01040045CITY OFUrFiSIO
PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO,
010/f004_9
OW'NER'S NAME:
APPLICATION SUB DATE
04/11/8001
IPHONE.
_
SANITARY NO. CONTROL NO.
ARCHITECI]ENGINEER:
BUILDING PERMIT INFO
.
BLDG ELECT PLUMB MECH
LICENSED ClOn )NG RACTOWS BE 1 ARAI'ION
I Imtcby
,1017 Desert t
p,
affirnn that Inn, ieen.W under rmviximtx of Chaptar 9 (commencing
w'uh Section 70gB of Divloun l of the Bmine" and� Cade and my liceme
-Preoon"im.3,
me..xe cm.)�-ary— Lix_
�in full frac and cB ,. /Y^
Dote `i �•�u=Q( Cnntmclo -µw
REROOF. -
RCH DECDRA ION
11 he used
I undcmmmJ my plana bull be uxJ ax pnMlc rwords
Liaensc.d
DER
OWNER-BUILDECLARATION
I herebyerebyaan
lfir License Lew for the
11. exempt from the Colum,
following ease.(Section ]
on Bueines a
Code:Anycity oenunty
/1
iand.se.dennal
which requires a permit to corona aper improve.
onu ore asig any emacs
` �1
h permit t
prior to its issuance. e.also requires he applicant for such permit mice
signed hain,em
honarse licm.edpSellounmepnwi.lanametc11he,I arsumn.et"'mr,Com)
S Ft. Floor Area
q'
- Va tion
(coon he in,I, a whh Iheren an and the fofnn 3 nth allued ineoud i n,rAnysi Gale)
or that he to exempt there utna he blas far the exert Any vpenalty
^f0
subjects the ant in enaan
applicant lhr lPPllcunnnacivil penult y
ofaminre than
-
vvnyapplicanlr,($50nni(nuhJmts
of notmnrcthanfivchnndrct{dnllun(55(aB),
APN Number
Occupancy ype
❑ 1, as owner of the popery, or my employees with wage. a, their mile compensation,
will do the work, and the structure is not intended or offered for sale (Sec. ](N4.
_ Required Inspections
Ban xinrss mad Penfessians Code 'I Contractors License Law one, not apply o ant
i' of mny Who bands nr ims
poer nms
the,., and who doe, such wink hielf
pngough
or
thhi, own employee,. provided that soh nnpr otmenta ore oat intended in,
305 - FRAME
offered for star. If, however, he building or improvement is wild within one year of
completion, the owner-1milder will have he hurdcn ofPoving her he did no, build or
307 - INSULATION
improve for tan"w of sale.).
❑ 1. asowaer of the n, cxelmiNel Contracting
grope y run y with licensed a,
601 - ROOF TEAR OFF
venaraet dte (gee. ]044, Buwineo and a Contractx
nd,am:)'nie Gnomon'`
60�_ - ROOF PI_YNOOD NA I I_
does
Limns Law dams nil apply to to owner of property he bond,
woo builds or hnpmvao,
aaemort M,'h,
Cowho csLicem me such pmieri, with a eammeton.) hren.eal .,.an, to he
603 - ROOF BATTENS. .
Contractor's licence
❑ I am exempt under Sec. , B se P C for this reason
604 - ROOF IN -PROGRESS" -
Owner Date
WORKER'S COMPENSATION DECLARATION
I nearby alYmt under penalty .1 perjury one of the following daclimaim.e
'•
❑ 1 have end will maintain 1 Certificate of Consent to selbirsure for Wbi
Compensation, as provided far by Section 3700 of ,he Labs Code. for dm
,
perforanre of the work for which this recruit is issued.
❑ I have and will muimain Winker', Cnmpen,ain I Iu,nour e, us reynined by Station
3700 of the Labe, Code, fnr the perfnrowner of the work for which thio petmii is
_
sued. My�+Wararr s Comins`mini"on Insurance carrier and policy former are:
Carrier._�r-^ T_Lwy7Policy Nn.: --t. C. 5 t,3
'
CERTIFICATION OF EXEMPTION FRObf WORK HRS'
COMPENSATION INSURANCE
(This m06(m need not be cnmpletW if the mein is for one hundred dollars
($I 00) or Irmo.) -
I certify that in he performance of the work nor which his permit is i ... ed. I
shall not employ any penin in any manner to as to become subject e, the W'orkels'
Cn at ematinn Laws of Ceiburni Date
Applicant
NOTICH I0 APPLICANT Ill alta neeking this C'enitlmnm of Exemption, you should
Inc conu soniea to the Workers Cnmpensaum,oMkion. of the lobe, Code, you mol
forthwith nmydy with such povidon.o or his permit shall be stented revoked.
CONSTRUCTION LENDING AGENCY
1 hereby afnm that theta is a cansuuction lending agency for the pefmare e
of he work for wh ten this peril is issued (Sec. 1097. Civ. C)
'
Leeder'm Nwne
-
Lender's Add....
I certify Ihm I have at this upplicmion and stare thanhe aMnx information is
comet. T agree to comply with all city and county ordinances and state laws relating
tobuilding construction. andhereby authorize representatives ofilhis city to enter upon
theabove mentionedp pe.pet purpose.
(W) bra t I india ly andkeep harmless the City ofCupertino against
t. a:int Y Y 'Y 'buinn( -niA
- J1
Cityit
City e..ylcuc of the 6mu gafhn pernit
APPLICAN'r.-y-
SOURCCN ULA IS SNDSAND OMPLYWITHALLNON-POINT
�._�- y --/l -D
IssuEd'byt /.'� ��rt�>-yam.-� ; Date Spy/ti'
Signature of Arplivani unsafe dW Dale
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
Will Ihcapplicnm or tuutrc building eaeupotrmal
nt store or handle Jdi uus d
Type of Roof, .
ns del incl by the Cupenlnn Marieiml Code. Charter,9412, and it,, Iletdth and Sefety
-
Code, Seetion 25512(1):'0
5512(1):' /
❑Veru fxr
All roofs shall be inspected prior to any roofing material being installed.
Will the applies., or future building occupant use equipment or choices which
If a roof is installed without first obtaining an inspection, I agree to remove
mil hmanlnus air contaminams as defined by the Bay Arca Air Quality Management
Dive"
,
all new materials for inspection. Applicant understands and will comply with
°Yes
all non -point source regulations.
I have read the 645 the
me. tlaf, rcyuircnmnts under Chapter
California Ilealm @ Safety Cade. Stations 25505, 25537 and 25514. 1 understand the,
hareems
If hebuiloft does at comedy havcalenvn,. aha it is my responsibility to nmify he
I f
``
�A
manpam of the oquireme a which w, be met prior m issuance of a Cenificme of
�
7.
GeOp00Cy'
_Date
gnature of Applicant Date
All roof coverin rs to be Class "B" or better
Owner or out avireJ vgem Dae
OFFICE