01050193 CITY OF,CUPERTINO '', - .
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: -
BUILDING ADDRESS: PERMIT NO., * '
W:f 93
'OWNER'S NAME. - EOTER" APPLICATIONS A ,
M1 c
'IIONE: i r - " "' -; - - ".. SANI'T'ARY NO. r
X0 o ARCHITECT/ENGINEER: r BUILDING PERMIT INFO -
B ELECT PLUMB MECH
FF. 1 ICI NSED CONTRAC[OR'S DECLARATION y I h by Ban Int 1 I' nod d p f CI l l 9( a ng Job Description
With Section 7000)ofl)ivisifan 3ofthe Business andPrefei nvCah dmylcenso - -
6 y f s in nor rc fl r I
WWO a f Lies CI U, # _ .,
WW a,�y Dal Conoacmr REROOF.;
ARCHITLCTSDLCLARA N
a l d n y l l :nau recurred l p bl u,m. Soo- REMOVE SHRKE- &, IJDODriSNIN6LE.•,
o a E u f . sial INSTALL 30LB. FELT, 7/16" DSB,''
OWNER—BUILDER DPCI ARAI ION
I laded,affirm [,,I I plEID the C I' t License Law in,the
G 3�
Which
hi h orraircia
rental
e fIt 9111.1t 5 B1 u.lI e, ni,riwa,
P fJ Ch J Apry' all,
l y r1 tons
aj ill "
'
also a Ih Ipl tt Ip et flLsigned nartert
math -. 1 aFit n p nn t t i : L onsCor9 Sq. Ft Floor Area - . . Valuation
(wnncnengweb Safnn7Wand D vldm 3ofthe Busncsered r.An, motion -
' or that he is wampl Therefrom and the basis for the alleged exemption.Any v'mlatinn
of nt Section 7031.5 by silly applicant topermit subjects the applicant as a civil ltheully
'or not annrc conn Five handled dollars($500). - APN Number' • - Occupancy Type
El 1,as owner of me prnpeny,or my cmpliwees x all wage.n,Their sole compcnsmlon,
will de the work,and the stnmturc in col intended or oRexed for sale(See.Marc,
Businee,and Professions C6da:The Commctork License Law does hill apply m no - Required fnspectibn9 - ..
r of property Who builds 6r Improves thereon,and who does ouch work himself
or breath I', ,,a Inceilled that ach p l it,, let'andendi
red lot Sale.If, e the n rob b or implarclareat Ia within one .it of36921023. 00
cnaidetion,the hall Mill have the rural r provingt lh JJ IIIharbor
-
mp Pum i ).
'o I - I the property, 1 . ycontracting with licensed
l
atl0 Project(So,.7044,Basilan,anll CodiInCtt ' 305 — FRAME
construct
ie La J t l applyoaw l ly i h IJ p director . 307 — Il$ULgTION
Int or inch pp, la will t ielaeg unl ln
Cur Lcbpye 601 ROOF.TEfR OFF.'
0laaexemptttndtrSee, B&Pcfor tilts aeatnan
-.
.,
60'2 — ROOF PLYWOOD+ NRIL
Owm t Date
WORKER'S COMPENSATION DECLARATION ? - 665 RQ17F BpT I TGMNJ ,
Ihereby Ill ill antler Penalty„rPlaintsone of the lbuowmgdeclarations: 6�4 — ROOF IN—PROGRESS'
❑ I hnve and will nal...an. a Cenlrcate l,I Con"seat m WiLansme orWorker',
Compen,alien, as provided for by Salian 3700 of the Labor Code, far the + -
Nalconaneeaflheworkre—hieh this p nnrl aissued.. - 17.
-
mocand will nminmin Worker's Compensation Insurance,as acquired by Section t t
37 If the Labur Gad.for she poll om.ance of the work for which this permit is - -
issued.MTWnfkeisCom nnnlion inond Pulicy_timber are ,
•.N/�P�h''/.Cki -' . QdYU23 7 '
Carrier. 5�f� r bey
ERTfICAEXEMPTION
FROM WORKERS'
COMPENSATION
- , -
INSURANCE' - -
q, .
(Thi,aSet n....nolonot he completed if tire penin,is forane hundred Julian s
($100)or less.) - -
1 rearly tial ill the poll Ill k forxl h d p i1,aeoal l _ ,
bar el employ a ,person in any pamier So ill ,,boon a wnleal m he Walker"
` - cormcnsatime Laws of Calitbrnia.Dan. -
Applicant r ..
NOTICE 10 APPLICAN f 11,after Ski.,g m Certinneacof faserroplima,yea should
,Z� Obecome%ilet Ili life Worker compensation incerisions trip,Labor Card younmst "
fonhw m comply With a ch poolacts or tiny recent shall be deemed revoked. - - -
^F _ COUSI RUC IION LENDING AGENCY -
IN hyRa that there nsl 1 an,hi for the Wrior c _
W
'If the ork for which l if pe-nt', .,tW(See,.1097.C Iv.CJ
(� Lender's Name
.7 z Lender's Addms,
t..) Tearmy dal I raise leadthis frithealiol,and,tt trial IIKne information -
FT .1 orctr.I.,me [ply .In.11ca,ud Iy I' d Same l' raining , t
V mbuilding mrsmvft dlerchy,uth presenmfves of this city to enterPon
yyy GT7 the b i d P I'II - 'P 'I P P
Q,I (W 7g J ry dk pl 1 or .apcnlno Lg'nsl
V] habil s,jldg [End I Jaxpcme wf chi rue✓gprpsl old_
V 7.i Ch'Ito cense, cc eC
.. souNn Dsa"Dw .I, la SoN.Pd T
SOUR Ec Issued by: 'r - Date ,
s alas ppreanf/Cater<ma. . - am `Re-roofs. 4r
{ HAZARDOUS MATERIALS DISCLOSURE'
11th 'Ipre I nrcbam s p t'Irc hall M 'mta1, -Type ofRoof ` . a• .
Spot'
'bId " pal Code Ch'1.1 912 nithe Health dSlly ,
od S i 255.120
w ".All roofs shall be inspected prior to any 'roofing material being installed.
Will the apphc ill .r care haddfig c,niont iso a9 l t o,chweer wmeb If a roof is installed without first obtaining an inspection,J agree to remove
earrith 1 cI e' til Jbytl Bay A A IIyM Management
District?
all new 'serials for ins ec[i licant.understands and will comply with'''-
DY " _ all non o sit source ' aC
I have theM1 sec' quirt m ns order Chapter 6.95 or the
^ C If ' l &SrIyC d S tat. 5505 53 1 55.14 J .wn Iha1 "V1
rfth h- - not ilY.l al I t l' p ..l.l I oti th — , ••
It f '"n enb w .I b• p Cenaf ate of
Dc _ — Si ature of Applicant 'r ' ,Date -
o ranaharaa,agent " Da,�1, All roof coverings to•be Class "B" or better
OFFICE