00080050 a9 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
v`BU I LOING AUU RFSS: PERM I'INo,
OWNER'S N.I4Lr^2 rt'1 JOHNSON AV APPLICA"(0008W50
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PHONE: CONLEY, ROBERT SANITARY ft/07/ffteo,
❑O ARCIErECGENGIff BUILDING PERMIT'INFO
w— BLDG ELI'C'I' PLUMB MECH
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F y_ I.ICHNSED CONrRACI'OR'S DECLARATION Job Description
I liner,rural+that l I.... need underptw inmof Ch,mtar9 fnimmm�cing
with Section 719X I of Div' nn3 of the B oinu,s and'Praf,ions C de.Ind my licen.e
ie in full fora and clfcct.l,i -
z a Liccnw Cl." Lic.x '
K a Uac Contractor '
wLLo ARCHIIHCr'SDECLARAI[ON REROOF TAR AND GRAVEL TO COMP
.�.— I I dershuul my plan,eh,dl he used a,puhlic resent,
o<a Licensed Pmre aional
IE OWNS -BUILDER DECLARATION
I hereby affimh that I a crud from flat Contractor's Liecnee Law for the
C Z S following m:uon.(Sauna 703 1.5, inenr and Prolbveino,Cn It:Any city nr c.army
f x❑ which reywrcs a lermit m aim:ruct,:dfi,,tnyrtnve,demolish,nt repair any smearc -
n3x priono it,is,minee,:ds..reyuire,fhc applicant for weir permino file aligned sfimmem
that he is licensed panuam loth.provisiomuffhc Contractor's Lidenhe Law(Chapter9 Sq. Ft. Floor Area Valuation
(commencing with Section 7001)of Diem..3 of the Boorws,and Prefersinm Craft)
or that he i,exempt therefrom and the basis for the alleged e.vemptien.Any violation
of Seer 7031.5 by tory npplicdm for.,permit subjad,the upldicnm to a ,,it pchu ally
of art marc dwn Ire ifnndred doll„x,($500) APN Number Occuca��pe
J
V,t"s`wneroflire Prosed,onlymnde tt,with wages a,theinnle compensation.
will do the work,and the,tuemre is not intended or offered for sale(Sec.70U.
Business and Professions Code:The Contractor',License Law does not apply in an 3751 8028. &quired Inspections
sway of property Who build,nr improves name t and who does Bach work himself
or bought ho.own employee.Provided that,uch Improverncros arc or
intended or
offered for sale If.however.the building or improvement i,sold within one year of
iImpletion.file owner-builder will use the but of proving that he did not build or 305 — FRAME
mprove for papaw.of,ma).
307 — INSULATION
r
D1.asownc or 11+epn,ptry,aae,ewdvely,ommnErraticalsilt Erratical con;clo.nth
consumerthe projeo See.70,14,Ba. and Profs, s Code,)The Contractor, 601 — ROOF TEAR OFF
aensc Law does not apply u,an owner of proeny who build,or impnsves fhcreon.
and who contracts for such project,with a contractors)licensed Foran to the 602 — ROOF PLYWOOD NAIL
Commnors License Law.
C l ma exempt trade,See .B.N P C for his re,,on 603 — ROOF BATTENS
OwnerN, Dae � � 604 — ROOF IN—PROGRESS
I WORKERS CON 'nNSAHON DECLARATION
I hereby affirm andelpenally
Celli crom or one of the rnuowhouledwarnn,:
C I have and wlll maintain a Cenilieet ill Cnnamt m x•Labor re de Worker.
4 ComPeoanceo as provided Et by Seninn 3issu of the Luber Code. for IM1c
perhnmance of the work far which this permit i,issued. v
❑1 have and will maintain Work,,'%Con+pcnmtion Insurance,an required by Section V
371X1 of the Labor Code.for the parnrmunee of the work for which this noil I,
sued.My Worker's Counpem0tion Inwmnee carrier and Polley aundmr are: '
Cattle. Policy No.:
CCN I'IIICATION OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
II his,,00n neral not tw nntp1,fcd if the permit Is fur.Inc hundred dol tan
(51(A1)or le,.)
I cenify don in the perh+mhance of the wed for which this permit is issued.I
shall nm employ any scram in any nr m+u,m fensmu table,, ,,the Worker,'
Conilstws el caldbrnla.ratenn
Applicant
Not ICE TO APPLICANT:If,uf¢nvaking this Certificate of E,nnption,you should
become subject to fire Worker,Compensation pmv.ions of the Inhor Cole,you must
Q O fnnhwith comply xifh such powi,lon,or this permit shall Ne dttmed revoked.
r = CONSTRUCI ON I-ENDING AGENCY
> I hereby affirm That there is a conswnion lending agency for the performance
of the work for which this penton is issued(Sec.30H.Ci,C.)
L C Lender',Name,
7 Z Lender',Addrew
C.1 0 1 certify that I have read this application and,file that the above mrnnnations
E.. enrrect.I agree to comply will)all city and county of inanees and,tate laws relating
Q V :o Wilding construction.and trembly amhodze mPre,e tatve,of this city to enter upon
”; he:hbovonteminned pmpeny fill inspection purposes.
r6. (We)agree msrve,indemnity and kcal lwnnless the City of Cupertino agmna
V) liamd,ics,judgments,mai and expenses which old,in any way;mane n,kion aid
U Z City in cmneyvenee of the granting ill this pvnnit. '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS, y'
Signafarcnr Applicanvcmnranor Late Re-roofs
IIAZARDKAJS MATERIALS ASCLOSURB
Wiinthe applicanloretureWilding l„upamstore inhandle hamu,
,.,wnhmcm� Type of Roof
a,defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Seen..25531(0)^ C No
0 Yes All roofs shall be inspected prior to any roofing material being installed.
Will he apphnrotormmre huimingoclafant arc cq:hipmento,deli=ea which If a roof is installed without first obtaining an inspection, I agree to remove
it Iumdral lair contaminants a,defined by file flay Area Air puaWy Management
District? all new materials for inspection. Applicant understands and will comply with
❑Ye, ❑N.' all non-point Source regulations.'
I have read the haza loon,timerial,mgoirtuwnf,atom,ChafEw,6.9,9 of the
iftheWilingdoffiotcur Code.Semon,255115,t itis anti25534. itytoundemor Ibe
ifthethe
a hicvcamname[ oismy msM+n,ibilitymnatifythe I1 J,.r4G` f\' \ —.
occupant If the myuiremenu xhich mush h ran prior m issuance ora Cenificam of
Occupancy. Signature of Applicant �— Date
own.,or tmmari,ea Ogen, - Date All root'coverings to be Class "B” or better