor
istnuelf
hmi gh his rxf.enply : p 'dc 1. I ' p sold
I' t leder
' rrferca for sale Ir however,me building rmpn,wmLm I old who,n me year of 305 —' FRAME '
Ianpleaon,me owner-badder will have the burden of pmeing that he did or build or - . 307 I.NSIJLATION
mprove for pgipoge of pale.). 5'
❑1•usownerbnhe prdper S air,exclusively contracting with licensed eva racrort to 601 ROOF• TEAR OFF ,
.. Lr .t the project Bee,7044.Business lP f ,mase 13rn a,mmeioT. 60 — . ROOF ,PL•YWOOD NASI -
i I I : tapply I of P Pry 'h h Id. inferiors mere.. ' � 1 pe '
and n t t:-r h p'peen, wd ornmetoas)licensed parsyam to ate 603 — ROOF E•1ATTENS'
Crn ti
❑I,rp p, nderSite. B&PCfmmitmatrn F04u ROf]F.nIN—F'ROl;RES5 :
Bate
WOR KER'S COMPENSATION DECLARADON ` "/r' '
a.I licmb vfdnn nouns h 1 mr ur one of IM1c followin leclnntlians: � �•t. -
_ ❑ I h d :II uWarre.Connfiesne of Consent to clf-ir,airefor Worker's
�. Cupp t' ' provided f by Section 9700 f (he Labor Code, for the
perficaparre ol'tl k for whichhis ,is issued.
4
❑Ihave J Willa, t W k s Convacirstrion Insurance, required 1yS ,on r' is �. .
3700 of IN Labor Cod for the perturrience ot the k for whichthis pernat is
as d MyWorker's C p ion lasuratice c arrier and Policy number sure. Y _
Put 1 NoJ7tF �ir IATIONOFEXFh11IOYP ) DD ��• O
COMPENSATION INSURANCE-
(I his n need noth mplet d if the period . f e hundreddollar, - v
(SIM)or I .') �� x.
I tvrtify than in the Perron re¢e el tl link lar which Ihls perri t-e issued,I- _
shall not employ any person in any mnnncr co it,no heaxme ahjea to the Wod.ers' - -
Crrri,r aeon Laws of California,Date _ -
APII , -
'�NQTICEIOAIPLILANI If,after rk g thisC tf I of Bxcnpton you l ld -
xbc hl a Ih W k C pc , p ns of the Lthor Calc you oriel _
rouhwt0 comply with such pravidon.surthis prior,shall be derntN rooked -
u
FSn •"x CONSTRUCLON LLNDIN(' ENCY
I he by drurn that th sl Y I d'ob tb n Y Far the perfo. unce , 1.
W ofd kf hwhthspemtl's seicd[S .Puri3Or,C,) i 1
Or 0. Le J Nature
z .Lend 'Addcw �•., s.¢ -
0 I rfly
, a ,lh dlhis'MI J,n'cAal h 'M f t s
cI Iagreei entirely J Id sold I Ig
tobuilding f dhi b su Pe ftl . tYt tupon
the h e I I property forinspectionpurposes,
' .
P+. fW) b , d rY dk ph y i,I C,y sCPn 6 sl a - e
V] hadCit n s•seq nese ,. 1 expof this
h 1 ray-n vry y xenv a6dn t tied
U'Z cilY i,cons�nz,ktnn Staining ofm'pe"ardt. ..
APPLICANT UNDERSTANDS 6DP WILL COMPLY WITH ALL NON-POINT •' Issued �� �I`-l�J" Cc; Date
SOURCE RE .ATIONS y•
c/-2 S-o
$Ignal n APNicam Cana cwr Dam Rei-rOOf$ s '"
HAZARDOUS MATERIALS S DISCLOSURE ' r '
calla appuc t future baldingoccupantstoreorhandleM1�tionsinternal- � Type of Roof
4,definialbytheCat f Marici,col Code,Clrpir9.12-and the H all,wad Safly - -
Code,Section 2553201 so
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Dyes If< All roofs shall be inspected prior to any roofing'material being'installed.1
W11 m ler= r I en 'las "p t eey'p t -1 twmen If a rcof,is installed without first obtaining an insp'e tion; I agree to remove
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cath "Rus trc t9non r def dby the Buy Are:A Qualry Mragement pp
Di t ct. all new'materials for'inspection. ApplicanCunderst hds and will comply°with.
Dyes "" all•non pots[source'regulations.
1 have rend trip ho,andon,onalonral, uproarious ander Cluipar,695 rf the Sst. ,.
Calilarn'a'Hedth&Slty Code Sinton. 550525533and•55341 understao'dthat k •t�< _ '
if the n ldingdoctor,curreally based Error,that it is daYne,car,ithiliqu,truly the
ecu pain of the requirements Which nt st be ruct, rno issuance f a Condrettle of to
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"`1'a"`y 1 a Signature of Applicant Date
nei rr amrdeed anent Date - � Al 1.roof coverings to be Class'"B" or'better -
OFFICE
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