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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 � 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 bazu 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