00090111 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUI ADRl ADDRUSS: PElthll r NO.
OWNER'S NAME. O'Ju .O:a ST ITERAPPLICATION SHE DATE
rhyl — ANDjEANSANITARY NO. CftN'I'ROL NO,
O O O ARCHI'NICUENGINEURI BUILDING PERMIT INFO
J p IILUG Ii LPCT PLUMB MILCH
ilii I . J 11 11 I _I
LICENSED CORTItACIY)R'S DECLARATION
z 5 V? 1 herein rant mat 1.am seen.,,rimer Job Description
O _O >° Provnlrm,of Chapter9rumm�lent
F�Yt�s with section w3nB)nr Divieion3oftM Bntsinusnd s aPnducinm C<tdu,orifimy license
d in full force om(1
i:ieen.ecla°. __ REROOF/CEMWOOD TO TILE_ ADDRESS;
3 IL
2 N D;nc GI CrnB;ado 1
G / \RCHITIiCI'S UECLA
t=°I T understand my pan.,nett rte n,m n,pirate reeotd, 10913 y 10923, 1.093 BITTER OAN, ST
aadq
ad p O I.ieene d PI'ofcsdonal
yy OWNIiR-11II1LDERIA LAItAI'ION
W Iler,by:dBnn I'm I Lou e%.mpl�ou9nm thin Commclor's Lice....Luw for the
m
C a followinguires a I Salon 90315, t.alie.improve,requires Jemoli.h,or rtpair any snuclurc
c. poo l I 1 q m (Lor tf hpv to 10 t Law
wA Gatement
bar he f II 1 m n a nn < t .t m L l—illi, vd.) Sq. FI. floorArca Valuulion
Ica cl8x'alllh n 7000)frand mcc liaot fo amu❑......... dlor,Anyv i Cndc)
:flew he i. nnrl any applicant
and the haul.hmhe ullegnl mpdon.Any l"nail,
of not co thto iv my drNicnm Inr n ponnil suhjec0 me mPPlicanl w II civil Ixnvlry
nrnminoremanrvenmtdrtddnllnt�IsslxlL APN Number Occupupcy���e0
01.n,ua nIr none pntpeny,it my InTph yees with„age,a their rile cI i,cmwier, S I
w,It do lho ork, I.I lh bacIre.11 11,11 uncludrd or ollered 1c, I Lace 9044,
Balincill HalI C IleCon1' 1 '1 ,ul 1 1'pplyto 11Be L I'ed Inspections
w i p p p WE,1 d I p he t who d work h malt 3265101 . p
nil than Sh his oxo enygoyeeu Provided that such improvements am riot intended or
offered for role.U.howcmr,the building or impowcomm is sold within one year(if
completion,the owner-milder will have 11th buNen of proving that he did not build or
ar ctarrltmr,eof%ale.) 305 — FRAME
❑1.ni,owrmnnhel,tnpnly,aIncwlllrieelycourn gwithreen.nlcoamnmsle 307 — INSULATION
,ads,...t the pmj,O(see.)IW.Ba,inm.and Pnofcs,ion,Code) He Cmnmem,,
ueen,e Law,does not apply to an ox ner of property x no buildv or improve..mcreon. 601. — ROOF TEAR OFF
and who contracts lot such poleen wish a commctor(%)licenced pursuant to the
Comamor,LEloll LUw. 602 — ROOF PLYWOOD NAIL
01 wit c%rano Urd.r sec. ,11&P C Bn rid.rats.... 603 — ROOF BATTENS
oxncrhale
WORKER'S 101119?N'SXFION D17CLARATION 604 — ROOF TN—PROS
I mischy Riffilin andcrremally ofp,) y one oflh follow in,declarations
I k,a cid ''ll 1cill a L ,Sec IC tt L' . I Wokhe
ri p i I' I I n' Se 1 t]INI t the Labor r C I forthe
pen of wont,In, n nm' permit'.' I.
011 d 'll - tt Worker Cmb 't I . c y 'rclbySeton
3900 or(lie La or Code•dor the perlmtn cee or the work tor which his PbTruo ie
alma.hly Wokcr.C,)rrcr.mtion Insumurcn wrrmr-Lid Policy rarthn amu
Comer'. Pok,No,:
CERI'IFICA'NON OF EXEMFr10N FROM WORKERS'
COMPENSATION INSURANCE
rill,,,action ucml nal be conullbod i1111e pet mil ,furore handed dollar,
ISIUfp or lesv)
I.erl mut to the per6r!name of the work for which this pencil is ismeJ.1
,hall not employ my person in on,moaner xt t.to orT H Ila die Workers'
NOICamCnwllnn l�G,tCalibiyl '!_1
NO11CI3'IU A C1,n1171{ knug lbo 11,11 E, tfxe p�L unn,yrni shuul:l
Mcnmmnhjc'I m the Wunkm's Compmn.omm provision,of m.Labor Code,you ma,,
O forthwith comply with such provision.or mi,permit shall M1c deemed minted.
F ti Chat h,rc k a or,LENDING AGENCY
a I hcrchy whorl 1hi.Ihcrc is,am,d(Secb Icrding agency fa tire Perlbnnancu
D7
of 01c,work lir wlticlt this pcnnit in Ix,ucd(Sec.3097,Clv.CJ ,
F Q LCWar' Name
5 J I,cnJcr',Address
U O 1 certify that I have mid this oppGcutim and stale tka the above imbrication i.
ran.I agree to comply whh all city and courtly rMiramc,and,lam I.iw,relating
0 U m hudding,rnsnacdon,end loch,1w1[ lie rrnnesc...I sr—I mi,cry ,,inner opts
rW Inc anovc-tncrlionrd Pmlwrty for n,pcmlon Imlinama.
t..n M. (We)name R.,.vve.iademrlly tad keepInroad...ate Cloy of Cupertino against
V) Eanihtic.,iudgmems.r is and espcmo xhieh may in raywas ac
_ true against aid
U L City in[orse,geave of the pranging ofthi,permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ,a..••tS__``
Isstle(I by:
SOURCI7 REGULATIONS. Date `�vv
Signalum of Apthe,mUCunaoclor Dum Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Boom building occupant store or handle hams material Type of Roof
as deoncd by the Cupauina MuNcipnl Cnde,Chapter 9,12,urd the Ilcallh end Safety
Cad.,mead....255]2(00!
F3 Ye,
FJ Nr, All roofs shall be inspected prior totally roofing nlaterkil being installed.
Will It,appEcamnrhome buddinoccupant a,,cgni rrmaI,,dcvicesxInch If a roof is installed without first obtaining an inspection. I agree to remove
it harardon,air nttmmninnms as defined by the Bay Area Air Quality Management
alrim'1 • ew Ina for inspection, Applicant understands and will comply with
�t
El Y,, El NFL) all mol point sot ce regulations.
I for"read me homNor,ntmeriuls mquGoni.m,under Chain,.6,95 of the
C.alilbmia I lcalth&9mtety Code.Senium 25505.25533 and 25534.1 understand tem
ifmchuiId' .cromaly have amu.ant.that it is my rc,ponsinility mnotify the 9 Y U
ccupvn t the re irenlcut,which rants nc met miry or issuunee of a Certiliaam of
Oacuplmc
�� Signature of Applicant Date
owns
rdAL tie crit D;n,e All roof coverings to be Class "B" or better
OFFICE
a11� -