00080153,CITY OF CUPERTINO;
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nmcnwGDIVISION .PERMIT' ."
CONTRACTOR INFORMATION:
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BUILDING ADDRESS. e
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PFltMTTNO.
OWNER'S N048 B v LH
APPLICATION SUBDATE -
12I .000.
PI10N'E: CRANE JOANNESANITARY
NO., •',CONTROL NO. - -
Z ARCHUTCTIENGINEER:
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BUILDING PERMIT INFO -
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BLUG ELECT - PLUMB " MI!CH
LICENSED CON'TRACTOR'S DECLARATION
JOb Description. -
pp Ile byaff thtl f enseda I n fChnple 9(co nmeulg
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with S I )000)!D'- 1 flue Ru IPpRiskin, Cale nd m, hecau'e
<sit felt anJ
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ADD 1J2 RIGID INSULATION/TAR R• .GRAVEL
Dom Lomrator/-�1. M.
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ARCHITECT'S DECLARATI
londensfrindne, plart, sshelf braised us public ruord.
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Licensed Initowsmeal
OWNER BUILDER DECLARATIONss
I hereby d1fin that 1am 6 e e f the Contractor's I 1
tell g (S m 90iI 9 Bruce,, d P I :( d Ary citycourt,
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❑ isuch recarre,ne I c .1 I. L'It" im"ove, d I'.I p y.t ore
pr or to it, issu care, Two copies the applucer,cor such mort to file dgnW swmmem
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S•.. Ft. Floor Area,
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Valuation
- Ihm he is licenced pursnmm)othe provisions ofllet Gmwaor's license Law (Corner 9
(ern cibg with Section 911110) of Division 3 if he Business and P,ofico °ns Code)
or that he is nsempl Iherefmin nM the basis for the alleged exemntion. Any violation
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rman is mY'red atfnr,aP ', bjcros the nppr II ncivil pentully
era I - m,nnnven handred umrs(Asnm. -
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APN Number �`
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Occupancy Type .,
❑ I, as owner of the property, or my employees with wages as mein sole comnenawion.
will do the rk . o l the ounctureI imeanded or othered far still See. 7044
-B.,inew and Pr fei Code I he Correct Liweew, Low drs not apply t an
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jre(lMnpections -
aen fpp3y Who builds l 1h1 kti 11
(irtmr ba his provided d m t sun' r ve t, norimmortal l f the building I.. 'tyear d
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3051—FRAhIE
churpleirran, the b'Id will have thl dnofpmvngthatliedidmoholdor
imp afar purpose of e). -
']t�7 �- INS._L:.ATIQnI
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FI 1. a a (if the p n n exclusivelyc (g it It d tr , to
601 — ROOF TEAR CUFF
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L,1 itl pBx(S 7041 B:- dPr,'ne C -d ) rhe ContractorI
.. 6.01_-..RQOF PLYWOOD: NAIL
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ic :el.uwdresml ley, n corer rc,,,ywhobnls paiwe, uenwn.
are who contracts for such
nd p n with madramora) accused nnr.unnt to me
603 — ROOF BATTENS. .
Contractors License Law. 11
❑ I am exempt under See. ,B&PC badhis rws°n
P,OA ROI:1F' IN=F'R06P.EG5
'Owen • Date'
-' WORKER'S COMPENSATION DECLARATION
I hereby affirm undo penally of perjury nnc of me following declarations,
a.
] I have end will morturn a Cerificaic of Consent u) pelf insure far Worker:s':
Compensation, ;is provided fee by Section 9900 of the Labor 'Code, for the
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perm ... ch ee or me work fm which this peimit is issued.
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Khave wad will mninluin Worker's ComOcnsetion Insurmlee, ar required by Sector
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of the Labor Code, for the purrnnot nce of the work for which his permit Is
issue d. My Weaker, Came,micafiou Inure c - d Percy number are
Ter on
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(7�J`/�•� Ily�
Carr'erJ[([(G V/1/ policy No"Y4 NO /"noon
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CERTIFICATION OF LXEMPFIONFROM WORKERS'
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COMPENSATION
- ATIONINSINSURANCE
- I lus section need a°I be completed if the permit is fa mr, hundmd dollars
(SIM)nrles..l -
1 cenufy that in the perfommuce of the work for which Ihis ponm Is issued, I
Shull a°I employ any pefmm in any manner ro as to becomesubjectto the Workers'
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Compensation I; w of California. Date
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Applicant
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NOTICE APrk f. ific, rmkun,mi, nits !L pI you should
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comesu11 aotheWoA Workers n :el Po fiLy null
�• In.nhwlh comply with p or tspermt hall he occurred revs koJ
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3 CONSTRUCTION LENDING AG ENCY
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I hereby offom Nat there is a condmown lending agcney for the performance
of the wank for watch this tenni, is issued (Sec. 3097, Civ. C.)
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Lender's Name -
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Lemlo'.Address
� - ImnfY thou l have-enduh ppli,mnt and slaty that the above mmornewitin'
scorrect. I agree it) comply with up city and comity ordinances nd suite laws rcttng
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to budding construction, and hereby mdhnrize represert°dves orthls city to eater upon
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I the vnoverneninned Property for inspomion purposes. -,e
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p4)agece to save, indemnify and k p formless tite Cly of Ca,erpro agurst
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1 liobl'f judgnants est. and espenses naj.in any way wen v, against said
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' muequenceof the gran
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APPLICANTCOMPLY WITH ALL NON�POINT
APPLICANT UNDERSTANDSANDWILL CO
Issued by: Date -
REGULATIONS.
_nate_
Signature ofApcuumt/eomr°ctor `-- .• '•
Re -roofs
' HAZARDOUS MATERIALS DISCLOSURE
W
Will thoupdr,rat or furore bu'Id'ng p ,,-tri, h II trisection, -tdaL
'Type of Roof •" .
- tis dcfned,by the Cl perlm Mu is pal Code!Chapmr 9 12, and the Health and Safety
Code, Snatch 25532(0?
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-All roofs shall.be' inspected prior to any rDoting .material being installed,
' W"tit plica t f I h ildo"' "Coupon,cApup t device, which
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If a "roof is installed without tirst'obtainm an'in's ection, I agree to remove
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emilk cont Ia. defined hyo Buy Arta Qarty M�noge nem
s!ric,^
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all new materials for inspection. Applicant understands and will corn I with
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,all-non-pointsoIurceregulations. --
r ry
I h d the h- t 'cI Tey t e Chapter G95. f d
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Calf Hnhh&Safety L 1 Scorns 25505,25531 red215341een,a d mndll t
ifthe ld"yG t Nytr Grant, mY pit fry
em vI f the rya t which m t b I P"i' m'vw off C Con fnul of
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Occup y
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Signature ofApphca It Date
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All rpof coverings to be'Class "B" or better "
o—wit' mr ee age � byte
- . •..' OFFICE '