00070182 CITY OF CUPERTINo -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUII.DINGADDRESg: - 1117RMTI NO.
OWNERS NAME:: - I APPLICATION SUB DAT;',
07/28/2000
PHONE. _ .. . - SANITARY NO. - CONTROL NO.
o O C ARCHITECETNGINEER:• - BUILDING PERMIT INFO
uHLDG ELECT' PLUM` MECH
tlOn Job Description
LICENSED CONTRAC'TOR'S DECLARATION
S H z I hm ereby ITrthat I ]licensed d provisions of Chupler e,tensional
F cc wthS I 7000) fD 3 of the Busing 11 ,fes ions Caleanantyllcenm
1 °c
—70!610—
[.Ivan • �/� REROOF/ASPHALT
• A Cg HITEI's mmaDt CLARAI ION r -
($C$C_ 1 understand my plar,lball be uwde,public cord..
y 0 C Urinated P :.
1 ',nal ^ , - .. /O
OWNER BUIL DER DFCLARAI IOU
ad I h by hffi. h has l m v..V from the CombracniC,License Law far They O
C 3 Q fall g oa.wan.Section 7031.5,Blame,and Professions China:Any city or ready
C tii,h 4 1 It a t,alar,improve, I'h an;'Ircaae
aim p'a t t '.auunw,nl.o cyu res lhwPPl t to Ince saiahmllevfgnW r.lmeneal "
thathe is licenced pusuan,to the provisions ofthe Contractors,Ucessa Ltw(Chupter9 S Ft. Flood-Area Valuation
(commencing with Section7(M)of Division 3 ofihe Business and Professions Code) q• '
ar that be is exam,marefmm and the basis for the alleged exemplion.Any violation
tilSection 9131.5 by any'eppllcmt far a permhsuhjr,, the nppllanntto a civilpenalty _
al'lot'rare ilia"five handful dollars tsSO)).' . ' APN Numbers Occupancy"Cy t,
°L as owner of the property,or my mnplayce,with c'es it"heir sole cam'.."ien. '
will do the work,and the structure Is not intended or offered for sale(Sec.9844, 36eeWgS. L40
[in'Proressint"C„<la:The Commcio's Licotso Law does not apply to an Required Inspections ,
I, r of prnpuny Who nnuds nr im,o,c.merenn,and who does,oath work m oself .'t - - -
,it through his own empli,ycesprovided that such improvement,arc'mo intended or 305 — FRAME
olrcred Por sale If,haxever.the building or improvement is sold within ,he yeagof.
completion,theouO,haader will have the harden noting that he did not hold or 307, — INSULATION
,intpmvaforpurposco(nala.l, -
01,asowneronneproperty.sm exclusively conlmcling with hceitsed commc(ors to -601 — ROOF" TEAR OFF
construct the inject(Sec.9(H4.Business and Professions Cadc:)The Contractor's602 - ROOF' PLYWOOD NATI,
License Law docs not apply m an owner of property who builds or improves thereon,
sad who cmnrava for Inch prpiects whit it canmazmns) licensed rnl sinal n he' 603 — ROOF. BATTENS''
Comic cror'.c Liver,.Law.
❑1a.r.c,tptunderSet Bxif•Cfor do,a,son 604 — ROOF`' IN—PROGRESS
Owner Date '
WORKER S COMPENSATION DP.CLARA9'ION
I hereby affirm an der penalty of perjury ane of the fol lowing declamion..: I' '
0 I have and willmaintain a Cendleate of Consent to'sel Gimmmr for Worker's
C 1. as on,vldcd for by ,Scction 391) of the Loinr,Cod, lar the
performance of the work An which lhi.c permit is i"ued.
01 have and will tmainoin Worker's Compensation Insurance,as required by Section
TIBB of ilia Labor Cale,for the performance of the work for which this permit is -
iu.uul.My Wur!k is CCon[tCjY,,roan lnsilrunco ca........I Policy nu({otheer me�
Cartier.,RTIFIL'AI'IONO PINJ TEM,Na.: TRIS �hR
„ COMPENSATION INSURANCE
(Thos section need and be c nad,.d If the permit is for one Imarred Dollars '
($IV))or less) .tr
I cenify That in be performance of the walk for which b Jammu is i...ad,.I
ehNl not employ any pervnn in tiny mnnncr so as m laconic object to the Wnrkerr -
Cu
pollen sa.inn lows of California.Dal, -
Applicant
NOTICE TO APPLICANB:If,after making this CertificateofExertions,you should -
0 -
become subject m
the Worker's Copensntian provisinns of the Labor Cola,you must -
O Gmhwall comply with such provisions ar ails parnl'a shall bq deemed revoked. is
y . ^
CONSTRUCTION LENDING AGENCY
I hereby affirm that There is a p.,mards n lending agency for the perfomunct,
Faz7 of the work for which Thi-s permit is issued(See,31X17,Civ.C.)
Lender's Nmnd
z Lender's Address ..
l..) I verify that 1 have revel his application and state that the above intonation is
W Ey correct;1 agree to comply with all city and county ordinances and state lawn relating _
0 f) III haildatgnmxonmk...andheraw,nthorl,represntnd,re,of this city to con,.,an - -
,,y the libnve.nmminnad,ripany fro btspe,I inn Purposes.
E"
911, (we)agree msava,iadermily and keep hood...the Cityof Cupertino against' _
f>n liabilities,j e'neraas,coos and expenses which nay in any way accme.Rains said
V City in consgn ant the granting oft 'yy permit. .'
APPLICANT ON STANDS D B.L CO .Y WITHALL NON-POINT IsSuedb
ERF . GONS. _ ^ y: _ Date'
SignatureAPp-�tleantfinn eons Data Re-rOOf$ -
HA9ARDOUS MATERIALS DISCLOSURE
•'Will the tlpplicarl nr Boase haihnns oaaupi I stored handle haa'arJam Imncrial Type of Roof -
as defined by Tho Cape(hit)Municipal Code,Chapter 9.12,and the Health and Safety '
Code,Section 25532(.;! -
❑Yes °"" All roofs shalLbe inspected prior to any rooting material being installed.
wwlhaappllaotitorfnurehaddingoccnpwnn.aoid'altet;tmde.it—rich If a roof is installed without first obtaining anins`pection, Iagree toremove
unit hazardous air renwminanhs uv deli tied by the Bay Arca Air Quality Management c ,
,oispich all new materials for inspection.'Applicant.undersfands and will comply with
°Ycx °N all.non-point so ce regulati
I have nud the I r t y I. anile Clarinet (.JS. the - e'•;
ifine an ilndth, SolelyCnl Sections 5505 25533t,n1i, si 1 d '.t nil that
/••y �-a� ,
ccuantldmRdresnorampantly whi oat 'tet lots yen tiltyt ncideo //
occupant of the regove nerve which mnq be mm prior to issuance of a Cmificot f - �
Occupancy,. -
' .' I 'Signature of Applicant 'Date ,
Owner cramhotized agent ' - Date All roof coverings to be'Class `B" or better'