00090112 CITY OF cu)�PSioNNO
lPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: I'IiRM111'INO,
L71171 rA G 0 1 1 11
OWNER'S sl BITTER2 APPIACATION SUIT DA'I3
(/'��w1 PIIONE: ' s " SANITARY NO, CONTROL NO.
BUILDINC 11110111 Will
.C Z A<CHI'I'EC'I'IIiNOIN13Elf:
O BLIIC ELECT PLUMB M-CH
t,..1
[- "G LICENSEDCONliTRACTOR'S DECLARpP1ON .lob Description
I in"'I"ulfinll 11h."1 aril cutsul uoderpmvisinns of Chap[er'l(enrnnrencing
isl-y wllh Seolinn 9IX10)nf Dlvivion3nl'Ihc liux'mcxs nudl'n,le"ans C'ide,and my lwe'se
"abill bone nnA effect
a i.ioti-Cla" c�3q en=I1G(� SEM TO TII_F_
}�3 nate _VV— S DIXI,AIR
AltClll'I'IiC'I"$❑ECLAIt
5 I uidentand a plum"hell he ned as p.. rca,nE
wY
5 p o Liccnsnl I'ndesslonIll
i' OWNER-ISUILDEIi DECLARATION
w Illrrchy nflirm,hat fact exon,from the Convacmrs Licwn,e Law far the
C fallowlny rea"on.(Serpi..70315,Businrss and Pri lessions Code:Any ery ormnnty
I❑❑ which require,a pBmII(I)constrict,ober,improve,dcmalin,,it rcpnif any stmw
cm
x
We pr t G I t l,lac tf _ d p It II 4.'k I. accent
ILII licensed . tl n I Id c t - 1 ((9apr-9 S(. Ft. Floor Area Valuation
(cnnnrnc tgwlhSriIcan 70(G) If�v's,t3 VI the Btsinesx,il id Pnfe"stun"Code) I
I,,'hall he Is exempt Wn'ofrnm and the Iasi,fir r'he'allegul exemption.Any rolilion
if See,( 70115 by all'."Ibrian for a permit iroBvis the rib,lim Ib at,nd,rahy
afntnmimlhnofiocn ["'Idclkat.($500. APN Number Occupancy yp'e
❑I,is wen"of[he property,or my rmpliyee"wllh wages m for.,"ort eompmwdon,
will I d k d IIII,not I I Weed for a (Sri.2044,
Bn" Profession,r c Il .0 t- t r it 1 1 t pply I,,air '' ," 'MIM, ed Inspections
nl pram fy Who bt Id"t I peters d eon o: d wh, w,s ch work IM1mself
or in 1,his not en,ploycc,. owidoltill anm'llnprovemenm are nil illicit or X05 _ FRAME
offered lit yule If,hind r,the building a nim en Is sold within line yell it
"col,......,d.I�(wis"Willd" ,I[have thethalyd,n orla inb mal le did It(,hll lel it 307 —' TNSI_II_RTIOIEI
❑1,anawaeroffire pnopent.'ImexnelsmelyeantaelmRwidlu nsedrinlmrti ti 601. — ROOF TEAR OFF
shier[he project(Sm.7094,Business Ilan Pntfes,ienv Cade:)The Cintatmrs 602ROOF PLYWOOD NAIL
License Law does nor td,ply ,,an owner o1'properly who hailds or inyances Ilawor,
and who cI foo, for such prole''ts with a roto onandJ licensed paromry li the
CinlrrOaa.l.beiseLaw. 603 — ROOF BATTENS
❑I am exempt undcrser. ,R&PCirnd"Irma" 604 ROOF IN—PROGRESS
Own Dom
WORKER'S COMPI NSACION DI CI ARAI'ION
+i ellsIll I will
I P '11Y f l U l Y f ll b l r f Worker's
or
❑ ol
L d 'll t C 11 t 1 3 di s t t If' f W k is
Cn 1 t d l f by stricter 1900 f e C fartea
pct Irl work for whichthis I 1.
❑IIwill 11 W k C C l " ire c k f Ilysection
4200 f d I h 'C Cd f d 1 i I cIII are: is
port l x
.0 d MY Wnrko'n C p� sit t r i euro and Por r h
Corder'. Poll,No:
CERPIEICAI'ION OF BxB%B,'fION FROM WORKERS'
CO\11'ENSATION INSURANCE
(This sermon crud not he completed If the Permit is for ant hrmdned dollam
($I00)or I...)
I certify Bill in the perfor"m"er it the w'mk for which[his permit is issued,I
clad not contrite'Illy persan n any mums"sots to hen rte suhfep m Ihr Worker,
Cmnpcmntinn L.ws n(Cnlif nlu.Ilam _
Appinne
NOTICP.'fOA I'I.CANT:Iffmr inning Ow Cmvifio ofEmnlptinn,you 11 Id
hewn,whjen to the Worked.Cooll)Ci inn provisions(1111C Liar Code.youImnt
Q I'I n orilh ran,ply with milt provi"inm or WLs permit,hull he dermal rcvaked.
^ ti CONST RUCTION LENDING AGENCY
7 I hffi
hereby affirm hal[here is II cnnslnlclien I rdn"I'linry tile th
e"U'roc nc,
W of the work fnrwhich rbie p,I it is Icwed(Sec.9097,Cor C.)
Q I,ondor'e Nmne
z Lenders Address
I renif,'hill 1I ad thisLlILL! anal:I'I II'Id ;thoseI II -.
W ty
correct.1 g t >mlly thin city and I) 'I' state lawc
OU toh 'Ifg Onsliri,IunI,andlc,h)udnl nepre.ed.tve'al re's sly Illemr span
y W the'Ihive-nmatloned property far ropectlin primases
ti by
(We)..... ,,soon.lndci.riJy indk - I "litscity ICI t aai
V1 Ilnb It dg Ix,, t d p ." 'Y't nnY Y Lelinst aid
U z Co' ofd y l this p
APPLIC UN ERS ANDS AN WILL COMPLY WITH ALgqf NONPOIgNT ISSLIed b
Iti SOUR E L TI( by: �� Date / V
s'Ignnh.. of A.....r mrcanmaem' Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will'lie apphram ar fmare b[dhfmg arinpart"bon or handle la.emanxm'Ileill Type of Roof
Is ferried by[he Cupertino A9lnicipal Code,Chat 9.12,and the I Icahh'Ind Solely
Cod,Serlion 25532(a)I
❑Ye. _ ClNo All roofs shall be inspected prior to any roofing material being installed.
wW it,,applita I itrince hnddingo,,r,i rise er,nipmeanrilea ire5 w I,i,h If a roof is installed without first obtaining anins inspection, agree ree to remove
amithamNimair emlamica.ka,defirsd by the Bay Arte Air Qa'elity Manlgomrnt � P
Di rimI all new materials for inspection. Applicant understands and will comply with
�1 ❑Ye5 0 N no - int source regulations.
I 1 the l 1 1 1 ts Ch 6.1) 0l'Wr
C,lil Id &s f p C l cl' 25505 25511 d 25534.1 t ¢I War
'flheb 'd n shi t [ that an y .I or:,c cent, r
oeee b he e l Lire is wit ch nest l t pran,to toy ri r C v'fel,tor
he
Qp� Signature of Applicant Date
owner ,anW.....I apet Ate All roof coverings to be Claes "B" or better
OFFICE