01070096 -CSTY OF CUPERTINO
BUILDING DIVISION PERMIT : CONTRACTOR,INFORMATIQN:,
BUILDING ADDRESS: PERMIT NO.
21891 COLUMBUS AV EXTERIOR SOLUTIONS 01070096
APPLIC TION UB DATE
oy/�t�g'SN� E: ROBERT K AND JOAN TRUS 1771 SMITH AVE 077202001
PHONE
H:1� (408) 358-1233 SANITARY NO. CONTROL NO,
❑s z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
LD ELECT PLUMB MECH
z W L_J L--1 IJ 1_1
Nh
z S w 2 LICENSED CONTRACTOR'S DECLARATION Job Description
O z-o I hereby affirm Not I am licensed under provisions of.,Chapter Code,(commencing REROOF.
t.,HFin with Seatoneand of DivisionJof the Business and ProfessipnsCW and my license
¢mist Lcenseforceandeffect p T/0 WOOD SHINGLE INSTALL 30 LBFELT
z w 6 License'€1.�OLic# r
3'a y Date comraaor - 7/M ll OSB & �X
LL O ARCHITECT'S DECLAR O -SUL(JT/OJ
„g 1 nmasmne my plans anal)be ansa as pnmm reeoNs I b i. CP..f_.oT�.'e �2e51 D ems% R' L G
��
w z m O Licensed Professional PQM
ce.E. OWNER-BUILDER DECLARATION
a_m 1 hereby affirm that 1 am exempt from the Contracmr's License Law for the
Fzd, following mason(SectionJ0J1.5,Business and Profexsions Cale:Any city or county•
be O which requires a permit to consuuct,alter,improve,demolish,or repair any structure
i3ce ce -prior to ts issuance, I eq ' the pplt for such permit to file a signed statement - _ - --- - - - -- -
th thg'41< s apo u nd,h-pro si fib Cpntractor L«nseLawlCM1 pt 9 .,t >,Sq.-FL Floor•Area x ++.. 976'iduation
(< en<ing with Set 7a10)or Div.' 3fthe Business and Profeasmn.Cod)
or that he is exempt therefrom and the basis for the alleged aempmiab.Any violation
-of Section 70}1:5 by any applican{for a permit subjects the applicant m a civil penalty
:of not more than five hundred dollars($500). 3 5 611$16 YPm1020 PERMIT 1.1 Occupancy Type
°I,as owner of the progeny,or my employees with wages as their sole compensation,
will do:the work,and the structure is not intended or offeredfor'sale'(See.71sas '-Business and Pubrewichis Code,The Contractor's License Law does not apply to an 305 - FRAME Required Inspections
owner of property Who builds or improves thereon,and who aces such work himself 307 - INSULATION
L_
or through his awn employees.provided that such improvements are not intended or
offeredf - Ie:If.however the Inildm or n rovement sold-within one ear of ..__.. . .._ _...
completion,theasm buildervell have tthelnnlen ofprovngmhamhedsaildor TEAR OFF l '. ..• t. . '•r.
imp...cforpamfaalel. 601 - ROOF
osen
d net 602 - ROOF PLYWOOD NAIL
❑1 o f[h p nly t $ licensed t [ t 603_ .-t ROOF BATTENS ...�.:..-
contract thproject(S .vas Business and Professions Cods.)The c t t 604 - ROOF IN-PROGRESS ': - `f'
License Law does not apply m an owner of,roust who 1 Ids or impress,mcrour, '
bd,,ho commas for such.prolens with a.commetnrts).licensee amxaxrt. -the. _._._.. ....__.. _. _._.__ ..._. -._.._.... __l.__.. _. .. .. _.._. .. _._.,.._._ _.....
- Contractors License La
i
'
111 am exempt audit Site t 11 "F: "' ,R&PCfor this reason
Onnairi ' .Dt [
WORKERS COMPENSATION DECLARATION
I therely affirm underi pen Ity of perjury ne iof sem following declarmW ke /
❑ I h c and .dl mamm n f Genif<toC meoil self neo for Worker's 3/
- Ce, rar nn s-prodad f by Section3700 of the Lebo Code. for ,he
P e f e of thework f which this p t d.,
i h d will trandait,Workers C mpensanon in omnc a,regm red by Section
tM1 L b
.a
Arm t o ins y a P l Y n m ai<.�— r.. .... - ..., _-_.:... , ,..........
Cal for the perform ntt of the work'for which thisPermit s
Issued W rkr
XFM No OM /10RS7
t C TIFIfACOM OFE TION ION FROM WORKERSFROM WORK8R5
_...� COMPENSATIONINSURANCE —,,,_,r_„
u
(Th :enlo`n need not lie compl t d if the permit is for one hundred dollars •'' i - t i
,
($100)or,less:).,.I'lt.. yi..-„_ :q m, ,o,dr
Y.,khat ., 1 1rforril 1 h. o k for which fore permit prom
'shall not employ any pe any ma s ro become subject to the Workers '
A r ensati Laws f California:Data
p: p - __... .........._.. .... .. _. .... _. .___....
NOTICE TO APPLICANT If,after newho,finsCnf t fE pi n,you should
be b,' uo th W rker C'mparA t on p ns of to Laho Ciia:y u must
00 forthwith ply with such Provisions or this pc.it shotl be deemed reoked.
._ .. ,.. _ .._ ..__. ....._. .. .
F'� `! CONSTRUCf10NLENDINGAOENCY "' ” '�' "- _-
' 1 boreby affirm that he a construction lending agency far the perfrnbahnbf., . y
of the,work for which this Permitissued(S 3097'Civ C)
'.0. Lender lsame_u ,_...:.. ,w.. _. .. ..., ......_. ._ ,. _ ..__.. ... ___..._ � _..._..._....
:Z)aZ L d Add s,_
-learrifychat 1 haverand this application and vbtmfibrubtlrbsovc informations
.ommin.1 gree m comply wall 11 city'and county ordnance,and a m laws relating',
V to building construction.and berdbyandince,representatives of this city to enter upon
lW !the above-mentioned property for inspection,purposes.,
urposes. _„ ,
Psi Ove)agree to save,indemnify and keep had'els th<City of Cupenind against
r Vl i b'I u j mem t nd expeQ yy((M1 ;in y y a tie pgal ,t said!
C,1 z C tY l a`ce t ih grin ing piss i�
- APPLIC' UNDERSTANI A tb CCI PLY t ALL NON-P 11NT 155ned by: Date '
611,
t9 gP
_:,Vill thepe h IHAZ RDOre bor"it Id nT«I uLaDISCLOSURE�r M10 ie h` �1 Date �; Re-rOOf$
PP s p alaradaaminimal, , .Type of Roof
a d F d by the Cupe t M : al Cad Ch pt 9 12 ane the Health aW S f ty_ -
iCdeSct1n25552(a) to- v F i < -- ° : kill 4t AI rt' ( '
1 t
All roofs shall be inspected poor to_any roofing.matenal being installed _ ..
vt Will the applicant rifirmic
s building
by the Bay Q equipment l ryManagement'h If a roof is installed without first obtaining anlins ection,'I=a Tee'to remove
e t h a s s cont ml tg p g
p erstands and will comply with
P
ntta new mat na s or ins ech besot and
_- �t ) t all non-p'oi source r- �,tr s• "
a 1 he mad theh i d ':ndro mal rcgmremem pact Chat 695 of the r
fabs bit IdHealt S f ty Code Sir, s 25505' a d 25 }p I understand that
i oe note lyh re-noir bltyG y _ ..._.
'« p t e,r qu ¢x 'n and be, - e s of
ouf Ilii
i
r o pan - Signature Date
mm o n<r amnprirea g Date All roof coverings to be Class B 6r' better
,i
... ""f ;.,. .._.. OFFICE .... .. _..___ ....�-