00070116CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING
1'ERhfTNO.
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OWNER'S Ib NEEL�
AI'I'LICA'1'1 S10 'I:
'HONG:
GM2-7644SANITARY
NO. CON'rROLN0.
ARCHITECDENGINHER:
BUILDING PERMIT INI'U
BLDG I71,17clPLUMB MCCH
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LICENSED CIN I'RAC'I OR S DIiCLARA'IION
nlr ,tlnnthcenscdunderpnviaao,ACIm,a,9(aomamusing
Ihembyrnth:
REMOVE PNC MIP"B"(13RAVEL ROOF AND ISYAI
fiS
w;lhsecda 7gX))orni,l.ianlarmeBn.rues.amn'mrexi„n,caee.anamrraen.e
TAR AND GRAVEL
is in full force and creel.
AND NEW
Liceme Class Lic.a
Dale Cartranor
ARCHITECT'S DECIARA11ON
[understand my plan. shall heused m public recomx
Licensed I'rofesumael
OWNER-RUILDER DI?CLARATION
'
I hcmby a0lnn Nut 1 into exempt Gum .be Cor bo clor'x License I.aw too Ion
bol o rm, mama (Section 9031.5, H ties, and 11 lv aiunx Cade: Any,,,, insanity
_
which requires a permit in carOmet.:Jnr, improve, demolish. or repair any suucmrc
_
primm its kOrancc.alo)quires thenpplictnt for.wch permit o lileasi,sedslecancnl
Sq. Ft. Floor Area
Val Uil(1QIt
1u;lli
7 +�tSlt7
that he is licensed! Contractorspanaanl to the provisions ofthe Contractors Law (Chapter 9
(commencing m Section NMI of Division 3 ofthe Business and Profession, Code)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation
Of Section 7011.5 by any applicant for a permit subjects the applicant to a civil penally
roe
APN Number
Occupancy Type
of not mom than hundred dollars (s500),
37534017. 00
wtofa ....,cosada„,
O1. orswis
�,heatm..Talo+.y.11,It,, amployea, h wages To their soleo
Required Inspections
will du work, and the sra,mm I, not intended or an"d rill sale (sec. 9094.
Burmese and Proresxims code: Has Conlmamr4 Licanne Ino does not utility to an
orr of property Who hoilds or improve, thereon, and who does such work hour cil
mraugh
305 — FRAME
his own employees, provided that such improvements are not intended ar
Offered Tor sale If, boat,... the budding or improo mann Is .old within one year of
307 — INSULATION
iompletion. the cox net will have the burden of proving that he did not (wild Or
mprove far pa,wa afore).
601 — ROOF TEAR OFF
01. as Owner of the prnpcny. nen exclusively cnmmeting with licensed avnrucun"tis
602 — ROOF PLYWOOD NAIL
,nma the pmjeel fsce. 7044. it-insd r
reror ,o ., Code) Corrosion'sheCorrosion's603
Lixtamsc Low does sen apply to o nwnet of pmpany win, build, tot n,prm'cx .hemon,
Land
— ROOF BRTTENS
who eantmnm for,n,lt ......cell onto a s.nnaca'r(s) Eaaed pur ton la the
Low.
604 — ROOF IN—PROGRESS
Cona tan", L,cmue
❑ 1 am exempt under Sec. . B & 1' C far this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
,f] I have and aill t Certificate I Consent or - If' s tor W k
j
COMIOTIOLMOn. its provided h M1y s t 171111 I to 1'h Code I r the
pert tl I'rt for which this parmi is issued.
❑ I haveard will maintain Worker s Compensation Insurance. qu r J by Section
O
PW of tbe Later Code, lin the performance d the work for which his permit .s
O
is m& My Workers Compensation Imumnee cant and Policy number are.
Cardec Policy Ne,
CERn19CAl'ION OF CXENIMON FROM WORKERS'
COMPENSATION INSURANCE
1Tmo section need not 1%, completed it the lienon is for one hoodred dollars
lSlll111 nr 1vssJ
,
1 certify that in the performance of the work for which this panni, is issued.I
shall not employ any penin in are manner or as to become subject to the Workers'
Compensation Laws of Cameroon, Dam
Applicant
NOTICE TO APPLICANT: 11. .five making thi, Certificate of Exemptinn, you should
become subject o the W'orker's Compensation provisions ofthe Labor Code, you mush
kunhwith comply with such provisions or this permit shall be deceased recited.
CONS'TRUC'T ION LENDING AGENCY
1 hereby a1'Iinn for them i, u c anOrno .. lanolin, agency fur the perltmnunv
,
01 the work in, which this permit ie issued (.tics, 3097. Civ. C.)
Lender's Name
tender's Address
I certify that 1 have mad this application and store that the a1'oee information is
rest. 1 agree to comply with all city and county orditonnce, and slate laws miming
to modmng construction. and hereby aatboriee reprmentmives of this city to enter upon
the mowanoationed property far mxpectmn purposes,
(We)agatemsave. indeannify and keep harmless the City of Cameam ,against
liahil'nia,, jodgmcn,e. ,ova and cxpntxcx whish .nay in Tiny way ammo ugaina slid
In the althis
/; „ix
w
City eouseyucnce of gr.nning petion.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
7—,,to
Issued by: Date / Y
y'
SOURCE REGULATIONS.
Re -roofs
Signature afnpplieanvcantracnr Date
HAZARDOUS MATERIALS DISCLOSURE
"511 the applicant or fmare building,acopam atom or handle huarolms material
Type of Roof
as defined by the Cupertino Municipal GNe, Chapter 9.12, and the Health and Safely
Code, Section 15532x07
❑Yes ElNo
All roofs shal/be prior to any roofing material being installed.
Will ole..pphaant... uOm sodding.ccopan, use couip.neworde,,,,,,deh
If a roof is installed without first obtaining an inspection, I agree to remove
nil hoardous air cennou nails as defined by the Bay Area Air Quality Managmnent
otrict'r
all new materials for inspection. Applicant understands and will comply with
O Yes ON,,
all non -point source regulations.
ne.ns trader Charm, 5 of the
I have mail the hsmrdo., maerials mquimu6'1
Califamia Health & Solely Code. Sections 25505, 25533 and 25574. 1 undaaand that
/
if the building docs not currently have atemm�nm that it is my responsibility notify the
///
occupant or the raprbary nts which mast be .nal prior to issuance of a certificate of
//��
/'ZZll
Qeen"mar.
mature . ppl icant Date
All roof coverings to he Class "B" or better -
I
Owner Data
or aumarimt! again
OFFICE