00060067 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PHRMI'INo
OWNERS N.n ;75t JOHNSON: APPI-CATKOO 1n-067
HONE: SANI'T'ARY ICr1�Ct4//'Cr2@�` �KO.
BUILDING PERMIT INFO
o ARCIiITECT/ENGINEER: 11LUG IA.IiCI' 1'LOME MECH
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y z LICIiN51iD CONTRA(]DR'S DIiCLARA1lON Job Descl'IpI100
O z—O 1 hereby dTrm that I um L coed under provioom.of Chapter 9lenunmoving _
F_F 7 with Senimn 7(00)or Division 3 of the Rnsinen and Profc,simns Cale,and by heense
m j is in full force and effecl.
Y,_ 6 LicenseClass I.ac.a
XDi r Dae Commoner
_.`O v ARCHITECT'S DECLARATION RE—ROOF
I undeeimnd my'plan\shall be,moil us public naoNs
ze-y7
s x a O Licensed Professional
c L_ OWNER-BUILDER DECLARATION
I hereby affient that I am exempt from the Contractor's Licensc law for the
=za Rdlowing maxim.(Section LI3I.5.Bu%ino%and 1'rofich%ne,CINe:Any city or county
C which" ims a permit to construct,cher.improve,demmlisb,or mpuir any structure
x=o prior to its issuance,also requires the applicant forsuch Permit it)file a signed.aatement
s 3'� that h:islicensed pat.uam to the pmvioons of Contractor.,Limme Low(Chapmr 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7(XXp of Division 3 or the Ru%iness and Professions Code)
or that he is exempt therefrom and the basis lin the alleged exemption.Any violation
of section 7031.5 by any.,loon,foe a pemdt object, he applic.m it a civil Penaer OCCUber
of not more than five hundred dollars(S50(n. APN Numf4irS6ypC .
❑1,as over,of the propcoY,or it,oo,k,cav with wage,.as their wlc compcnsufon.
will do the work,and the structure is net intended or offered for sale(sec.70.14. '
Du.me,\and Proms%ions axle:The Contractors License Law does not apply Io an 37531057. 0L%equired Inspections '
owner of property Who builds or improve,Ihemon,and who does arch work himself ,
through his on employee,.pmvlded that such in.pn,vemm vs Bre not intended or
offered For hale IL however,the building or innprovemmal is sold within one year of
completion,the ownei-huider will have the burden mf proving That he did nm bold or 305 — FRAME
mpmveforpnmowo,d,). 307 — INSULATION
❑1,a,owner)fine property,am eaclnavely enmmcthng with h<coved contractor,n, 6@ 1 — ROOF TEAR OFF
clmsnnet the project flee.7044,lin\InmI
es,aPmfe„i) nr
Iis Cote)The Commo , -
Llcone Law does not imply Io an ev oar of property who buihk or Improves thereon,
and who cotnorcu for,nen nrojeel.with eoar.,aods)hemsed I,In,aam to tine 60?_ — ROOF PLYWOOD NAIL
OmtracEl arnexcoptrtin\claw 603 — ROOF BATTENS _
❑I nm exunlpt under Sce. .If h I'C Inc This reason
Owner nate 604 — ROOF IN—PROGRESS
WORKEId'S COSIPENSA1ION I IIiCl,A11A I ION
I humhy ullirnn under penally oI'pe Jerry oma of We rnllowing declmaimns-
kI
have and will antnin a Cntiliane til Concert Io odflo nm for Worker',
m, vr,.e nn, a, providedfur by Seelimi 3700 of IIt, I.uhm Code, lin dm
pcdonnun a of the work rnr which ILI,permit I,inowd
❑I have:md will on lnuin W(Ha's Cn n,n oil Inwrancq ns required by Scelion
3700 mf the Lulxrt Cnde,fol'Ibe perlbnna nee of the work for which di,permit is
koa,d.My Workers Compcmntiun I...umncc carne it N licy tmmtcr ate:
Carrier: Policy No.:
CERTIFICATION OP E%Eh1Y1'ION PROM WORKERS' Q
COMPIiNSATION INSURANCE
This section need not he completed if he Permit is for one hnndrcd dollars V
($100)or less)
1 cenify that in the momminave of the work for which this permit is ,wed.I
shall not employ any person in any manner so us It,hat subject to the Worker.J
Compensmem Inns of Culifumia,Dam
Applicant
NOTICE TO APPLICANT:If.of c,making this Ceedlieae of Exemption,you should
Femme subject a,the workds Compensation provisions of the IaM,r Cade.you most
O 0 forthwith comply with such provisions or this pemnit shall be deemed revoked.
ZF Z
f” CONSTRUCTION LI"I... AGENCY
1 hereby u�Rml that them is a co.,um'on lending agency for the perfommm'e
of the walk for which this permit is issued(Sec.3097.Ci,C.)
S Q 1<nder's Name
.5 z Lxnder's Addnes
U C) I rani fy that I have mad this application and%true that the alnewe information is
fi ;: cntmcl.1 agree to comply wih all city and county ominance\and state laws relating
O U mFvildimgcommmtion.and artery authorize repta\entmives ofthis city tnemer upon
} W Ibe alum-mentmned proif lin inspection pmpne\.
rr Is. (We)agree to s..x.indemnify and keep harmless the City)I Cu,sedi m against
Z liabilities,judgments,costs and expense,which may in any way accrue r,mml wad
C„) Z City in consequence of the granting of thus per it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. y'
Sagnamre.1 ApplicaMCnnlmem, nate Re-roofs
IIALARDOUS MATERIALS DISCLOSURE
Will the applicant or future hadding occupant slim or handle levalloo\material Type of Roof
as defined by the Cupertino Mmdcipul Code,Chapter 9.12,and the I lmlth and Sarov
Code Section 25532(u)I
OYc' • 0 N �y All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfuture boildimgocrnpannmepilasont ILevies,whmt It'd roof is installed without first obtaining an inspection, 1 agree to remove
moil brmnlnm til,ennluminants us defined by the Hay Arco Air Quality Munugealent
raceme'? all new materials for inspection. Applicant understands and will comply with
ave, 0 N all non-point source regulations. .
1 have nod tire htzrol a rialk requimnanls under Chapler 695 mf Ile
Culdornin Ilndlh k Safety Cnde,Suction,2550.5,25533 end 25534,11 desladthus
if the building dem nal anmmly hove Burman',lhm it is my rtxpnnsi bit lly)..miry the
' -
c,aprnl of the rcquimntenla which moa be lout .for w issuance nl a Cenitis:ua fit
cuporay. '
Oc
- Signature of Applicant Date
Ownermamo.Dedagau, Date All roof coverings to be Class"B" or better