03100090 CITY OF CUPERTINO "^"tea ori a 7WW ' `,^;P,
BUILDING DIVISION PERMIT CONTRACTOR NFORMATION -
s .p 4w akT,iy
BUILDING ADDRESS: WANG IS MAINTENANCE PERMIT N'03-100090
111 -11 CHAnWICK PL
OWNER'S NAME: PERMIT ISSUE DATE
EUGEN
E: SANITARY NO. CONTROL NO.
(408) 828-8537
ARCHIM
08 828-
ARCHITEC tENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
o t� o
30oC LICENSED CONTRACTOR'S DECLARATION IobDescription
0
f f�G 1 boreby.M.thu 1.m licensed unpmvlaiou of Chepim 9(commencing
with Section 7W)of DiWa on 3 of de Busimaf and Profucou Codu,and my licence b
In full fame and effect REROOF
5Z Lkena Clue Lic.X '
Dem Contactor INSTALL LIGHT W TILE
ARCHITECTS DECLARATION
I mbcuund my phns.IW l be usand!as public rtwNs
7
G Licensed Profmional
OWNER-BUILDER m the RATION
C 0 0 I hereby resum .ffiremsect on I em exempt from the Contractor'sCoLicence taw for IM
C O O following muan.permit
t ](131.5,m after.Land Professions Code:Any oily or county
+�$ whirl, its Mu•permit m cnnuruer,alar,i t for su h permitdcomillst m e.signed statement
r
weactutatement
F�Iv^ priormitsiuuan put......
requires lM applicant far such permit U.asignedsutzment
�SF tint heir licensed pursuant todtz of Divine of oat ConuactofalJwnmlaw(Chapter Code)
Sq.Ft.Floor Area Valuat, 1000
6 s (cat he Is oompt Section 70f1U)of basis f r h al Business and Profcas til Cme)or
Net he I.exempt therefrom and dtz bub for Ila alleged uempoon.Any violation of
Summit 7031.5 by airy applicant for a permit anb)em the applicant in a civil penalty of APN Number Occupancy e
not mote Nan livelivehundred dalWs($5 ). p y `T 7'p
❑Ido .war and propuny,or my mchm,Inman moyee wbhvagua Neo sole wm,Busman.
35617078 . 00
and PrthewWe end the h.Cont arms Lmmoodded.Law dosel not apply
]04, Owner of
and Profesalone code:The Cmnuvcmr,Llanse Law doer not apply m an owner car - Required Inspections
property who Mid,d,or im proves thereon,and who does such work himaelf or through his
Over employees.provided that such improvements arc not intended uoBerrA fmsale If.
how .the Wilding or improvement issold within one yer of completion,the owmn
builder will haw dtz Mden of proving that he did not bond or improv for purpose of
X sale,).
❑I,as owner of the Property,em exclusively contacting with licensed convectors to
couuuct the pmject(Sec.704,Business and Professions Code:)The Contruur's U.
cense Law does not apply in an owner of property who build,or impresses themon.and
who contracts for such pmjecu witha commobar(s)liaised porsunt ro the Contecme.
License taw.
❑luncxcmptundu Su. ,BkPCfami,muon
Owner Dam
WORKER'S COMPENSATION DECLARATION dx
1 hereby aRren under penalty of perjury oro of the following deelandou: ca,
❑I hew and will maneWsaCenlikam ofCoeent to self-ilium her Worker,Compcm _
RED
salon,u provided for by Section 3700 of the labor Code.far de pcAmmance of the work for which this permit is issued.Q 1 haw and will meinuin becomes, reWorkers Compensation Inwran ,as quired by Sectionr 3700 of tic labor Cade.fu the perfurmana ofde workfar which this permit is issued.
My Wmimes Ci mpensadon Insurance artier and Policy number are:
Cartier. Policy No.: x W
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
flTusection rued not W complekrd if du permit is forom hundreddollus(SIM)
or less.)
I century that in the performance of the work for which this permit Is issued,l Nell not
employ any person in any manner an as m become subject to this Workca'Componsmon
Taws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this CeniRatz of Exemption.you Amid
become subject to the Waher's Componaation provisions of the Labor Code,you most
,JO forthwith comply with such provisions or this permit shell he deemed revoked.
Z'—' CONSTRUCTION LENDING AGENCY
I-r 52 I hereby a n m thn dart is a construction lending agency for the performance of
LIC„>„ the woh for which this Permit is weed(See.3097,Civ.C.)
A Landers Name
Q z LandersAldma
O Q I comfy that I haw reed tri,application and sitz the,me show information i,
IT,^. cannon.I agree to comply with all city and county ordinances and sue laws missing to
Q building coruwcoon,and hereby authorim mpresenuGwa of this city to enter upon Nc
W abovccmen,ionm property for inspection purposes
(We)agree to an.indemnify and keep harmless the City of Cupertino against
IA Ilabilides,Judgments.casts and expense which may In any way aceme against mrd City
in consenscrec of the
of
V s rmit.
APPLICANT UNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature o(ApplicantDem
HAZARDOUS boding mmuS DISCLOSURE Type of Roof
Willy applicant or furore buildinge.Chartatoneor handlehaaim and
u defined by du Cupertino Municipal Code.Chaptzr 9.12.and the Hulth and Sa(ep
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu ❑No
Will the applicant or future building occupant use aquipmcnt or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havardnus air mmuminem u defined by the Bay Area Air Quality Management all new materials for inspection.
Disuict?
❑Yu ON.
I haw mad the huardausmamdalsoumimments under Chapmr G95 of the Califon
ria Health'SafetyGoCe,Sections 25505.25533 md25534.l undcaund muff use Wilding
does not currently ban a meant,esu it is my rummul hiliry m story de oxupanr of the
mquiremenu which most be met prior to issuance of a co it ato of Occupancy.
Signature of Applicant Date
Own.,or anthch,ml aguml Dam All roof coverings to be Class"B"or better
CI'rY OF CUPERTINO ��-+''' _' # " T., ", -
BUILDING DIVISION PERMIT CONT. &TORANFORMATION.. .BUILDINGADDRESS: ♦P NGt S+ MAINTENANCE PERMIT NO.03100090
121 GHAQWICK PT_
BR'S NAME: 495 FIRLOCH AVE PERMITLSSUEDATE
NE: SANITARY NO. CONTROL NO.
(408) 828-8537
ARCHM-CT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
!000 LICENSED CONTRACTOR'S DECLARATION
U F I beachy.(Frim that I am licensed ander provisions of Chapter 9(cammancing Job Description
]1. with Sceditil 7 ))of Division 3 of the Busmusuipfil Professions Code,and my license is
.<�in
in mfi fora effect 7;41o REROOF
syz Lic nM Cl lic.x
it° Da 1 CTSIARATION h INSTALL LIGHT W TITILE
ARCH1,51 I understand my plans shall W used ea public recanLv
6
c
10.1
L7 Licensed Pantomimed
OWNER-BUILDER DECLARATION
)a 0 1 herehy.(Eric that 1 am exempt from the Contractor's eLicense Ac taw fur the
:°O whlich quiresa (Section]IDES, ,,Business and Professions Code:
S$ which quires a permit ralso e cnvuucL altar,i applicant for such
h permit t or mash any swnam
-iy that hor es I issuancersuant to the the
ovisisofthe Contrctor'mournfile a e Law statement
s-0
thatheWit pursuant 7 h)of Division 3 theeBusinar'snd Professions
Code)or Sq. F[. Floor Area valuat 9000
t F$ that he is
(commencing Section and of Division 3 of the aged Business and on.Any
Cnde)of
that Section
u exempt tsay applicant
li and the bub I, be alleged application.Any lineation of
act..7W LS w any applicant for a ppinniuubjects Nc applicant a civil penalty of 3�A 1!1 M r O 0 Occupancy Type
not more Nan five hundred dolhrs(5500). * 'J0+1'
❑h u owner of the property,a,my cmploycea with wages u their ole campenu0on, ff/ f // -
willdotheworkendtheatmbmatis not intended or offered fonale(See.7 703.=
and Professions Calc:The improves
teems,Lima.who Law soon
oat apply m an owner ofRIgU fe&If16 eCC10n5
prop...erty mploy .,ponorimpmwsthinipar roods dassucnt wick.,iffeed far sale his V 3tLJPIl5/. EC��( /P
ewnempinyau,ping a,Ithansuch vememprowmentsaa not las of duroRned the
3 II� D
huilder ill haw the b r Improvement is said a Within0.yea or murnpleimprov foror.the owner- /
builder will hove the burden of proving Net he did not build or improve for purpose of 601 _-'V•R T
sale.).
❑I,as owner of Ne progeny am exclusively contracting with licensed comacmrs to 602 - ROO -P OD AI I'
conswct the pmject(See.7D44,Business and Professions Chile:)The Canuanor.Li. 603 — ROOF BA
cove Law dote not apply man owner of progeny who Wilds or improve theater.and 604 - ROOF IN-FROG
who concocts for such projects wish a contatctor(0 licensed pursuant to the Convenor's
L_i�^se L.W.
t9 I un exempt under Sec .B At P C(or this moon r
Data
WORKER'S COMPENSATION DECLARATION
I hereby M.under penalty of pod.,mu of use following malaria... ,
1 hew and will maintain a Cenific.uof Consent to self-locum for Worker's Camper.
cation,as provided far by Section 3700 of Ne IaWr Coder,far the peramnemce of the
walk(or which this permit u issued.
❑1 have and will maintain Worker's m
ker's Capens.tion Insurance,as mquired by section
3]00 of the Labor Code.for the performance of she wart for which this permit is issued.
My Warkcr'e Cnmaena.dnn Insurance artier and Policy number art:
Comer: Policy No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cons Mellon add not W completed If the permit Is for one hundred dallm($1111)
or]as.)
1 sonify Not" rah perfnrmencc of the loft for wIt h Nis rmit is:swig I shalt not
employeny r in anys r.ors... eco 9xt "f.(�t fu Workers'Compevetion
Lows of CaT alp V
_ glee rat � G t
'NNWE TO APP CANT:If.after making Nis enificau of Exemption,you ahold
become subject to the Worker's Compensation pr visions of the Iaacr .Ceder,you must
�Q forthwith comply with such provisions or this Permit shall W deemed revoked.
z'► CONSTRUCTION LENDING AGENCY
I hereby.11Um Nat there its mantructlnn lending agevy In,the pofurmemx or
the work for which this permit Is issued(Sm.3097,Civ.C.)
YQ Lendoes Name
z Lon seer's Add..
I eelnthat 1 have read this ea plication and sten that Ne shove information is
i F building 1 agatet to comply with all city and county nNimnas and rata.'laws relating to
V bitive-gconsled proand hertmby action preisca.representatives of this city to enter upon the
N W abnvc(We) cd progeny for impaction I, ad Me,ha
ti gy elder)agree to sew.Indemnify end keep marina the City o(Cu most id City
N inmisequarjudgment,eStetsindof thisexpenses which mgin any way accac against said City ATI
APPLICANTCof UNDERSTANDS LAND WILL COMPLY WITH ALL NON-POINT Issued by:S4tQ� Date / v
SOURC REGULATIONS.
Re-roofs
S urcofA Team/ ontractor au
HA'ARDDUS MATERIALS DISCLOSURE Type of Roof
Will Ne appeie.m ar(utua building moupam store or handle hemduus material
as defined by the Cupenina Municipal Code,Chapter 9,12,and the Health and Safety
Sec.
E]
Will
�Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices;which If a roof is installed without first obtaining an inspection,.)agree to remove
In haam us air contaminants as defined by the Bey Area Air Quality Management all new materials for inspection.
uict7 /�
❑Yes p�``yNu '
1 have mad the hazardous maurielsayvimments under Chapter 6.95 of she Cal"a'-
McHcaW&Sefct Cede,Sections; and25534,1 understand Natlf Ne buildin
y e
docs net currently hewaunena that in is my reapovihilitymnotify the aaupent of Ne ,/�y/�>
ayvircmcnts which must Is,met prior to run ofa comficauof Occupancy. � d
�� J ignature of plicant Date
own suNorisdagenAll roof coverings to be Class "B"or better