010400431-4
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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT -
CONTRACTOR INFORMATION:
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BUILDINGADDRESS:.
PERMI'1'NO'
APPLICATION SUR DATE
OWNER'S NAME:
�PHONF.:'
SANITARY NO. CONTROL NO.
zpAkCHITECf/ENGINF,Ek:
UI
BUILDING PERMIT INTO
E
BLDG ELECT PLUMB MUCH
d
Z LICENSED CON ',Ader'SDECLARATION
e II m (list brl licensed under prowisiops-rchpt )(aontmene ng
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lob Description
w wall
,I s Y 7W0)ofD 3 ftncH d L J rut ly) ficntse�
i' fur fr /I SC
C L Gl:
Dead C U I
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REROOF ,
� - R HITECT 5 UFCI Al1U •
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OWNER -BUILDER UFC, ARAfION
I belchl affillo that 1 --I orwolid firm the C t L' I n
. (Section ,HIS Hu,niell 'Itp nil f..i CW Ary ,y county,
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Q whicfalltavh
Nm
9 p „ r, J minor; ysl r
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es Pro,, I I the ppl tl hp n trot lvvsig md.amsmcn
— 'hot he is licensed pucvuedto me pmvismtnof the Contractors License Live (Chapter 9
(wmmencing Section%10)ofD"bum
5' ]'+[, I"IOOr Area
'Valuation
whh 3 of the Business and Pfol'osvions Code).
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el that be is exempt therefrom nnJ the basis for ale allcgrA exemption. Any viululion ,
of Section 9031.5 by any applicant for a pumdt subjects the app] cont to a civil penalty
'mom
of nmthan file handled dollars ($50T. 1APN
Number
Occhpan
°I as noroftl p ps tr or, TI ywith ago, a, th r: I Ipso: fon,
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will do d kand th .tut i I', ddoron dr -.I (Sec 9IHd
squired Inspections
Bmshm,, add Profe,,nat, Coll I far Camrawt.C,.i 1 ens, Lw J t apply m air
Who
owner of property builds oImproves thereon, andwh does sh work himself
or drought his own employees. blooded that such improvements um oat mended or
offered for side. If, haweven the hadma, at improvement I, 61d within ane year it
305 — FRAME -
remoter iatt. meowncr-mader will have the barren or proving that he did not build or
impatvc I'or puryose of salt.).
307 — INSULATION or
°Lasowner othe property, amexdu.ivelycontntcur, onlicensed eomm..... la
60Y — ROOF TEAR OFF
anstma the pmjcet (Sec 7(J . Business and Proressima 1,1,:) The Contnanrk
icenseLaw (fees not upplytoanownmafproperty%heboldsorimproves thereon,
- 602 — ROOF PLYWOOD NAIL .
and who contracts for.suen projects with a .ontractor(s) licensed pursuant m m`
Conwemr's Licence Law.
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603' — ROOF BATTENS
,B&Peli,rntmm�.°n
604'. — ROOF IN—PROGRESS
Owneremp,anaersact
Owner
WORKER'S COMPENSATION UECLARAI'IDN
'
I heahy aHirnt under peraily of pocmy monflhe fallowing declared I,:
❑ 1 have and will molnmin a LnlBcme of Consent to sell -insure for Worker's
Cmnpensa0on, as provided for by Section 3700 of the Labm'CQdQ, for the
perfmmxmce of the work tins which Ilii, permit is issued.
° I have and will maintain Worker's Compcnwtinn Insurance, Its required by Sertuar
3700 of the Labor Cade, for the podial ince of the work for which this permit is
issued. My Worker,, Compensation Insurance carrier and Policy/muddler arc:
Gtmicr: Tin frr miry
s! No:
CERTIFICATION OF EXEMPHUN FROM WORKERS'
COMPENSATION INSURANCE
'Co, section trend not be completed if the permit is far one hundred dollars
($100)nr les..) .1 -
I certify that Ia the perronnnnee of the work for which this permit is issued, l
shall not cirri, any person in any amnner so as to Mcome subject ,, the Work,,,
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Co upensmion Lows of Californio. Dam
Appllcanl
NOTICE I APPLICANT It, uftm makins Ilio Cm,ifcoc of F'annptiom, you should
'
tuome subjccrm me Worker's Compensation proviAmis af,hc [saber Code, you mus,
fo rovi,h comply with such provisions or this peril shall he deemed revoked.
CONSTRUC'T'ION LENDING AGENCY
I hemby affirm 'hat there isaconsoudion lending agency for,he perforamoed'
.1 the work for which this permit is isumd (Sur. 3097, Co, C)
.
Leader',, Name
Lender's Addrem
I ecoiry mat those toad this application and slim that me above intbno u no is
11
rz, i g t n I IYas tn'11 city d ty 1' and 't ,arelaws
P f g
tub dog t it dh Ili I fr Cle pct
,hc chose mentioned p p fry for pot p q ..
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(We) .91. to I.so.ordennartyo Jkeep l Ie: ,hefty C,,pQ.iQ.
'g'm
i
iublY
liabilitiesdI em.. , d v which an) against L.J
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Cottyuece m theg n6I'thIo
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APPLICANT DERRTAN 'ILL COMPLY WrrH ALL NON -POINT
SOURCP 'G LA )NS. //�0
s
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Issued by' JQ �' A/r.�J/t�s--ACL l �, Date
Signature of Applicant/Contra, - Datc
Re -roots '
'HAZARDOUS MATERIALS DISCLOSURE
Will the applicant our flume building occupant mote or lwodle hanWous material
Type of Roof
m defined by the Cupenino Municipal Code, Chapter 9.12, and the Hcslth and Safety
Code, Section 25532pp1
El Yes
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All roofs shall be inspected prior to any rooting material being installed.
Will lis-11Imummounarabuilding etmedbytire alusccaAt,LodlyMeoaswhhh
emitict' us airconmminameasdefinedtry,bcBay ArcaAupminyMnnagmnen,
11'a roof is installed without first obtaining an inspection, I agree to remove
tai p g
°t""`'"
EI Yes
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations. "
Ili Into it me drand.o, ambaurl,y - m t' under Charter 6.95 of the
Calif b lfth & Safetv Code, Sections 25505 5531 and2553J 1 understandIht
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iIthe burldio,does un on. rally moo a tereau, door i I I, or,mp ibil fly to nodythe
mccultim 11f 1 wlra.nQQI1 h ,1 holder p' r I.. f Q C nificme of
N-
orc °
Signature of Applicant Date
All roof coverings to be Class "B" or better '
ner or dathorired agent - Data —
OFFICE