00080040 CITY OF CUPERTINO s.'k' PERMITNO.
nUD.DINO sto RMIT CONTRACTn) u i �,n T �1
RRITFiUNNY MU CE 00080040
BUILDING ADDRESS:
SANITARY NO C L MAL DATE
CHRISTINA N 1.655 FORMAN AVE 08 �����1`2
OWNER'S NAME:
v NIC CONTROLp
HONE: (408)265-5147 ❑
ARCHITECiENGINEER BULDING PERMIT INFO
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=z LICENSED CONTRACTOR'S DECLARATION REMOVE RogbKffP PR, GRAVEL ROOF
z 0=e I hereby affirm wt 1 am hummed undo provisions of Chapter 9(c.suirg ll
m F W wiNSauon 7000)of DivisirnJof Ne Business tied Pmfeasions Coder.admylianseu
in full forte ad<Recl.C ss
�yC
W IJUnan w Lie.X
3 u Uam — CSDECL
ARCHITECTS W used
DECLARATION
TION
I understand my plans Jsell be used as Public newNa
>•a o Idcrnxd Pmfemiovl
u ^_ OUILDER DECLARATION
C Z< 1 hereby.Rims that at I am em Bexempt from Ne Commmo s:Any c taw for th<
p following reason.(Seats.con.tr Business and Professions Cade:Any city a county -7000
wnirn rcyntret.permit m frmuufL dmr,improve.demohen.a mvdr aor xmsflnm S Ft. Floor Area Valuation
c.3� patheislicenencndso rtquim provisions
of for Contramunrfles Law(Chumem q'
that he is licensed pursuant m Ne provisions of the Conewmfl License law(Chaps 9
(commencing with Seaton 7")of Division of the,Business and Professions Code)in APNN t d• tvJ Occupancy Type
that he's exempt ther,from and the basis for the alleged exemption Any violation of
Swoon 7031.5 by any applicrnt fors permit subjects the.ppliom Ina civil penah,of
t mom Nen five hundred dollen(35W).
O L.,Ownuofdcoprapent'.ormycmployeeawith wagceas their-In wmpemaGon, 305 — RR4aWFd Inspections
will dothe work,and ueewcmre lanm intended oroffead for sale(Sec 700.4,Busineas 307 — INSULATION
and Peofe wions Code:The Contractor's License taw does not apply to an owner of
propmy who bunds or improves thereon,and who does such wok himself Of through 601 — ROOF TEAR OFF
his own employees,provided that such improv,ments art not intended a offered for
sale,If,however,the Wildingo,improvementuroldwithinoonyearofwmpleGon,the 602 — ROOF PLYWOOD NAIL
tt-Whave N,ilder will hbundcn of proving that W did not build or improve for pm-
puseofalleJ. 603 — ROOF BATTENS
O 1,as senor of the property am e.cluelvelr convecting with licensed contractors m
construct she pmject(Sm.7W,Burnessardr
Profession$Code)TheConptarxu- 604 — ROOF IN—PROGRESS
,retie law does me.,1,so an owner of pnopeny wW Wilds or improves thereon,std
who contracts fa such Miwu with s wmntta(s)Bees nerd puau.m m the ConbaclMs
Ewen.law.
O 1 am esernpt oder Sec. .B k P C fa Nis moans
Owner Data
WORKER'S COMPENSATION DECLARATION
I and
under patalty le of oryateofIWfollowing r declaratiWixioo
1neve nM will for bynection 700 ofCamrnuoCo,icnrorefes Workers Compere-
,mirk,r provided for by Secuen 37W of the I..Wf Code,fa the perfomurcc of the 7�
wok fesdA this pemut is issued.
an
❑1 have end will maintain Worker's Compensation Insurance.h his er by Section
37W of the tabor Cade,for the performance of the wok for which this permit is basad. [\
My Worker yCampnµ—Inryrvpyc cy and Policy
Comer. Q t/TIC A Policy No: (l U
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This.wnimi need not W completed ad a permit in forms,hundred dollen(SI W)
we list.)
I feebly that in the pedormawe of the work for which this pemdt is issued,l shall
not employ any Person in any msnarso aro become ubjm(totheWmekre'Compcn-
uomn Lawa of California.Data
Applicant
NOTICE TO APPLICANT.If,cher musing this Certifbm of Exemption,you should
Wemne subject to the WmIsm.Compensation provisions of the Labor Code,you most
forthwith comply with such provisions or this permit shell k deemed mote.
CONSTRUCTION LENDING AGENCY
I hereby o fnothat Neo is a construction lending agency for the performance of
Z 2 the work for which this pmnit is issued(Sec.3097,Civ.C.)
Lender's Name
a > lander'e Address
(� 1 comfy tom 1 nave ted this application and sum that the aWve mfomuuon is
A. 0 comet.I agem to comply with ell city ad county ordivncra red euro laws misting to
7 z, Wildinll,mr. cuon.and herebysullurise representatives of Nis city to enmr upon she
U abovbmcntioned property out inspection purposes.
(We)agree to ave,indemnify and kap henmuu the CAY of Cupertino against
U Iubiliurs,jdgmena,costs and!espeme,which may in any way same against said City
>„ W in mut"ucae M inn granting of this permit.
t: G APPLICA "UNDIASTAf��{{�IljS A' IL I,COMPLYWITHALLNON-POINT
U z .SOUR :GULaTIOIjS.t/ f
un UT QtRCD�(c 8-?-u(1
mmol ApplicardCon ewtor Due
HAZARDOUS MATERIALS DISCLOSURE
Wiil use appLunt of future Wilding owrom,store or hadle baaWnus massrial Re-roofs
as dcfad by the Cupertino Municipal Cod,,Chapter 9.12.W the Hwlth sail Safety Type of Roof
Code.Satire 25532(.)7 yP
O Ye, ON.
WiLl the applicant or future Wilding occupant use ml ipm,nt or devicas which All roofs shall be inspected prior to any roofing material being
emit nefadrnsah mustaminrnaa,defend by the Bey Arc.Air Qalit,Management installed. If a roof is installed without asst obtaining an inspection
istrict7 I a ree to remove all new materials for inspection. Applicant
pop ❑Yes ONo
uC e�stands a dAfilll comply with all non point source regulations.
1 have read the havrGws materials myuimmcnu under Chapter 6.95 of the Cali-
forma Haslth S Safety Code.Swim 255DJ'216J3 end 255M I understand Nm if the
building a tcmrer neva am, ( y¢Wnsibiliy to ramify Ne dccuPanl
.I of du is which mustet psi t f lean of Occupancy.
Signature of Applicant Date
err or authonw!agent Data
All roof coverings to be Class"B"or better
OFFICE