00060026 CITY OF CUPERTINO
BUILDING Dtvtstoi PERMIT CONTRACTOR INFORMATION:
RUILDINGII@IJ6eq MC KLINTOCK LA RESPONSIBLE R .HMIT0 .
OWNEI`'sft� S14USSEN OLE P AND BIRTH L 918 N RENGSTORFF APVLICA ;c
HONE: ftF17 (650) 969-6151 SANITARY NO. CONTROI,NO.
ZO ARCHITECTIERGINEER: RUILIIING PERMIT INFO
❑
SDG,_ELTPLUNIB MECH
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LICENSEDv .CONTRd ard,.$....mo RA('ION
hereby 0)oI tha(I nm licensed uedem prEwilimoof chapter9 n sylineing Job Description
°q=w Ivan Sem on 7(and ofiect. on3onne Rnme„old rmm,sionseode and mylaeme RE—ROOF
I,et. lora and elfin.
z z u Lia mm Class Lie.It,
y P i O Dam S DEC A I
ARCHITECT'S a,:LAic records 6 .
w 5 1 made rs(and my plans shall M used av public neaNs
sto _
ce p O Licenced Pndeaionnl
OWNERdiU1LDER UfCLARA'I'ION /
I hamby mI'nm than 1 am uusrf Rum Inc Gnomons', Any Law fur(ho
C Z Cs following rm,on.(Snail t Wit 15,dueinc,s and de rcol h.oil Any city lir county
u,Fo which its issuance.
also In con.w4al¢r,fall forsuh crinin lirrepairnay etrucwrc D
3� that he
sliensed Purse n9nirec hrvisiocanl the Cohperminor(Ie arso signed xhmmem
c. Inashecrrein.licensedPursuant7the rmDivisi n3 comusin's uanY law(Chapter9 Sq. Ft. Floor Area ib
or tmmcmis exempt with the en om anof Division J of the leged sx end Prolusion CNC)
or that he is 31.5 hmy al,pli and the basis 1rn the alleged enempnnn.Any violation
of Section 7W Ls by any npplicoll fora Ikrmn subjects the applicant ret a civil pcnatry
nruul mon has flan nmmnd malar,(esraq. A24'§VE*42, 00 Occupancy Type
❑Lav owne,ot topoPCay,ornry,rT1oyl will wegas as l ncirode Conrpenullun.
will do the work,and the Iouemre is dol loca l or ull'emd for one(Sec.7144.
nu,re,.and pros .aa,C„de:The Contractor [All Lew does nm apply In all 305 — FRAMEequired Inspections
of property Who holds,r improve,Ihereon,and who docs such work hiloolf
or through his own employees.provided that such improvements an not intended or 307 — INSULATION
offend for sale.If,however,the(wilding or improvement is sold within one year of
mnpled9a.the ouher-budder%iu have the burden of proving that he did not build or 601 — ROOF TEAR OFF
`mproveforpugweeofsme')' 602 — ROOF PLYWOOD NAIL
❑1,u,owner of the pmpeny,am exclusively aomruaing with licensed conn:nor,w 603 — ROOF BATTENS
construct the pacer(See.7044,B.,mc,,Erol 11 te,sim
ons Coke.)The Comcmr's -
iJes el,cwdoel no(apply loanower,fc perrywhohmld,orimprocvmere:...' 604 — ROOF IN-PROGRESS -
I who onmmts ror erect projects x inn..oor(,)Recoil p........t En the
CxuomraaeKs Liccne law.
❑1 int exempt under Sec. .It&P C for this moon
Own,, Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following de-clarroonv, -
: O 1 have and will muinmln a Cenif m of Concv to self-insure for Worker'%
Cmnpcnm1lun, as pmwldcd Ins by Smllun 3700 of file Labor Code, Int ha
perfor m ice ill(he work for which 11111 permll is issncol. -
❑1 have and will maiomin Worker's Compensation Insurance,as required by Section ,
3700 of the Lt hum Gvk,for the performance of the work for which this pem(it is
sued.My Worker's Compenmlion Insurance Cartier and Policy number are:
Carrico Policy Nn:
CERTIIdCACONHOFSAT[ON INS RANFROO WORKERS'
COMPliNS,V10N INSURANCE.
('this section hour nm he conrylcmd if the pentyl as tar ocebndred dollars '
($1(Xv or le.,s.) -
I cenif., but in he led actual of the Ivor,is,,which this permit is issado.1
,hall not employ any person in any manner so as to become subject m the Workers'
Am,.,alion law,of California.Date
icant
NOTICE TO APPLICAN'n If.after making this Certificate of laamption,yno should
become subject to the Worker's Coripcns:mion provisions of the Labor Cl you must
Q O hamw ith comply with such provision or lh is pennu shall he deemed revoked.
CONST RUCrION LENDING AGENCY
I hcmby all!rm Jolt lbem is a mnsuusllon lending ngen l fill the Pelfmmr oce
II the work or which(his permit is issued(Sec.3097,Civ.C.)
Q Leader',Name
;5 Z Lender's Address
U O 1 certify that I have mad this application and state that the alwve information is _
ii t_r correct.1 agree to comply with all city and cman y ordinances and stale laws relating
Q f,
to building Conslmninn,and hvrchymbonte representatives of this city to enter upon
ry] the above-mentioned poll for inspection purposes.
y p, (We)a, ( ify and, ,hanalco,IleCty of Cupertino ugninst
4 lion E j Id t E'anall cXpoo,c, i i Y ill.r1Y way al'lain,s:Eid
UZ
City ,conve,a fdefaritgofhisperfit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ,Issued by: Date
OURCE REGULATIONS.
sigantun ofnppreanvcon,mnnr Date Re-roofs
fIAZARDOUS AIATEHIAI_S DISCLOSURE
Will d:Cappucantorfuture building Meapamstore mhandle bm:odcu,ordenal Type of Roof
as defined by the Cupertino Municipal rule,Chapter 9.12,and the Health and Safely
Code.Section 25532(a)'f -
❑Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
Will lfit applicant a home haddn”acculaIa,CC'n'mentnm:lueice,wl...1, If a roof is installed without first obtaining an inspection, I agree to remove
mit hazardous air cmnalninan(n as defined by(be Bay Arca Air Quality Mmmgen¢n,
i,Iricl+ all new materials for inspection. Applicant understands and will comply with
❑Yes 11 No all non-point source regulations.
1 have read the h vardous mmerinls requirements under Chapter 6.95 of the
in
California nnNe.Sections25505.25533
l d25534.1understand
ndecnahbuilding
nesoll,aenlybore tm, hilitsoyropneinil tlenorepanl of the eslunuml which Must be not prior to issuance ofa ceniicate
of
vFmc Signature of Applicant Date
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Owaarmanlhodrtdagnn Ume - All roof coverings to be Class "B” or better
OFFICE