00050175 CITY OF CUPERTINO y :BUILDING DIVISION, ' PERMIT - CONTRACTOR INFORMATION: -
, . MANEY P13RMI'f NO.
FUILDINGA , <
OWNER'SN h I I — .. ;.. - APPLICATION SUB DATE
LONE: 4 ., • a SANITARY NO. 'CON I'ROL NO.
jn�Z ARCHITECPIENGINEER: i , , BUTLDIN( PERMIT'INFO,BLDG _ EIECp PLUMB MUCH
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ce
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o I n by LICENice SED
iD CON rBacTDRps DECLARATIONmvision,of n -g(c L r Job Description • - ..
c •r.w sillf r card rec nnsnran"HI n,luProfession,cde,ane,ty REMOVE`BUILT UP ROOFING 'REPLACE WITH S
x ;.i rnfnme.amd-erred +, - - e.
�(0O na LlecnseClaxs Dom Counted
�:na CARCHITECT'S
- -
a1' r
�, f ARCHITECTSDECLAOLCLARAf10N v
�S'�O j I understand my plans shall he used :public wordx ^ -
aW�
trlap0 Licensed Pf al
OWNER BUILDER DI CLAIdAIION - ..(.•
w_y I therefor afron that I am exempt from the Contractor's License Law'for the
following water.(S,cti,,a 703 1 5 Bre d 1 t :. Code An,any come, -
S52 loid,eirchourspermit :r i ❑at,impm,r,derell......epair oicynno,mor
de c poor 1 tissuance, tirapplicantl hp lIE1 8eltalmn
c.a mat he Ii l r a l Inn f th,C timber 1 L La,(Cheipte,9 ,S Ft. Floor Area - Val
Ice , d t S 7000)it Di 3 1 tire Buninic,and P fibNor,Code) �'• - • - -
o their he is exempt locrefroad and lin basis her the alleged exemption.Any virlsfirb �.
of Section 7031.5 by any aPPI' nt for a permit sneects the applicant in a civil penalty
of her mom than Five hundred Jlors,(s5aB - - APN•Number Occupancy Type
❑L as owna,of the properly,or my employees with wages as Ihelr nvle contrcnnarmn,
31630092. 00
Ea 71 k I the t 1 t J J or Ofirood to, (Sea.7044, -
Business and Professor.,C I .The Cornmenur.'Li,c,,,e Lave does not ply Ir an Required Inspections
=
owner ofn p ty Who builds mo ffirmon,oid'1 d :such work1 :If '305 — FRAME - -
or through his own aciployeA.provided that sucir_ruipmenback am not imaded or
opened fsale,If,h ei ffil,1 o g or improvement II within onercan of' - - 307 INSULATION -
coa II r tileh Id will dfp� grhI'1 IJ
hap r pro r ) -
ROOF' TEAR. 'OFF
❑La ,w'maralther pay,. i Iy contracting with d contract r 602 "—' ROOF Fal_YWOOD NAIL is
mmmat tire effort(See 7044 Husinc and Tons f..- Code 0Th C ,
Uplinks Law dopen
es net apply to an owner e redeem,who bond. m..ovca mere.m .603 .— .ROOF BATTENS -
and who contracts for xmoomejwL willf a eounwelge)licensed pursuani m the
Contractor's license Law. :. '• ..604''- ROOF INLPROGRESS" '.
El I nm exempt under See. . ,B&P C for anis reason .,
Owti 1 ..Dale WORKER'S COMP FNSAI ION DECLARAI ION
Ihereby aft J p by fperjury of the Ill ngJ P t -
' Ih J Ilmaintain- Cifr fCounter, t If' I' Wokr
retention, : p Jed on, by Seen.. 3700 f d Labor C Ie f the
crf fth k r h'h Ih'.patten ed.
. M1 d 'll i t W k Compensation Insurance,a.recoiledbyS r •0 I.,r
0 f tire
I abor, C� I f Ih ��ecc•�i�n�r/�u1.nion
f the
work for
f to tl. permit is My C, in PWe'9Y r'no,and
(' •I�SZ� Y— -
a icy amnics,are
br C MPENBATIONINSURANCE + i
CP-RT I NOF EXEMPTION PROM W O KERS„ - r
(This acorn account be amounted if the panni)is for one hundool dollnry
1 reality that in the reamermance of the work for which this parnth is irmed,1 ,
shill rint mllpl(j,ady percesh In ally man ter mus to become subject in the Workers
Compensation Laws 1 f C I f 'a Datef r«, - I ,
Appl a 1 - ..+•
NOTICLTOAPPLICAN'I If after mak bthir Cenlecmtc of Exe npl of yotshruld ix -
becomesubjecttotheta k "Comperoant n"A the Labor Code,youinnst - -
Q O forthwith comply with h p nn or thisp -unit bar h de n J}evoked.
z CONS IItUC I ION LENDING AGENCY - -
F wr 1 hersKy chiral lunt them nae',in lending"'aday I'or the perfor a me
Wfile work for which this permit :sewed(Sec 3097Cis CJ. r
A Lenders Name - a!
z Landa C,Address
Q 1 minify hall have end tlrmplicrtianabdttthtN b ' f .f ' t
GL Eby correct I agto comply with sit city and county oublencesend stare laws Mining' . -
O (, to hmlfng construction andhereby a0o - Irecarbl n,of fit, ,,,In ever eros N -
�y r� the ahnve-mentioned property liar In pecoon purposes. " --
" rCy W (We)agree ln......ndemnlfy and keep hormlcssme City of Cemenlnn against
71 oliahl'Y: 1Jg t: c .a and expenses may it any way.ccruc rgiva �tid
V-� Clty' ,a,.cnw of th 6m rung of th1. perm t. - /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT (,� N�
SOU EREGULATIONS Issued by: "' DateT
ismamreef caul/ I r Date Re-roof' '" ..
HALARU US MATERIALS DISCLOSURE
wet herephas e rt buildingocwpam"amanh dlresidues dentrow 'Type Roof
as JeOned by ma Ctpanno Muncyal Code Chapter 912,and the Health sed Sand, - -
Code,See ion 25532(0)'1 l _
❑Yes' orvr 4 Ali roofs shall be inspected prior to any roofing material being installed.
Willme,tpphcam rr fatale building nc,Tcitt ase equlptnu.nm br devices wlikh If a roof is installed without first obtaining an inspection,.I agree tolramove
emit turned...dh wmatnina`mn ae dermed by the Bay Area Air Quality Managemm�t.
District, - all new materials for inspection. 'Applicant understands and will comply with
❑res 0 N
all non-point sourceregulations',
1 have .it the harunlous imcf,iala is mi cmenra under Charier.6,95 of lire=
Cliff door Health&Safety Code,couriers 25505,25533 and 25534.1 understand that
if the gniIli ing does not cbnrmtly have a Room,that it is my re.pomihil lty m,Field the S -
ecupan of lire brifireadirrit, loll unset IN,min prior or,,maracenfa Cenir. f •-
ar°" Signature o£Applicant t - Date -
ownafternoon!agemr All roof coverings to be Class "B"or better
• - .: ,. - OFFICE