01050073 CITY OF CUPERTINO
RUILDING I)IVISION PERMIT CONTRACTOR INFORMATION:
BUILUINGADDRISS: - PERMIT No.
r
OWNER'S NAMF APPLICATION SUIT DATE
PI oshr SANITARY No. CONTRol.No.
73
O z 2 ARCIII'I IECCIIiNGINiT1711.
�00 BUILDING PI; MIT INFO
�w_I- BhOG/F.LIiCT PLUMP{ MF.C11
u q I-GI I_I O 1�
Job Description
- IIIt IalEUCONTRACTOR'SDIiCI,ARACION
S p6 1 hcmby X))of thin I nm.1 the
mime pnd prof of r,Cod 9 mamnmcense
Ili with Scctialand o[Divi,ian3ol'Shc ltu.inew and protester,Code and my license
,c rte
is in full li,rcc unJc t.
�c�a i.met„e sly. =^ �9 Li<.«_(Z` 74.�9{�.� REROOF.
aN DocCon./'� � nR, (:III'I'IaCI"SUECI�r\RATION /-
0 g 1 under,and aw phi,,shall he med as public meows
Y
G 5 IJcrn,cA Prul'c,«innul
o�
OWNER-ItUILUEH DECLARATION
hereby ur0nn that I lure excnq,t from tna Cunauetnr's hiccn,u Law for tree _
t>� following reason Iscctinn 7031.5.Business and Pur ion.Calc:Any city or county
S❑
'lactates,
n eh n:4 cruit t n.t t Ile I J nllsl nY stru,mre
tf hpermiu is .6ned,tammcm
morn licensed lu•u n then ......used m ContractorsL U. ode) Sq. Ft. Floor Area Valuation
(eammunemg acts Scam,ore and he boon 3 of Inc Bosnia,Imd ion.Any vi armor
or thatheis exempt tang applicant
li and the psis for the cts the
pplicanun.Any violation
of Section 703,5 s any applicant for a permit,Wjects the nPplicum ret u civil Penalty
of not mora,tat,ave l,amo-<n dollars 15slxn, APN Number Occupan y
❑La,owner or Ise p.....r ,nr t,am,loyces with wages us m=irsale=nmpemalimr,
will do the walk,and the amucmm in not intended or oRcmd for,ala(Sec.70,14. 41.
Bm;nes.,sad P.me..ina.•Code: Contractor,Umensa Law does and apply to air Required Inspections
orr nr Wapeny Will,holds or imnnw-thorean,read who docs such work himself
through his own employee..primidca that such improvements am ant intended or 305 — FRAME
offered for sale.11,however,the huh(larg or oupmvctncnl is said within one year of
otnple0ymq the owner-m icer will have me rmwen of proving that he dm not Wild or 307 — INSULATION
improve p lop i,n
❑I,as owner of the pearl am exclusively coatrratin,with licensed court m 601. — ROOF TEAR OFF
,, m=t ate project(See.7044,13 n .e atold Is fia,mr,Codao The Contractor-, 602 — ROOF PLYWOOD NAIL
1...
,a
eans,Law docs ma apply to an owner of pn,pny who builds or imposes flumen.
and wire contracts lop such projects with it contractors) Ilocned Pur a.ml it,the603 — ROOF BATTENS
Connxmr',Liacnm Law.
❑l an,scald under Sec. .1{&1'C for thin m:non 604 — ROOF IN—PROCIRESS
Owner Data
WURKER'S Co MI`17NSATION DI CLARAI ION
I hereby affirm under penalty of perjury one of the following declarations:
b 1 have and will maintain a Certificate of Consent in self-inure for Worker's
Comryn•minn, a.• powidcd fur by Seen( 9700 of the Iahar Code, for the
fed riamsofthewad forwhichthispermitnissued.
❑I haw and will muinlnin\Naoko',Cnalpea,oimt Insurance,ae moulted by Section FIN ALE D
17W of the Lahr Code,for the performance of the work for which this permit is
issued.MY W�t kye Cp�npon 11 a In,arnnce cunler:md I'aJyy autaber are:
Cmomr: ST.oIo'I'�policy No.: 2S, 5 o 1 /3/6 MAY 15 2001
CIiRI'IPICA'I ION IIP IiXFMPl'ION FROM WORKERS'
COMI'G9SATION INSURANCE
(This wall.need not M completed if the permit is for one hundred dollars BUILDING
(Sl(p)m Ices.)
I ect if,that in She perhannumro of the work far which this permit is issued 1
,null not etnpiny any pa...m in any at....wr se,a,to hecnme subject In the W..kers'
Comam—oion Laws of California.Doc
Apprcant
NOT Cr.'I U APPLICANT.It.niter Tanking this Certificate of Enemption,you should
become object ,, he Wader,Compensation provisions of the IaW1 Core,you must
Q O forthwith comply with such pnrv'ninnx or in,permit ehall he deemed revoked
z 14 CONS'CRUCfION LENDING AGHNCY
a 51 hereby anion Phut them ie a condnmtion lending ugoney for mvn
e N,arnce
of She wad tar which this permit i•issued(See.3097.Co.C.)
6. Q Lender,Nano
z Lamlcr',Address
V C Icraily that l havemaJ his application and stare that the above information is 5=�
:as re,, mmeca.1 agree u,comply with all city and county ordinances and elate law,rioting
Q [) a,Is dingnstiuction,mn,J hembyauthnd,=aluesernlives of his cit,W ricer ups
f� Sho
e.uls ve-mentioned Prnpeny for inspection pugxws.
'y` y (%'a)agree to save.indemnify and keep harmle,s the City of CoPanino against
Z) liabilities.luIgnite m..cast.and.'ales which may in any way accrue against said
VZ. City in mnsiquence of the Booming of this
Permit.
^ APP CANT DNI)ERSTAND AN I)w1l."OMPIA.WITH ALLNO -POINT Issued by' /�� �ti7��iee” Dal
Sit, CI�F;o p 1'I
}g/mol nrpwcomntetm / —Dam Re-roofs
HAZARDOUS tdAfERIA1.5 DISCLOSURIi
will d,o appli=ant ar pantos Banding,Kcapnot store or handle nn.,,wml,material Type of Roof
Us deli net]by the Cupcni no Municipmi al Cale.Chapter 9.12,and the Health aSnfny
Code.Section 25532(.)?13 �
Ya• 'o All roofs shall be inspected prior to any roofing material being installed.
Will the appr=eat orloluranmrio ,euPaul a.eenm'ip,n<marneai=mwhich If a roof is installed without first obtaining an inspection. I agree to remove
emit hazardous air contaminant,a• - eJ bythe Hay Arca Air Quality Management
Distriee all new materials for inspection. Applicant understands and will comply with
❑Ye, 0N all non-point source regulations.
I have rend It,lin urduoa.....aerials re ire tnet 1,,truer Chapter 695 or the
California Health K Safety Code,Sections 25505,25539 and 25534.I understand that
it building dxe not enr.ealy hale a Root,that ire 11 my resPnsibi lay to roti fy the
<cupant of the mqulrenaenhv which must rte met prior m issuance of a Car ilicam of
Signature of Applicant
Occupancy Date
g� '
owner aamad.ed anent rete All roof coverings to be Class "B"or better
OFFICE