01050135 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10423 HENEY CREEH PIACE EXTERIOR Sm iiTTnN3_ _
OWNER'S NAME: APPLICATION SUB DATE
c
HONE: SANITARY NO. CONTROL NO.
dl
(408) 398-1233—-
09Z ARCIIn'ECTIENGINEER: BUILDING PERMITINFO
cw o c^� , %DP1 ELECT PLUMB MECH
6ip� I _ LJ I.1 I-1
LICENSED CONTRACTOR'S DECLARATION
z l'J y K 1 hardly off nn Incl I um lis<med under provi+inns of Chapter 9(cnmmnncir, Job Description
pa,a,1S=� with Section]fXNry of Ui 'n n3of the Business unJ l•Ill'c..ions Co,loundayliccon, -
<5 m Y j is in lull force and effect.
w.. < License emas._.TC_� tress REROOF—REMOVE SHAKE�ANDI INSTALL -30LB
E%o d u Dale /- f/— eemmemr_L
W E;0 ARCHITECT'SDECLAR. Soc,UT/OVS }- F/ — FREE
Mal$ 1 nn crsmnd my plow shall bo trod as public mcoms 2`+a O#SD "SJ
T
w p C Licensed Professional
ce= OWNER-BUILDER DECLARATION
I hotly.(Sect on 11. exempl from the Cndodw Craft:
t:Any v an,for the '
C?� which ngine,.(S.oil at0}LS,Bminer,imp Pe,derodit.or
city or county
Extp which)its oc n Peart re construct,pplic improve,for
ou h retain it ar repair any mmcturc
i 3� patlie ssccuse personal
requires the hovisio so the Coh �ctor miensele a signedstatement
Ihmheenscan aithSeanmlo,heprovialOnsof,MCieRolallfmnsclnwonsCer9 Sq. Ft. Floor Area Valuation
Icmnnleneis wish leaden].NB Of Divisionb ul'the liminess and uct.Any vi Code) _
of Shut he 7 exempl nharcfmm and the hears fn,Oso ia,tilA uaampho,,Any violation
ill'Section eIll Libyanyapplicantollfor aearnlds)) ,enhjmsthe npplicummucivil Tenuity -
arl,mmaremnmlivahllnercdaalmtslsslxll: APN Number Occup�lrly7"���
OLlsa owner Ili lhc p...Carl Ili an,a:nployeuswill,wagevas than,sole emnpeneminn, -
will Jo the work,and the structure i,nut lmended n,,Bored fnr sine(Sec.9044,
Business and Professions Code The Contractor's License Law docs not apply to an 2424 8020R��kred Inspections
ovalarof pm)pcny-Who builds or improve,thereon,and who does such nark himself
Or through his own employees.provided that weh Improvements arc ma intended or
offered far sale.If,however,the building or improvement is sold within one year of
inplcder-
on.the,webuueerwill hm
meeburdenofprovingthathedidnotbuildor 305 — FRAME
improve for purpose of ole.).
01,as Ownerofthe property,mat exclusively comruciing with licensed contractors to 307 — INSULATION
camuvct the project(See.]Bu,Business and Professions Code)The Contractor' 601 — ROOF TEAR OFF
License Low dues not apply to an owner of property who builds or improves thereon,
and who commit,for such projects with a comel ls)licensed pursuant to the502 — ROOF PLYWOOD NAIL
Contractors Liceme Luw.
0l ran exempt ode,Sw. B x,P C fill this reason E03 — ROOF BATTENS
Owner WORKER'S COMPENSATI(1NDIiCLAItALION 604 — ROOF IN—PR613RESS
' "
I hereby affirm under penalty of perjury one of Ila following decIamdnns:
J I have and will mainmin a Ccnlfane of Consent m,self-insure lin Workers
Cnn,pen. ecol he provided fnr by Section 1](111 of the Labor Cade, fnr the
Porto atm n,the work for which Osis permit is issued,
hoe and will maintain Worker's Compensation Moranee,as reRuired by Section
170(l of the Labor Cale,for Ne performance of the work for which this perm,is O
named At NfirAcrs Cnmpe mien.�y�r�,,a cortin and Policy number ore:
Carrier. � iec.71� Policy No X2.370/ .
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the pennh is fir ono hundred dollars
IEIW)or lms2
I canny thin in the perforinnncc of the work 1'or hick Ihlsjtnnit is issued,1
'hull nm employ any pct an y manner sn u 'ch 1 m the Workerx' -
i
Co Insult la,wF lY 'IfOm16 Dala int
Apdwam ,�
NOI'ICE'I' AO .a usi vxcTPL Rshaald
hccnmesoh)ec the Worker's Compensation provixinns oflhe Lidameltdc,you most
O li,nhwilh cply nh such proisiov or This pemnil shall he Jcaned revoAce,
F zI CONSTRUCTION LENDING AGENCY
a. ? 1 hereby li int,thrt,here is a combat Fending agency fnr the perfom,arim
of the work for which this pcm,it is issued(Sm.3097.Civ.C.)
L Q lender's Name
D z lender's Address
V G I madly then I have read this application and state that the above information is
G; P correct.1 agree to comply with all city and county ambulances and nate laws relating
V to building construction.and hereby adult represenmtim,ofthi,city to enter upon
the above mentioned progeny for inspection purposes.
.Fi y
Wo)agree if)save,indemnify and keep Funniest the City of Cupeoim,against
W City Innes,sequences,cons and expenses which Inny in my way accrue'gains,said - !
V z City In consequence R the grunting of This rennin.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WI fit ALL NON-POINT IssDCdb Date
BOUNCE REGULATIONS. Y• '
SigmeumafnppuaanOCannermr Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the appream,r rune building me,Ipaol samra or landle ha amara mnuannl 'Type of Roof
as defined by the CupeNnO Municipal Cade,Chapter 9.12,and the Health and Safely
Cale,Seconn 255121sT,
oy" X. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or farm,building menpantlive egcipnumorde,imswmm If a roof is installed without first obtaining an inspection, I agree to remove
emit hazMous air contaminants as defined by the Bay Area Air Quality Management
Di'mad? - all new serialsfor inspe tion. p ' ant understands-and will comply with
OYe,' a all n -pd t source r u tic
to l
1 have read the hazardous materials requirements 25ncnu d 255 L 1 un erla of the
Cali t buiullcallh R Safely Code,llyhave Section,25505,25571 unJ 25514.IlymnanFeth _ —_ --
dnhehnilJi snmolant,off one nyr,ponxihililymnmify the
'alpan the a rcmenu whi m n In c of a Ceni to o
O¢IIp' cY - .
/ a� native of Applicant Date
D wr„ e�Iinri.ed Ilgenl DaI All roof coverings to be Class `B"or better -
OFFICE