00110146CITY OF CUPERTINO
BUILDING.DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT h8.0 1 1014'6
20i6E FOREST AV
OWNER'SNAME:
APPI.ICATj)rjs i:v) rt 2Vi0
GROSS DEAN G TRUSTEE
ONE:
SANITARY NO. CONTROL NO.
• ARCHITECT/ENGINEER: -
- BUILDING PERMIT INFO
BLDG [KELT PLUMB MECH
i
LJ l=
LICENSED CONTRACTOR'S DECLARATION
I hereby of inn that I am liscnod under provisions of Chapter 9 (commencing
Job Description
p
wish Secdon]UB(Hor snlofinellaeine,x an - n dm'liccnee
" '
REROOF� COMPOSITION 40 YEAR
nrwlrmce Irlo"i'i
t, in
j�'S
' me I � Corinne
._.
ARCHITLCf'S DF.C1, ettil(1N
-
] 1 understand my plant shall M uaJ as pub Ic renmie
Licensed Nefe,,inml
RATI(1N
Oat
I .BUILDERifr m the License Law for the
I hemhy ,Bier that 11. exempt from thed..it
' following mosso. (Section ]v.,anuhtsimxs and Co n
loos Cade Any city
i which requires, improve, de someone
canulattldmaimprove,dnns.it1 serrepairanye...I
.1s. u
primmits issuance,alsoet
suchpannins Glnw,
free
teethe ,,it ninf the Law(Carener9
Lkcnse Le,,ion, (Chapter
thmheisriit,
Ski Ft. Floor Area
I
�a1lllilL�1
vdpursuuanom, of Div
Unnm,enci6g wish Scmiun]IKKq of Divlelnn3 of the Horsiness vW Pro,es,ism Gxle)
the Business
or Ihnt he is exnnpt Ihercfmm and the basis for the alkgcJ exen,ptinn. Any violalion
of Seaton ]p11 S M1y any npplicam roe a pont, suhjems the applicum m u civil pennllY
m'morc
oolthatv
n ehaadmddouarx(s5a).
�t�t�r
AA' ujii�Sc,-. OQI
Occupancy Type
❑In as owner of the property, or my emplaycas with wages,, their sole compensnlion,
will do the work, uad ,he .Imctme Is not Intended or offered kit sale (Sec. ]IU4.
3 _ quired Inspections
05 FRAh -
Business and Profession Code: The Commucto.'s License Law dm.' not apply an an
who bund, improves
or"ie or property or thereon, and who dins such wort himself
I aaugh his ow, amd,ce.. poinded mal .ac 1, imlrrovm,ums are me imeadm or
offered on Sala. IT however. he Iamdmg or improvcmin is sold within one year of
307 — INSULATION
completion, the owner-halder will have the burden of proving that he did nal builder
601 — ROOF TEAR OFF
,top mve for p,tHar.corsak.r.
O L as owner of the pmpeal,aIt, es,hoively enameling with licensed nabumemr.m
602 — ROOF PLYWOOD NAIL
,nxnac, mo nroircl (See. nwa, 11 mass and Ittle"kan, code:) The comma" `"`603
— ROOF BATTENS
License Law Jens not apply loan owner of propeay uho build. or improves thereon,
and who eommau for such pmjeets with a commem(e) Keened pursuant to the
604 — ROOF TNI—PROGRESS
Csonamor's Liccoa Law.
❑tem exempt under Sec. ,Bffi PCfor this nus
Dole
WORKER'S COMPENSATION DECLARA]lON
•
1 hmnhy uffnn under Pohl dperjury ons of the following declmolionx;
❑ 1 have and will Certificate Sme of Comm m ,Labor for Worker's
/
ovidon f
Compm rat o it,he work Is,, for by Su1mn A]OH nl' ,hc Llthnr Calc, for ,he
perruhmanec of the work for which this permit i. issued.
p 1 have and will mdml;', x Compenwiu i 1mucmm, as required by Section
1]1X) of the Lu or the prforomm a of ,he work for which this pm,it is
-
issued.M cf.0 t .1111. I.,m nce ca^/y and�P.00llicy n�m�ramm.
Carrier _ P�liey NnJ`(_/.
O
ERI'IPICATION OIC EXRMPTI N Fl O\ \V C. S'
• COMPENSATION INSURANCE
`
C1eis action need not be e,mpl,tel if the .it is for ane hundred dollars
(S 10(h or lnsc)
I victory that in the perfomomc of the work for which this peanut is issued, 1
'
shall no, employ any person in any manner vo as ,o become subject In ,he Workers
`
Catnpnsation Luwx sf Qelilontl. rate
Applicant
NOTICE TO APPLICANT: If, alter muting This Ceaifinm of Emmaion, you should
lo, conm"adintto the Worker' Cntnperoo a provisionsof the Labor Calc, you roux,
tomb%ith comply with such provisions or this pond shall be, decmN revoked.
,
CONS'fRuc TION I.17NDI NO AGENCY
1 hereby affirm teal them is a consbuction lending agency for the performance
of the work for which tits permit is issued (Sec. 11197, Civ. C.)
'
Lender's Name
_
Unders Address
I ceury thot 1 have mud odsapph,into amt arm mot the ntsovh mmnnatm, is
correct. 11.1. comply with all city and county ordinance, and stem laws relating
to building commnmtissn, and hemby authorize mpmumaivn of 'his city m enter upon
me abovu.tn atinned property for iotpection purpt,ses.
-
(We) agree in save, indemnily and keep hannlev, the City of Cupom. against
`
liabilities, judgments, nexs and expenses which may in any way seem, against said
City inamun
"if"a.t hes grumh,g of,his permit.
//t J
�� P
APPLICANT UNDERSTANDS AND W LCOMPLY WITHALLNON-POINT
QUR GUI 'IONS,
.i J//
Issued by: Date
/l
'ignuwr nfAppbcunVCnmmcmr ]).to
Re-roofs
HAZARDOUS MATE RIAIS DISCL(15URG
Will the upplicare or Trina bwldinµ,wcopare stone or handle hazuNaus nrdledal
'type Of ROOF
as defined by the Cupertino Municipal Cale, Chapter 9, 12, and the Health and Satiny
'
Code. Section 25512m1^
Elves C1 bo,
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which
hazardous
If a roof is installed without first obtaining an inspection, 1 agree to remove
omit ter carton ,inams , v JeCnmd by the Ifay Area Air Quality Mnnagetuan,
mond"
all new materials for inspection. Applicant understands and will comply with
°Yc, °No
all non-point source regulations. '
1 love read the hamrda,x material, myuircments under Chapter 6.95 of the
California Health k Safety Code Sections 25505.25511 and 25514. 1 understand that
to notify the
e theemulsion re nom currcndy have a
peri r
of
/X
11\ s gs`\ � u
the
wcupant nl'the rcyuirencnts which must he mel prior n, issuance of n Cenifcmc of
last he not to issuance It
` ��11����.JJJ .1 V
(kc cYI
�o
-
lgnanlre of Applicant' Date'
All roof coverings to be Class "B" or better
Owam 111 authorized a gen, Dae
OFFICE