00120031 CITY OF CUPERTINO
BUn.mnGBIVISION PERMIT CONTRACTOR INFORMATION:
OI111.UING )DBL.'S; PERMIT NO.
001200311
ow',spR'S NAME: APPLICATION SUB DATE:
2 F - fnrlF_ 12/05/2000
IONS; SANITARY NO. CONTROL NO.
O.0 ABCHI'I'I: :NGINIiCR: BUILDING PERMIT INFO
kC F BLDG CI.CC'r PLUMB MECH
Nab I_I I_I I_I I—i
E. LICENSED CONTRACTOR'S DECLARATION
>- 11mAb no mal l aa,licensed nader Job Description
OZ_ Ya pmvixiona n(ChCode 9lcomn,eneise
F_r,� wits S«dors lIXxB afOh;>ion3anne Bsmes and r,orew.mna arae,and n,yh«nae
ax mwuh,reca f HOT TO HOT
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a U Uulc_f z S DECI or —
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41111 'S OI:CI.A rOM1
SH'ol I understand ity pians hall No meds public record.
d
Licensed Professional
g r i pWNLR BUIL Dlilk OCCLSRAI'(ON
G7 II Ly nilia(I
g rh til In jr I.so :L wlmlb.
g . S station u JI r.' acrd Any,awhir ts pc oa s he, p J I.h epair.Y baemm
Brian t issuance. Leorcyu Ili applicant f h I t signed statement
3 (limn licensed P nail thev ors I rratt rcLis u
Section 7 D s 3 fol 1 n d P o-Co1e)
Sq. Ft. Floor Area tion
ooh ...ad o tr.' h II l vs,rO,1 iryhr, •170
0
or Sa7on by any ma BsuImrndl oned.dhna,plirmlm a cvllornahy
ormormore itin tee hundred donna
($s(an. APN Number Occupancy Type
0[.asminronheprnpeny.nrmyemployee.ximwage.naheir.nleeourpeir,shon, 3751 804 1 . 00
will do the work,and he structure is nal intended or offered far.ale(Sec.71W, -
Hmine.s and Proree.imis Cade:rhe Ca rmamrw License I.aw docs not amply m an Required Inspections
N pnmeny who bnikk or impn,vew me w,amt who doe.rael'walk himsdr
or Through hew Own employees.prouded that such m
improvecau are nm intended or 305 — FRAME
offered]Or sale.If,however,the building or iniproven enl is old wimin ane year of 307 — I NSLII_FlT I ON
completion,the owner-builder will have the burden of proving that he did not hard ar
mpmvclarpurps,.cof.me.). 601 — ROOF TEAR OFF
❑L.,owne ofinepmpeny.:,mnxd...i.e comraeli„gwidruan.edeomnterorao 602 — ROOF PLYWOOD NAIL
Lpmt ten rho project(Sat.7W4.Bu. mrd Prura.. s tale:)"Tc Con(metor'a
cce,lawaansma apply man(wwrolr property wlin lands,or improve.menean. 603 — ROOF BATTENS
and who contacts for such proj«rs widr a eammctar(.)Weaved prooem to the
a
ContemrsLicense,"%'. 604 — ROOF IN—PROGRESS
01 ant esenia Omer See. .B&P C Fortin,reason
Owner Dane .
WORKIN S COMPENSAI ION DECLARATION
1 hereby ulBr under pcmihy of PrOvi,one of the following declarations:
jhave and will mainm'm a C.er iricate,Of Consent m self-in.urc for workers
Cmnponmian, uw pmvidal ra by Scwioa 3701) a1rhe Labor Cade, tor the '
Perlia a;re orlhe work I'o,which Otis permit is i...ed.
01 have and will maintain Worker's Comry:n.olion Insumnce,as acquired by Section
]TIB of the lanor care,for the penin is nce of the work far which this permit is
issued.lily Workerrrs Co/{ni,anssaattiiioon)�inwanae carver and Policy nuralar am:
Currict t/�—T11f:LLA'll lIN()Ir li%�'A1 I'��O FROM9 ZN
t�� COMPENSATION INSURANCE 32
Frus section neer not be completed if the permit is for one hundred dollars
(Sla)nr lees.)
I cun'dy rnul in the Imdommncc el me work Ga whish this peril is ..d,1
.hull n a lrPl iny I �o Ipa � keri
Camps 1 I Cal a D a
Apra {
NOrICI C eft Ili n' f l7verrai i, ,in should
nee, Ir theWorkers C P P rhea b Cm y rust '
O Innh .,nnlrwm.och P,dao,s or the prio�I shall be ducned evoked,
Z2
E' cobs rRum[ON LcNDING AGENCY
a I hereby aBir ohm there is a con.waion leading agency for the performance
of the work far which this porn is hued(tie.3WO.Civ.C.)
L A Lender's Name
z Z Lender's Addree .
U 0 1 ucnily that I have read this application and wum thin the aMxe infimnautor is
la. [.. correct.I agree to comply with all city and county ordinances and state laws mlating
0 U to building construction,and herebyauthoriee representatives of this city to enter upon
ry)
he ubrvcmentioned property For inspection purposes.
G (We)agree u,save.Indcmmry and keep harless lbs City nF ce"lin........i _
m rud,ili ic......ha nls,c,......d ex,row,,word,may It wry way u ni .....au said
U z Cry in eonseyuen«el�ihc gnliag ollas wnnil. ' e.. c .
APPLICANT UNI eOANDSAND.W CO PLY WITH ALL VON INT /
Ca RI:OuI IO�NS/, �” Ir Issued by: Date �t7
rec; 47
all�'ar: .Or L Data Re-roofs
IIA%ARDOUS MN]'[TRIALS DISCLOSURE
Wdl me applicator hlmre hooding occaparu saom(it laradle haaadon.mmereal Type of Roof
as defined by the Cupert))ino copal tele,Chapter 9.12.and the Health and Safely
Code.Seaoon 25532(.
0 Yes `%No All roofs shall be inspected prior to any roofing material being installed.
Will tire ahplienm(it hionebnlldbrgoccnPanluse eOrtpmenta,devlccwhich If a roof is installed without first obtaining an inspection, I agree to remove
mil h:vnrdau.air connmwaQ\ re liner by rhe Buy Area Air Qouhty Man egen rat
e)i.lrielo Ye, `,No all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I nate read the Ira.ardnna mmeam..requirement.under Chapter 6,95 or me
Cnliforniu Urchin&Snl'ety Core Scetione25505,25513wW 25534Iunrursl:nid Thal _
it he hording docs nal emnarly have a mmm�, len r iv my r,%Irrasihihiy n.notiry the e
occupant("the reyuiremans which nrusl I prior m;seater of.Cuniricmc or
°"apo°`y' f nature of Applicant ate
� / )r All roof coverings to be Class "B" or better
OFFICE