01050190 F CITY OF CUPERTINO .'
BUILDING,DIVISION PERMIT CONTRACTOR INEORMATION:
T,.4
BUILDING ADDRESS: - - PERMIT NO.
10265 Y PL - 010501.90
OWNER'S NAME APPLICATION SUB DATE , it
„ 05/29/2001
PHONE: - - SANITARY NO. _CONTROL NO, -
l.
ne O ARC]HTECT/ENGINIiLR:. - BUILDING PERMIT INFO
BLDG ELECT -iPLUMe•- MECH'
Z m z LICENSED CONTRACTOR'S DECLARATION . Job Description '
O Z-O 1 hereby vElrn that I am Ilcmrcad under promsions al Clmplcr 9(emonaoeing ,
Cw with Sna n 000(Int Dif,idonl lilmR . ::t 11 fnva ,s('odc all li tae -
a ? is ,full fame o d eget � p•/ '-
9 Liwne f 13 l o» IC_y�J��O��y-f / SHAKE ROOF'4'/2-CDXi;erPRESIDENTIIaL
yld3LLt•c. Date �/ RIARCHIR:Cr'sUF.CI�ARAp1UN ��li FINA� D
1 onJemm�J my plane yhull he aced as punlic rewnLs '
Licensed Pmes,imal JUN 0 5 2001
o OWNER-BUILDER DECLARATION
I hereby notion that l am exempt foom the Contractor's License Law for the
whic(:Z a toll g w i ]oil S B I I f. ' Cwt A y an county
�}O min, ,, pe l --s, t h p demolish, p y:otuum 11' -
n.3m
that
li tI cer uv:lnongo resfovision o thehar Central
perm nniceselyns,Clear,
ear,nl v
(containment,
ecemed pSrsnanno fcp 1Divisinf inecnnuactnrs License Laeime,Chadic)
or
Sq. Ft.,Floor Area Valuation
(c that he is a with t therefrom
loan of he l Division 3 of ea Business and Profnny vi cele) .
or that he is exempt fereGam and the avers for the alleged exemption.to Any vitiation -
nfSe more
by any applicant(or$Permit.objects the applicant toacivil penalty It I
- Lir nm n,nre conn Eve nrmdred dance,,rssoB7. APN NumberOccupancy Type
El1,ns owneroflhl propany.'or my employees with wages as their sole compensation, 34PI 807 1 00
.
will do the work,and the suucmrc is not intended or offered for sale(Sec.7614,
Business and Pmfcssions Code:The Contraclor's License Law does not apply to an - Required Inspections
., r of property Who holds or improves thereon,and who docs.such work himself
,hrnugh las owa employees,provided net xneh improvemems arc not mtendel ar ';305•:— FRANE .. -
entered Int sale.11;however,the huilding or improvement is sold within one year of '
completion.the owner-builder will have the burden(it proving that be did not mild lir 307 - INSULATION
improv,for purpose of sale.).
❑I,as owre,of,heProperty,stn cxew,ivell camnefin 601 — ROOF TEAR OFF;
nswm the Ser. r wire licensed wmramati 's —
Ates o face.]fua,nn,let.1 and rmrevelerswhcoin:)The cn,tmmnrs 602 -ROOF PLYNOOD NAIL e
.adwc codoetnIt,,mymIreownerthaco_llrwhonliceseimah,mo to
603 — ROOF BATTENS,
and who contracts lin such pmjegs with o wn0:elnq's)Iieen,uJ pursuant m the '-
1 shinR
Commonest License laws
0 604 — ROOF IN—PROGRESS-
' am exempt under Sec. , &PCfor lom
is ason
Owner r Date � •� ,
WORKER'S COMPENSATION DECLARA'I']ON - -
I hereby nffim,under pcnnhy of perjury one of the foll.iwing declaration,: -
/pry have and will maintain it Certificate of Consent to se161nom for Worker's -
c wrsmior, us inovidcd for by Swoon 57110 of Inc Ichor Code, far the ,
performance olden work for which this permit is issncd. ,-
O 1 have and will maintain Walker's Compensation Insurance,as required by Section
t]IXI of the Labor Code,for the performance of the-work for which this permit is ,
issued.My Worker's Cnmpeusatimt Insurance cehricf and Policy min 1,rave
Calif PolleyNo,7/.3-,,"
10ENU . 3�0
NIPIION FEONMI!51 ' - -
w ' COMPENSATION INSURANCE
(Tnis section recd not he complete4 if the permit is for title handrml donors '
- ($100)or less)
1 cenify flit in theperfcarri a ofthe work for which this permit is issued.1
shalland employ any .on in any manner so as In hecome object to he Walker,'
Cnmpcnsmion Laws of California.Dale • ,
Applicant -
NGrR:E TO APPLICANT.If.afte,making Tis Ccnilicatc LitE"nopich,you should
Ofree....i jee mine Worker,Compensationpommensof the Labor Code, no mum '
. forthwith comply with such pnvivon,a,this permit shall b,deem ed revoked.
z
F CON STRUCnONLENDING AGENCY
a > Thereby nuirm lhi,femisnc..ledSe. 097,Cegwcy fnrfeperfnrmucall, _ - -
of the work for witi[b this permit In ixnted(Sec.7119],Civ.CJ + ^
4 Q lender's Name -
� z Lender'.,Add¢ss
CJ Q I certify flit l have read this appllcalon and name that heshovc information is
:r. cors".1 agree to comply with all city:red county Intense,and sem laws minting -
0 CLI mwllding commmctlnn,Lind michy nmhmizc representatives of thin city locate,upon -
�.-W the alwwo-mentioned property far inspection p r,"is. '
F. 4 (Wjudgmemscostandepeandk which
any
to
liabilities,judgments,cons and expenses which may in any way uccme against said
U y City in ren quence of non gmming of no,amnia,
API'hIC TUNE NSTANDSANDWILI,COMPLYWITHAI NON,-t�OINT
SOURC EGUI ONS. L� =fJ, Issued by: Date • ��
6wmre of A,p¢a mmmor ` .Date / 'Re-roofs
LARDOUS MATERIALS DISCLOSURE UNE
Will by dbe Chca ilir r mm nw,I Cong e'Chico nnre Jr comma nIcahn and
Type of Roof
as Jcifrcc a fc :,,r iso Mu "code,Chup¢r v.l7,ami me Han]tn and&duty - '
ctwe.suran usi7(ro'! - '-
oY, - All roofs shall be inspected prior to any roofing material being installed.
Will the
N'ili appl
nicum or fwurc wilding tccupam ur,mpmcmmdkicix which If a roof is installed without first obtaining,an inspection, I agree to remove
emith h wrmmluntinanR Lie donned by fe iluy Are:,Av Qnnlity Munugmncnt
Dhtdet' all new materials for inspection. Applicant understands and will comply with.'
°Yea "" all non-po' t sour regulations.
I h e d be h ab li t ri I q n t. under Ctr pt 695 of the
California H nh k Sot ty Cad S t m 25505 75511 d 255iq d t A the -
-40
fff h 'Id' he at tlyh rc t In t't'. yr p 'h I'ryt ffy the 't �`
xcp t I 'girt h molwmu p'orm is........c cera Cent cue of - e -
'oaaparc Signature ofAppl' e Date
„
O rvnumhxi¢dage 6.l Dam ll roof coverings to be Class"B" or better - -
f - -
0FFICE '