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00020162 CITY OF CUPERTINO PERMIT NO. BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: �/.t 1 02, 0/ 6 2s HUILfU1� y�L55: .ISI �I// 7 •�•/' T�Dp �p1 IN .A..,N SANITARY NO. APLICATION SUDMITTAL DATE OWNER'S NAME: //�� i.J L> rHO Y��Ns Y—•'r�� 77- SAL � Z3—Z UPJA • D -P N/C CONTROLN nAyjtq ON^ d ARCHITECT/ENGINEEREUI,0 NO NliidM l'1'INTO N ffi xZ' 1:. LICENSED CONTRACTOR'S DECLARATION Z4 Z_ I hereby affirm Net 1 s0)licensed under provisions of Chapter 9(commencing Job Description gxwu with Section 7000)ofDivision 3ofine Business and PrnfeadonsCafq ape my license is �l— - /� a� /�,, in 11 force vpe eRecL 8 690 3a'1 ARl�GI.T W151A, 4 CJ1 l �1l>D 1� I-st..�f //F . z O Lienar Class Lic.M y ct a y Data Conv¢tor ARCHITE S DECLA TI N landau ell used P li � nn [s / 1`Ra o ° u npodaumona a y OWNER-BUDDER m the Cut.., RATION ut.. H�u, 1 hereby aRm1 that 1 R-uel-D from the Cenuaclor's License Co.for the /l KO,•-Wl tl •�•'1 n F�.gY;ftfC�i//'_� S M following reason.(Section 9031.5.Business end Imitation,Code:Any city or many if m which".I.es a permit to sca struck,that,improve,demolish,nh top"any svuctwe— It.,tonai,a......Alan"oiresthe applicant for such padNl to than signed statement Sq. Ft. Floor Area Valuation that he is licensed pursumno tie provisions of the Contractor.License U.(Chapter 9 V 000.bb (commencing with section 9000)ofDivision 3ofNe Basmaaa and profession,code)w ane APN Number Occupancy that he is exempt therefrom and the basis for the alleged exemption.Any violation of p y Type Section 7031.5 by any applicant for a pemdt subjects the applicant to.civil parch,of 3 6 V not more Nen Five hundred dollars(351113). ❑ Laanwnerermrprnpertr,RrmyempmyeeswiNw.ge,nmrhealernmpen,a0nn. Required Inspection,. will drone work,ane the he Cont is not bmm�d u,,Taw does forsake(Sec.]oa Business and Ay wh ons Code:The Contractors Lianse raw does net apply s lf owner of property who builds or improves machin and who awe ns n tine deed or orthrough his awn employees,provided that such improvements am not intended or oRered for sale.ghoweventhcvildingorimpmvemrnt that he id nnneildori provetfomthe Pon- go. if alas will have the burden of proving Nat he did not build or improve for Our- pose of sale.). ❑L as owner of the pmpedy,am winds ul conRacting with licensed curtroom- m a me La the es not (Sec,o an wneioess rope Profusions Code)9Te Convertor's Id- who Lata does not apply a an owner of property who mild,or improves thereon,arta a who ret for projects with aconvaemrfU licena purauanuo the Contractors ❑I P[ondcrSa. &PCror Nis rcurn i wn I / NU a b T�b ORKEIRSCOMPE SATIONDLCLARATION 1 hereby el(rm under pendtyof perjury one of me following decluetiotu: BUBO f-"N ('� I have and will maintain.Cenifcateof Conservt m self-iname for Wwkera Compere U I�w\\\\IIViII as provided for by Section 3700 of the Labor Cade,for the performance of the wwk for which this permit is issued. ❑1 have end will maintain Worker's Compensation Insurance,rs required by Section 3 airier ltkheyLabo�r pCgak,for Ne pertormanro of ole work for which this permit is ismeJ. Cannan Co. .satin .mr.camcr.irNoyy 5 w1-98 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This rem uul.nneed he perberomto of wanerk for which one hurdled anmars(I holt �� r� r-s r-•sO�a�--�D or lessll cedifymatintne performance of 0)r work for which his permit is issued,l anal) not employ any person in say manner an as to became subject m the Wwkma'Compen- sation Laws of California Date Applicant NOTICE TO APPLICANT:If,after nuking this Ceniocate of Exemption,you should become subject to Ne Warkcrs Compensation provisions of me Labor Code,you must forthwith comply with such provisions or this permit shell be deemed revoked. CONSTRUCTION LENDING AGENCY 0 Q I trrcby affirm Nnt there is is constomut lending agency for the perfurmanceof ti the work for which this permit is issued(Sm.3097,Civ.Q [,.,. Lender's Name F( 7 1,ander's Address W 0 I certify that I have read this application and state that Ne above i inment on is toren.l agree m comply withsll city and county met....is and,tam laws¢bating m Z building construction,aml hereby authorise representatives of this city to enter upon the above-mentioned property for inspection puryn,es. W F~•1 (We)agree to save,indemnify and kap harmless the City of Canadine against C) U liahiho's,judgments,costs and expenses which may i n any wayaccmeagaind said City >a PW. n cnnmquence of the granting of this permit. LAPP ANT UNULRSTAN SANU WILL C( WIT( A.L NfIN-Pf11NT V z ] RCE RLGl11.AT10NS. _ ig tare I' pp icon n Ra or m HAZA0.cumeb MAT IALSUISCLOSURF. �—Ig•u� WiOy eCarrilo.Future buildingrics,Chaptatoreor handle Heatdnamamnai Re-roofs as defined io the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,swrnnzss3z[a)? Type of Roof ❑Yes Willthe applicant or future building vempant.,a equipnam or devices which All roofs shall be inspected prior to any roofing material being unit hisaodous air contaminants as defined by the Bay Arca Air Qual lty Management installed. If a roof is Installed without first obtaining an inspection Ira'""' �,/ I agree to remove all new materials for inspection. Applicant ❑Y<s d I have read Nrhanrdw,mamwis regmm no pta 695 of the Celi- un erstands and will comply with all non point source regulations. I - Health&Sefcty Code,5 ns 25505.255 ehstandthe if theinkling does not cuorentlhovccn.tea it ismtonotifythanixopant pre rymremrmawmen mud . Team of Occupancy Owners a dna ate Signature of Applicant Date All roof coverings to be Class "B"or better OFFICE APPLICATION FOR CITY OF CUPERTINO NUEIRI IERR— 5455 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING tADDRESS IOL 1 v t �/� � RESIDENTIAL eff:!E COMMERCIAL OTHER OWNER'S n HAZARDOUS FIRE AREA I� .A -)el �� Y ., _ 1 `` YES ❑ If yeas I understand that. Class A NAME_ / _V� �^��--/ roof assembly is required. NO ❑ Inlital I.C.B.O.tt ADDRESS/ �$ 'q`'"f i�5 ^`�� iG`)`L-Y EXISTING ROOF COVERING PHONE "v _ C 6 — S `O�� NUMBER OF EXISTING COVERINGS I CONTRA--ChT�OR'S pp �� //�- NAME ` FM Utl'-t� rye,C TO BE REMOVED TO BE RETAINED C TR&ZIP ��3 S' 7 e s — S . - CA , ?,T(/ Z TYPE OF ROOF COVERING r XE ISTING PHONES fiJ 77 /-73-0' ( �n�UILTT-0I&OF f)I'- 1 '�❑`moi�r+, LICENSE C�tC.i `"' v� Vv j NUMBER ASPHALT SHINGLES"`' t ) i LICENSED CONTRACTORS DECLARATION C^> I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect. C -3ElSq O�O WOOD SHINGLES License Class Lic.Number Y or- Date Q `j Contractor +' 4` C— OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the fallowing reason. (Sec.7031 5,Business and Professions Code: Any city or county which r construct,alter,Improve,demolish,or repair any structure,prior to Its Issuanc o require yl(I� PROOF ❑ applicant for such permit to file a signed statement that he Is license tl urs"a j9 he proykiyk\ of the Contractor's License Law(Chapter 9(commencing with Section 7000) 'y i Islon - Business and Professions Code)or that he is exempt therefrom and the b 8 r the alleged AS LT SHINGLES exemption.Any violation of Section 7031.5 by any applicant for apermit sub) is ea ito a civil penalty of not more than five hundred dollars($500).1: //jj--�� 1 �� ❑ ❑I,as owner of the property,or my employees with wages as their sole c pensatlon�wID d� 1 SHAKES the work,and the structure is not Intended or offered for sale(Sec.7044, nese and Profes- sions Cotle: The Contractor's License Law does not apply to an owner of p party who builds or W SHINGLES Improves thereon,and who does such work himself or through his awn emp provided that ❑ such improvements are not intended or offered for sale.If,however,the but I � rovement Is sold within one year of completion,the owner-builder will have the burden ErjRlfol R(SPECIFY) ❑ not bui Id or improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O, REPORT NO. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS. I am exempt under Sec. ,B 8 P.C.for this reason Owner oats WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: / ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building as provided far by Section 3700 of the Labor Code,far the performance of the work forwhlch this g pe Il to issued, Q(J(� Seismic ,p have and will the pelf Worker's Compensation the wokfor Insurance,as required by Section 3700 of / ti.§Labor Code,for the performance of the work for which this permit le Issued.My Worker's 'Compensation Insurance carder and Policy nu bar are: Total 5Y8 , Carrier_s? f � ie; xl �� Policy No, S7t—?7 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.O (Thos section need not be completed If the permit Is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit is Issued,I shell not employ Y` any person In any manner so as to become subject to the Workers'Compensation I awe of Cali. All rooi shall be inspected prior to any roofing material being. fernia. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP understands and will comply with all non point with such provisions or this permit shalQbe deemed rel source regulations. I certify that I have read this application and state that the above Information Is correct.I agree to comply with all city and county ordinances and state laws relating to bu I ding construction,and All roof ��S be class�or better. hereby authorize representatives of this city to enter upon the above-mentioned property for in- spection purposes. 3 (We)agree to save,indemnify and keep harmless the City of Cupertino against Ilablllt.... OV judgments,costs and expenses which may In any way accrue against said City-consequence of graining of this permit SIGNATURE OF APPLICANT DATE PRE-INSPECTION: PLYWOOD: IN-PROGRESS: INSP, DATE INSP. DATE INSP. DATE TEAR OFF INSPECTION: BATTENS: FINAL: INSP. DATE INSP. DATE INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE QOPY CITY OF CUPERfINO e i" ' = rI PPRrPNO. BUII,DING DIVISION' PERP I fONTRACTORXINFORMPTION; -`,' M BUILDINC ADDRESS: +f _ SANITARY NO. ,V11'LICAPION SUBMITTAL O. OWNER'S NAME: NIC CONTROL# / PHONE: ARCHITCCrIENGINECR `:.5"( �'-•kBULDING PERMIT INFO j FL� <y NOTES �sN< Job Description ,/ J m6p0 f �r+( � jl.t \tet . •l ., - 'I 6 a Sq. Ft. Floor Area Valuation a3_ / APN Number Occupancy Type �^ I Required Inspections C� �C Z4 z ° a > Aw � z U O OU rn U Z Re-roofs Type of Roof All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection I agree to remove all new licant understands and will comply wmaterials for o nt source inspection. p rgulions Signature of Applicant Date All roof coverings to be Class"B"or better APPLICANT'S POSTING COPY uI r yr UUrnrcI LNU -- rcamrr NO. BUILDING DIVISION ' PERU ?CONTRACTOR INE'ORMAnON:•.A G� BUILDING ADDRESS: SANITARY NO. APPLICAIIONSUHNITTALD . j , /j� .�.�:��. •.'>x:+�l�?1.4.G.1 . r,. t„- :SI ?.db.�i / OIN NAMP. 11.,+� I �% �7 t .�,1 �-^• NIC CONTROLp PHONE: ❑ AItCHITIiCTIENGINEER oy �JW .. ,,: •7 RUI.DIN(S PF.RMIf INPp��-[�f"k`x} a d NOTES r Fez o z o Job Description wO6V Su vFi J M7 o� W�4 FZY 1�. �Cem !3 t A a a_ Sq. Ft. Floor Area q Valuation AIN Number Occupancy Type ,_ &4 _ , —Required Inspections /2 4OG/k-- y^27— vv /mac vis W z zo ao Uz UO Iz P OV U � Re-roofs Type of Roof All roofs shall be inspected prior to any roofing material being. installed. If a roof is installed without first obtaining an inspection I agree to remove all new materials for inspection. Applicant understands and will comply with all non point source regulations. Signature of Applicant Date All roof coverings to be Class`•B"or better APPLICANT'S POSTING COPY