00090150 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
RUILDING ADDRIisiS: I• IV,111 NO. 60-6p O/,5-0�XTCRJo2 �
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APPLICATION NAN1882KIM ST 7- Smir� 4vim 00 150
PUONEse � 9SSANIfARYNo .
0LERNERROBGrRT T c1� }
O ce z ARCHITEC'DENGINEER: - RIJUXING NIRA411 NFO
hoc . 1 08 — .3S8-1233 D ELIiCI' PLUME CH
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S LICENSED CONTRACfOR'S DECLARATION Job Description
0. u n Ih'rebvlifmm mal l am licensed under prmi.ion:of Chaper9 leonmeneing
OJ zn w with Scainn 71(X1 of Disision 3ofthe liwino.anEl•ndcuions Cole.1 dub lie
I 'm bell liren:nd effect
Y ease
��z< Lieen.ec,xy_ /`G3_9 Lie.»
Som" nate_ /-'ti—•S/b comraaor_ K Rtoai
��a, ANCIIITECI'S DECLARAI'IO SOaorioau Woo. SHAKE TO CELOTEX PRESIDENTIAL I//DYQ)
—�I
I I understand my plans sh;dl hu used m public rc nl
atS O LL LiccmN Prom.sinnal
OWNER-BUILDER DECI.A :TION
I hereby allinn 111:11 1 a mgr li'orn aara,aa' U-na,Low for tae
fZQ fnllnwin,mumn.(Section 7131!5 eRunincs unJ mm,ionn Coln:Anyehymcaumy
Ewhich require%a peunit to coawuct,alter,improve,demoli.h,or regularly sy ommm
S — pros t c at y the f much 'Dt flea belt cement
i! that he I' i namt dueImon, ifll C r' t ACIale Law(Chapter 9
marl s Mill Se r' 70(0 fD + ,of he Basin.,,' ds t ,. sCode) Sq. Ft. Floor Area gValuyation —
m mat he is evempt therefrom and the basis for the alleged exemption.Any iolmion 7 p �Z
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally
A nor mare than five hundred dolk.x($500). APN Number Occupal�c��•��
01,m owner of the prupeny,or my cmpLgecs with wages av dmi,vole eon+pe l,rumn. s��
will du the work,and the mraaure is nal intruded or offered fm sale(Si 7DIy
Huniaess and Prom,i+mv Code:The Ca;+lman;.Lieeme Law doe,not apply m ao3•'191 �@�4. tjl Cl iced Inspections
mr of properly Who build,or improves thereon,ail who doe:such work hlmwlf
through his own employes.provided Ihat such improvements arc not intended in
offered far role If lum'ever.the building a imprevemem is sold within one year of
nnnpledon.meowncr.Budder will have the burvelofpravinemmhedid aa,wild 305 — FRAME
mprnvc for pu.pn,c ol'sale.) I .
OLa,owmer Wlhc pmpeay,vane.clasivey comment,aim licensed eaolaaor,a, 307 — INSULATION
nsauet he nobler(See 7(144,Imo .and Prafex, rx Codc:)'rne Contractor:. 601. — ROOF TEAR OFF
Liiuaa
ndc Law does ma apply ,an wneenl pm�ny will) im
builds or pmvem rhercon,
and who cantmcls for much project,with a contractors,licensed pa,mol to the 602 — ROOF PLYWOOD NAIL
Commcaw',License Law.
❑Ian,exmnptmail,Sec. .aKPemrmi—eamm 603 — ROOF BATTENS
owner Dano 604 — ROOF IN—PROGRESS
WORKER'S COMPENSATION DECLARATION
1 hamhy altwo under,en.Jly otpnpo,ono of tial following dedarat loam',
3 I have and will maintain a Cenilinra of Concern m self-insure far Worker's
mper,ation, r. provided for by Section 3700 of the labor Code. for the /
Iw11 Hnannncu ot'ran work lin which chin pcmmit is'osacd. 0
I have and will maintain Worker's Gmmpcnsmion In.uranee.as required by Section
3 X of the labor Code,for the performance of the work for which this permit i,
imwaA.My Worker's Conpc vurinn mun;nm cuaicr uad Pulµy number am
4MSR.I Cfi.(� /�07 o,Na,
carries t�O_, PahcyNr..: _S5RADL3$ ! �O
CERTIpICAT10N Of I?a E11PTION FROM WORKERS'
COMPENSATION INSURANCE a
(Thin section need not be completed if the(writ is for one hundred dollam
IS 100)of lead
I ccnify than In the pafmmatne of the work lin which this permit Is l,.tard.1
,hall not employ any wo im in any manner so us a+became subject to the Workers
Compensation law,of Culifornio.Date
Applicant
NOI'ICE'Ii1 APPLICANT",IL al'le..nuking thin<irmlficen of lixcnrytian,yon shmdd
hccom'subject to rhe WorAcr',Cnmpn,minn provisions of rhe LnAa Cole.You nmv
O 2 fordwiih comply with such provisions or this permit shall he teemed revoked.
r Z) CONS'IIIUCTION LENDINGAGENCY
1 hereby affirm that them in a construction lending agency for the performance
W of the wank for which this pearm,i,i.wted(Sec.3097.Civ.C.)
L A Lander',Name
a Z Isndcr'.,Addasa
V 1 certify that 1 have teal this application and,tate that[lie above information is
4. [.. correct.i agree to comply with all city and county ordinances and stare laws relating
O [) to boiling Ltr,trlm11011.aTld hereby nnthorim arm cntmrves of this any m eater aeon ..
he ahovcmcneancd propend fm ify and keep
hmrnec
E„ G
(We)ago'm save,indemnify and keep humtlein the way rCameagainstino ai
VI Ilahllirics, d mix,cuss and expj//(nws C� iyrA�'�n rt way accrue against said
Ciire t �naaf@e"' int/arI ,l/
�••r
?A4A"
` UNDERSTA >S N LL NON-p INT Issued by: Date
. AppthanVcmnnrmar II00Re-roofs
MARPOD$MAITRIALS DISCLOSURE
l the applicant of future budding occupant store or handle Incallo,material Type of Roofby the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section 25532017
O Yes N° ' All roofs shall be inspected prior to any roofing material being installed.
. ltheapplicantort irehuilJingoccupant use equipmentnrdesire,which If a roof is installed without first obtaining rot inspection, I agree to remove
emit hxeaalno.air...in irmnwm deired by the clay At.Air Quality blanognnent
,Nmct7 ig
ria1, for inspection. pplicam understands and will comply with
0Ye9 �n I have read nate hazardous niuvolh ralolrenu•ms tinder Chapter fi95 of the
Cvlilaniu I Ie;Jrh h$utely Code.Scala m25505,25533unJ25534. underslnnJthi /l,if the bol decmnm corm ly ave t t hill it is... ..parrotilily lonmify th `�accup of he require nal ch m m i..mnce of a C in 11; fOccOApplicant Dale
o>~ Lraatn—a„d6sen� Dae All roof coverings to be Class`B'+ or better
OFFICE