01020132 CITY UOFY uI� N
RTN°
IPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMI9NO,
101.84 1.1:11+11ER I '1... R Er ROOF II'Ilii 0/020/32
OWNER'S NAME: APPLICATION SUR DAPI!
KWAN FIORRY T AND BEF2PITE: C OAKI_AI+ID Vol— LitIR61200:1.
PHONE: - SANITARY NO, CONTROL NO,
(408) 9P-5--9995
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BUILDING PERMI'1'INFO'/O. AHCiII'1'r:C'I'IfiN(iINL'i!It. BI.DG IaJdcq' PLUMB MI!CH
re u CI L= =1 1=1
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Incrcny aN or chat lieu lime d malcrl,rDECLARATIONi � ter o a,.;mneneins Job Description
with Seen...191X10of Divisi,�g for the Bmincs,and Pnfe\—onLgpNe and my license
q toroll bole vulllr 3w. Vf 29
g z < hiccn.c Clus.._ 'lip 'J' «
t6vi+ ?cOri. 1i°" nl¢cm cr•s urcLA RETIOVI'_ EXISTING 1 LOYEI OF WOOD SHAKE
t=°g mmnJnq'plans,hu n>eda,pa recr,v. I:I+IS'" LL NEW Io CDX, 2 I_f-IYER OF 30
yr
to C cop o Lice;uen rnnc.eiunnl
u5n 21� OWNER—BUILDER D the Comr10N
=' 1 hereby cotton that am eacnept Iron the Comrxwr's Licence law for the
at Z following moron(Seen o170315,tat. duc,x and P r.do,cons cads Any oily nr acture
❑ which requires a pernlil R,annxducl.;titer,in:pnrvc.Jcuuilish,or rC,air fury tincture
_
�_
m t prior to its issuance.color requires the applicant tor such pt to lite a signed statement
daneat he is licensed punaenrto the provision,of contractors Lice ,e l�w(chains,9 to rA a Valuation
(eommaming won Secann 70 of Division 3onhe Busmen and ftofasinac Code)
a A,,,he i. L mercrmn,I I ren buss,iia the ullcged a,err,lum.Any v rotation
of Neeson]@ L5 by any applicant for a permit subjects the applicant)It civil penalty 09 F
maul moor man R.e ntnarca sonars rssan. APN NISLIL Occupancy Type
D I,us nwnct oohs Prnperry,ar my engelayees with wngcs las their sola cmnpcn.minn,
will do the work,and the structure is not intended or oliemd Ibr sale ISce.9Raa, -
Businms and Pmrmsions Coo Me Cnmrmmr's License Law doe,not apply to an Required Inspections
r of property who huild,or import ..thereon,and who encs such work himself :r60 761.( 1%)I%)
orvthough In,own employees.provided loin such improvement,am not m :i3
intended :1.G2
catered ht sale.II;hu—n-r,NI hadding of mpowaucnt i, ,,It within one year If
nnepletion,the owne>builder will have the burden of proving that he did not humid or
lni'mum rat me weonale'' 3015 — FRA1,111
❑I,a notur of the no,dX stn t it i"i,emnn"Inum with liv'ensed anthucmrs a, -.. HS
Lcensconsumer the does
n (Sec.
appl 91wa,Baines,nerd edy who
builds
or Tne cemmmnr, 3O'I .I:I L.II.)L..PIT.I:I:IFI
and%hhwdaeanforsucwanownmmpmpenywnodInt rimpmvathin'he 601. — ROOF TEAR OFF
and who contracts 4,r sten projects with a amlm.orls) littnxed pursuant m the
cnn111,c.lptmdr,S,l, 602 -- ROf.1F' I'L..•r LICIF:IT) I'IG'1:1:1...
❑1 vol cscmpl under Sec. .Boot...P e nor lhz rmwn
Owner rare E,03 •— ROOF BATTENS
WORKERS COMPEct PON DECLARATION C."04 -" ROOF( T.N••••I' ROfi1F,.F:SiS
I hereby allime unJer penally of perjury one of the following declamtius,
O 1 have and will maiaain a Cenife:ne of Consent to sclGinwrc for Worker's
Cmnpcnmtion. ;o pmvidal in by Seaton 391111 A the Lnhur Code, III tlm
fiamancc of the work for which this permit u iamcd
have tal will maintain Worker's Rnnpensainn Insurance,as required by Section
J9t d the]..Nor Cure,for the pmfumnatec I the work Iia which dei,ferneit in
issued.My Work;,,O..imer,miiokn/)mnrance carrier t/ol�d Policy n....Mr are
Carrier:_Sj ,_ % Policy No.:_l_l— 6 a b _
CER'HURATION p CXEMMION PROM WORKERS'
COMPENSATION INSURANCE -
('Thi,section need not he completed it the to is rot nnc hundred dollars
ISI W)nr In„J
1 renis tlm.in the pentrun wn or the work Iia which this cran,in issued,1
shall not employ vnY person in any manrmr so as to become subject m the Workerd
Compco,ation Lau,of California.Date
Appfiwant
NOTICE'10 APPLICANT:Il:alter making this Ccnilieam of Immo nion,you should
enmbj„ R
cr ,the Workers Compensation provision, a
of the I.Mrr Cooll you must
Q O Mu
lonhwilh comply with inch powro w or this Kinuie\hall he deemed revised.
CONST RUCTION LENOINO AGENCY
x ] 1 hetchy a1Gnn deal there is a comtmetion lending agency for be performance
of the work for which this perms is.sued scc.3lm1.Cir.C.)
A. Q bender',Name
Q 7 ]code,',Address
V 1 certify that I have read this application and state that the aM1ave information is
coned.I agree lin co;n ply with all city and county oNinancea'end state laws relating
Q (� un handing conornot m,,Lord hereby call-ill rcpnsennaivel of l his Illy lu.1111 upon
r y rhe lie nime'd prop fly lin inspection purposs.
agme toreave.indemnif3 it keep harmless the Cityor Cupenino against
Imul'aies,ju tents,coos and e.vpenws which may in any way accrue against aid
V City i ” 111 c canmit. /
'E Rr
AP W T "P l 1 'f n'LY WITH ALL ON PI INT Issued by: to l—. Dale L^2 ��
5
ppncnolrc1 11 oma " Re-roofs
RDOUS MAI'I RIALS DISCLOSURE
Will the appf,mor forum hu'tiding arupem.arae or handle hmanhmsnmtenal Type of Roof
as def incl by the Cupertino Municipal link.Chapmr 9.12,and the Health and Safety
Code. D.ion 25532UUn
]Yes No All rool's shall be inspected prior to any rooting material being installed.
I
Will thcapplicant or Imam ildirrg aceupanttse equipmemordeviceswideh If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hnaandrus air contamimmt.as defined by the Rae Arco A;r Quality Management
Di.n' all new materials for inspection. Applicant understands and will comply with
�Yn' t' ra no oiht so regu I nave mad the hmuli us materials requirement,under Chapmrfi.95 of 1h ICallrmniallcvnnffiSafelyl: h,leclions45505,25531cull 55J4.l undestanlb lIilme 'ding des nm svmmily hove n mnam.fie iii,myuecupam 'the ne whichmu.aice nmrpriormiss
Occup:m
L 11
nature of Applicant Date
Oxmenc authari,cJ ager tame All roof coverings to be Class"B" or better
OFFICE