01060019CITY OF CUPERTINO
"' " - - - "'
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDDIO ADDRESS:
PERMIT N0.
OWNER'S NAME:
APPLICATION SUB DATE
II PHONE:
_
SAM ARY N . CONTROL N0,
ARCHDECf ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
G LJ G_I
LICENSED CONTRACTOR'S DECLARATION
I hereby aRrm that l am licensed under provisions of Chapt" (commencing
Job Description
with Secfiaa 7000)of Division 3 of the Biomass and Pmfessio 1.eM day it..
c
is In full force and a ajt`
License Cilia's Lic. a
Data Conuaaor
REROOF .
S
ARCHITEcrSDECLARAno
I
TEAR OFF/INSTALL 1/2" PLY
understand my plans sh be used bli recd
#30 FELT PRES. COMP.
LiccnsedProfes
j OWNER -BUILDER EC RATION
1 hereby .(Sort that 1 1m exempt from the Contractor's a: My c Law for my
' following reason. (Section 10315, Business and Professions Code: Any coon
I
Co��
which requires a Detrain construct, an s
improve, demolish, ore any swcmrc
v '(� J It—
O
aalter.pplicant
-.pnorto its usuancc, also q ir<s the epplicv,t for such permino file aligned statement.
asig
-
th a withSe'ion ttie of
(commencing m'i Salo of Division 3 of the
fDivision of theBacsneai selawonsCodr)
R d Profusions Code?
r s S Ft Floor Area
{ tl i -, + j a
i
Valuation
or that is dem t Therefrom arta the basis for the allegedo An
bar, a is lege
P eY violauon
a `
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of Section f.5 sant' o fora permit subjens Ne applicant ro a civil penalty'
'
a than iv
of not marc man eve nanar<d ealma asoo).
hundred ll
� APN Number
j: -L r•ea •.�$06c,�I$ancy Type
66
01, a owner of the imparty, or my employees with wages u their sole compensation,
will do the work: and the structure is not intended or offered for .1. sec. 100.4:-
Business and Professions Code: The Contractor's License Law docs not apply to an
-
Required Insp`ectiions • �" + t'*'
owner of property Who builds or improves thereon, and who does such work himself
36229034.00
or through his own employees provided that such improvements are not intended or
—or
far sale. If. however, the building - - within one year or
g ar improvement u
completion, the owner -builder will have The burden of proving Nat he did not build or
to
,.r
305
for
improve for garyos<arsale .).
- FRAME
_ � _
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O Cas o of th<proge. am eusi la with licensed c
._.._...- _ . .... _
___.. ... 307 _ _ INSULATION- ---
71 d PhyfiTmy
C.rt.rs 'a
License The doproes
License Law tlms not apply m an owner of progeny who builds or improves Thermo,
no (See. 1toa Biomes and Professionsildsor The Ceitheron,
601 — ROOF TEAR OFF p'!'•'• ri=''"f , ... 8't:
-
..and who roaming Livens forsuch-p ojects. Th T s r(s) licensed pursuant an be
C t mYs L came W
_..... _6.02 -`ROOF„-PLYWOOD' NAIL '
ion
0t mexempt und sec ` '`T -B p'A
603 — ROOFne,
air/efm_rhi
;� WORI i'sco PENSATIONDECLARATION �,
604 - ROOF IN -PROGRESS
lure',
M. under penalty of Perjury alit ofrh< following declarations:---
0 1 have and a Ccnificate of Comma Wohcr's
will'maitrtain to self -Insure for
Compensation. u, "far by Section 37M Labor Code, for
(� /
✓
provided of the the
pertormanae of The work for which this permit is hgomW;-
01 have and will maimam Worker's Compensation Iasurence, aaz repined bY, Seco.
37M of the Labor Code, for the, performance of the work for which This permit is
d. M Workers Compc Timi 1 ti 'e c 'tern P Imy ii b' vrt:
Comer 1 .. -PoITay
ER 1 � ATION OF EMPftON FROM WORKERS
r `
-
... COMPENSATIQN. INSURANCE '., t .,, ,
1. .�
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._,.. _... _.�� .... �. .. , .. .__.,.
(This'sectian need not be completed d The permit is for one hundred dollaa
_
r
\ +'r •-' i • : f _ .. I 't a j:;
(g 100) or lend ,
1
1 entry, that n the art nuance of th' ark fm whi ;,h perinis is issued 1
•a'half not
+
employ any Person n oby'Omme so as To beta svblecr to the Worker
i-;' t•')
Compensation Laws of California.Date
NOTICE TO AhT 1t n r ma, Th s e n fear of Exempt o you sh Id
.. v r
b roes ct to t
rot W k .'C mpen i p s of theL Labor Cade y must
ora I
forth Th reply tr th h pro a ns Ms pc T shall bed cd k d
- CONSTRUCTION LENDINQAGENCY
1 hereby affirm that Th consav r a 1< d n ag cY fo tlie'P rfmio nce
'ofth kfor Whchth p tl is d(S 3091 @ivC) "i
Y.,
_ -
1
._ Lenders Name ..... ... .... .. ., .m^ .....
... _..,-.___.. .._._._..
Lender s Address”
".I coni fy that I have rtad Niswpplication and state that above info rma,,.. is
'coney
1 gree to co ply th all city d co Ty s relating
-
'a b IU g consume'dh by auth aper nmlise 0Th' Tyt mer upon
th baa fit nerd 'to pent' f r n5pf T p ryoses
I (W) gree ms nd ion fya dk eph unless Th CgofC pen oaganst
��
Iabilities
b I T es judgment'cats d peroses h h y a y ay c e- B ins, said
City In co q nee of Ih g nngpf th permu '
APPLICA\T IJ\DERSTAvpS A ' ILL CypgMpp4Y Wmf ALL NpN�POL
SOURCE REGUT_ATIO\Y1r / /. //_^
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Issued b y. � C %gi`-'!Jn. LJ CC t Date /
Sgnaturc of ApPlieaMContrmar
Re -COOP$
., HAZARDOL$ hIATERfALS DISCLOSURE' "
'
Will thea licvno 1 i ebdilrhn aces Tvo
- PP g Pan a hamlle wamous mataaal
—Type of Roof ._ .._
as Con Bned by Th CupertlnoM mapal Code ChaPmr91?. and We H<althand Safety
Code $clan 2353 (1 ^
T -, r a r' + 5.1 {- Fv •I' -,I ,t.,:, .....•..e.
) t
-..
All roofs shall.be mspected.prior to.any.roofing_material being installed
WII th pplm m o furore bat ld g pant use<qu Dmenro de ice n n
harand
_.
If a roof is iristalled'wi[hout first obtaining an inspection, Iia Tera...' i'entove
g
us ah co T t. u def ed by the Bay Arca A Quality Management
� 0 mncT
all new, materials for.inspectign understands and w 11 comply with,•,-
Oyesl. 0 No ,
,Applicant
all non -point source regal
I h.,d d The huardo s mmerul Try ms a der Chapter 695 of the
California H IN & Safety Cod Sections 25505 5533 and 25534 1 understand that
ifth b Id gdoesn tcume Uyh repart. thatau my responsibilvym .f the
a p T fah whishm be tp roe. faC nfe roof
D a v y
� •" '
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--Signature, ofApplicant Dale
1�
All roof coverings to be Class 'B" or.better ,
Owner'araaT an:ea Dale .
... ,.... .. _ --- OFFICE _..__._ . __,. ...._ ... .. .. ..... _..