00100028 t: CITY OF CUPERTINO '' '
BUILDING nlvtstoNPERMIT CONTRACTOR INFORMATION:
",. � , ,• `,
BUILDING ADDRESS .r < PERMIT NO.
AIPA . T$
00�8OWNERSNAME' L
1.8901, ARATA WAY
PHONE '+ - SANITARY NO. ��/oQ'AM$<L�
KZ ARCHITECTIENGINEER: '• `. - - BUILDING PERMIT I'INFO
.1 0 0 < ,'... +• ;•", e. BLDG' ELECT .PLUMB " MI CH
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LICENSED COTORS DIir AItA91ON I
Z 8 PhYRtI that Iedowd p . nnr* ^4 JobDescription'
OZ0r '
hmGm
,illb Serum 9000) fF A faheBu d Profc.s was C 1Jmyl
a Ea n
isrr "'ad -
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o Dat LlQW 4� c #nae CLl1 �
QQ ARCIIIILLTSULCLA ION TAR AND• GRAVEL/BUILT UP ROOF..
C I understand my platy shall be rie .publiccords'
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pO ^Lit d P fess oval L to r. %
OWNER BUILDER DECLARATION s ;
w M i h 'hYff that l pt f tile Contractor L L .f the
s. ( '
Zj< toll $nehapa.(Section 7031.5,loond,,mul P-less Code Any da,.nir could, tt '• - '"
+ $S❑ which requires it permit to consound, Ito p demplish,or ri'annuary someard
-�+a prior to its':: n I q the ,fictud fimmeltmar,Tofile rognal,alardidem
math licensed p in In dooi,moseln c t t License Law Eparther9, Sq. Floorrea - Valuation .",
(ca never,with Sec1ni 90rP of DrAk l if the U ` IP nisCaysCode) At -
orlhathe is exemptlh r and f Thealleged ft A ) oft 1; I- t ' •
ofSection' 90315 hY' > pqr a thsrup t;uh)eclsthetpPl' at ac"1p Ity
'
ora amenrten 11dut,(xsnrn APN Number Occupmjy5b66 _
DI as 'r orfhoproperly."ayemployee.with will u.(her, lenancrrton 5 0� 1
It, will do in, k d tl a ct t d Joffered f (See.7044
lax 1 P .fCode Che c t' a c ':e I d t pply t R red Inspections • -
owner of praperty wh n Id: p m n ,ad wh+ l e; k n Ir , 37912039. 11
or through kilt awn v a,layees:pros ded Illa,I'-u n improve attend n t mended or, +r
�iffem4 fit, hit.Ir ha,rom,the nu'ld'nb p ens I Milhintanti,cor up -
' completion,Ili bill Ill tireborder timingfthtl did- tbuild d
mp fparlmn,plied.). 105-- FRAME "b
El 1.a 'tie nnep pet, 1,contract, ,I licensed I; t t f c,0? — TNSIII_Al TON , t .
nit i the project(Sec,70TI,Business rindPf. :ca )Tlcnoaetr " Ea�1 " ROOF TEAR OFF
License Low does no apply in art owner,of•pmpvny who hudds or'aprnves thereon '
and wha contacts for eh alts wird a amvacrnh,. licensed mt to tire _ •'1
Pml ) Porsu �� �
F.
Comraemra Lce+aae Law, - - 60ti :R00 PLYWOOD ,f.lAll +
(lam e,etnpt aider sea. ' .. B dcp C lar tis reason .-`603 - ROOF BATTENS .
owner Date 604 ROOF 'T,NI-PROGRESS .
WORKER'S COMPENSATION DECLARATION
r �.
1I ny upon r tic,parmlly ofPscilm,due it (he following dP t + I
O I hilve and 4 ill' ntn a Cenifilne IT Crold,t t If for N k p'
,c
Compensation,
aas. p d I r by S 3]00 f theL bo Code C II
pert r,
sa k l h 1 th''p t 1
+rJ 1 Imvc and sill maintain W rkcry Cornpersalman insurance,it,rec,u;'Al by Section - • 1 �+ -
f •
1
.. r'
3ZIN1f the Liber Code,d m performancef Ili k i h Ili. permit Is -4 - _ ' '
' ism d.MyW rka'tC p': I' m u
nlnsuund Policy it
r/-
Policy.No.,.
C l I I A IGEN OF EXEMPTION FROM WORKERS' "' •t •t r e ' '. [
- COMPENSATION INSURANCE -
IInstettnnneednetbeconfinedifthepenalas'rnr one Trial dollars , . bf - - „
($H%p or less) ..
I certify that in[lie performance of the work for width Ili.permit is issue(],1
shell not employ any pe,vor in any Town bee p subject to the Workers `
Cana'asufon Laws or Carf [)aid ...r, v • `'s. �(
NOIICLTOAPPLICANT If.after inakingthitCenificale atP pI' y h I_d
becratic ml,jectt the Worker,Compensation p '- :(if the Labor Crude,you rud s
0 Q ford 'tl emoply with mch p a m.mis parml,hall he deiialind accoodd.. - - l S r - n 1 nv
Z
CONSTRUCTION LENDING AGENCY _ i
I h byhim tl this nPermit .duct a lending ago )f_ d e Performance e,q
of the work for whichperms issued(Seec r 3097
,C C v C)
a5❑ Lenders Name a is ' ,,, ,
� z. Lender's Add
x.7 0 1 t'ify that I face rdidth' pplet t andart the(theabove information
called.1 agice to comply sith all city and county ordirande.,rod sonelost, eltion, r ..
C V ab Id g n...clim,andthereby l el lfrcx fah ety�.door upon
.�.(.W aneah tidp pc IyI 'tp i ram r
�.I y (w)agreenify and keepl I ;stheety ofCI tagainst'
LI V] I indifitics,jid,ral is -d IA,In...which nnY day w t t l against said + -
V Z City' asequence of thegat of thi.pee n(t• -+ . •''..
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT �M ( I' J
URCE REGULATIONS,_ OO .+ Issued by. $"•� '+ Date O `` _v
S'gi'are pI a nUGhn a - .Dae '. Re-roofs
- HAZARDOUS MATERIALS DISCLOSURE a ;•{'Will the until'dal Rorie n 'M' 6 P t.'I dl ha N .rbllrh tl Type of Roof
•' nfsd •d by the Capv in Mncpal Code.Couple,Jl2,a ul list Health and Safety
Code S t m 25532(.)' ' .- - ', - a,
❑Y ❑No All roofs shall be mspeoled prnor to any roofing inateriafbeing installed.
••
Will tile applicant of lame h'Id'y occupant a,,,
ocau,nowat tee'c,,which If'a'roof is Installed without first obtaining an inspection, I agree to remove
Dour'L .N (.at,cool t' os defined by alio Be,Ares Al Gamily.Manuge en ,
Dlzt to - all new materials for'mspection. Applic`anf i'ndersta,nds and will',comply,with
1 111 Yes - ON. .
all_non-pointsource regulations. -
I h� I e h d orders], y - t d Chain 6r95 f m r`
.
CaliforniaHelth&Safety CodSe 1,25505 25533.,ad 25534redoundtl t - t
ilhcbuilding d : ot rmHhave tn tenant, ril myresponsibilityt ify th 5 ;7,6 19
occupant t f th require t lien oust he et p r to iss f a Cvnll wt r ( (/
- Ocepp ncY' r T
Signa of Applicant - - Date '
Dow
n inmoa:ee,gput Date- All roof coverings to be Class B',or better
OFFICE7. t,
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