00060149 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
Bu1�DHYTER50EL AV PERMS "° 00060149
OW.`.RRd.,NAglr`i IANG C 0
�•d0NE: SANITARY NO. CONTROL NO.
7
ce G ARCHITECLENGINEER. BUILDING PERMIT'INFO
w G BLDG ELECT PLUMB MECH
�N= - LICENSEDCONTRACfOR'S DECLARATION Job Description
i Z—G 1 hereby aamt that 1 am licenced under provisions of Chapter 9l commencing RE-ROOF
uot—w wish S<nlun 711(I(1)of Dirision3uf the Busings and Pndosions Coda and myiicensc
In Inll fora and effect.
iz s a Licence Class Lic,b
n Dale Contractor
13 w G ARCHITECT 5 DECLARATION
O 5 I understand my plans shall h,used as public records
I a O O Licensed P,oia,o.nl
a'o OWNER BUILDER DECLARATION
1 hereby.(firm that I am exnnpl from the Cicrmacmr's License Law for the
a following ream..Siltation 7031.5.Business and Professions Code:Any cit)or county $13000
3 o 'hien requires Permit to compact,alter.improor,c.demolish. p y structure
prior to itsq the applicant for such Permit to file a signed statement
'he,be licensed a nom,hep I ,m,ha Costra,me,L Ice (Chapter 9 3.qe jIlt7n AQ`A r Valuation
(eons 'ng with Semi 7000) fD' nio 3 flit Bu'mess dProl'a,, ns Code? ) s r\
or that he is exempt literal rain and the basis for the alleged exemption Any%solation
of Section 7031.5 by troy applicant fora permit subjects the applicant to a civil penalty
of not mom than five hundred dollars SIM). 30APN NTRWE Occupancy Type
01,a, wne,urBar prnpeay.n,myempwyre,with wages anmi.I,c.mpensatium 307 - INSULATION
wHl do the mk.-and the.avucmre is not ime.ded or offered for sale(Sec.7034,
Busing,and Po,ex.mna Cade:The c;olaral.,.Licame Law does..t apply ,,an 6 0-L - ROOF PL �1 p)e�(IoUs,
orae
r f Who heeds no ice meecnn.and cab.titres inch wort.him,If L
of Through his oxo emplueecs,provided that such improvements is sol are not intended or
.offered rot Isle.If.nuwtaetme hellcat .. - tin sold within finit Isar fir � -- 60 3- '-' ROOF- BATTENS
g or imprommm ,
inmpletlon,the owner-builder will have the burden ofproving thdhedid not buildor 604 - ROOF IN-PROGRESS
mprove for pumnse fir pale.).
O 1,as 6 the
Orme property,7,zm Business
d Professi with Ilcensed cummmors m
unsuun the project(Seel 7033,Boniness and Professions Code:)Thempa Coothe mit r .. ,
Lice who
Law does not apply m an axnw th progeny who builds veimproves thereon, ,
_and who roLicens for . projects with a rommetort9 licensed pursuant to the ..- .. ....._ _ ._ .. _. __ ..
' Comatose License Law: _
❑lam exempt under 5<c:' � I- ,B&PCfor this reason
Owner Date " r—RNA
LEO
WORKER'S COMPENSATION DECLARATION
a. I hereby affirm node,penally of perjury one of the following Eed.mti.m: APR 3 0 2002
❑ I have and will mainfain a Ctrtificme ai Consent In sall-it,mrc for Work,,
Compensation, as providod for by Sectio 3700 of the Labor Cuda for the
performance of Ibe work lo,which This permit is Marc.
BUILDING
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the pcRorma are of the work fur which this permit is
issued,My Worker's Compensation Insurance corner and Poll,number are:
Carrs 1 s •.Polley Nsv:' ... .. -, . ... ... . .. .._.. .. .
. -CERTIFICATION OF,EXEMPTION FROM WORKERS', I `
COMPENSATION INSURANCE
Inc section need not be completed if the permit is for fine hundred dollars c p -
IS100)nrlassJ.
. ..... _. .1 _ . ..
I c'empl That in me perfminy do of the work for which this 10 t e issued:1 •-
shall not employ any person in any manner w as to become subject to the Workers'
Compensation w
ion Las of California.Dam
Applicant
NOTICEco APPLICANT the Wo'D It,arm,m:Aing This
u'rhi', fit Exemption,you mould
Q Oaccurate wbjml y lite such 'o Coksm,a,t his provisions of me Labor Codem,.lk you muss
fonhwilh comply with such provisions or this permit shall he deemed revoked.
�-vi - CONSTRUCTION LENDING AGENCY
a7 1 hereby affirm that There it's compaction lending agency for the performance "
D9 0 of the work for which this )
r Lender's Address
permit is Issue)(Sec.3(197,Civ.C., . .. .,- ..._. _ _ .. ... ... . ...
z
U O 1 comfy that I have cad Nit appeeaaon and state that he above information is
Ia+ Pcmreat.1 agree to empty with all city and county ordinances and state laws relating
. Q C•7 to building construction,and hereby nomadic represemabves or this city to enter upon
ty the ads uva-sari inaad ma,amy for irNe,tion purpcoa,
Eat M (We)agree is,sane,indemnify and keep Harmless the City of Cup prom against
h liabilities,judgments,costs and expenses x hich may in any way accrue againstsaid A Z2
U.Z City in consequence of the graming of mit.Permit. - r
APPLICANT UNDERSTANDS AND WILL COM PLY WITH'ALL NON PONIsSuedb ! Date
SOURCE REGULATIONS. Y'
Sign amrt.if ApphnanJCnmrnemr '.. - Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupxnl nitre or handle natural material Type of Roof .. . . ..-_ . . ..
as defined by the Captains,Municipal Code,Chapter 9.12,end the Health and Safety
Code,Section 25532001 - t'
❑Yes ' •' .ONO s,:•- ..
.... ,,, .. .•. _--ATI roofs.shall be inspected Pprior to any roofnS.material,bein
g.installed. _. ...... ._.
Will henppfianiorfuture bmilim,vo.....Ime...pmemorde,ia.which If a roof is imtallecip without first obtaining an inspection; Pagree to remove
at,motorboat air nmmmimm,as defined by Ibe Bay Area Air Quality Management
is.;cr all new materials for inspection. Applicant understands and will comply with
• ort. 0N - all non-point source regulations,
1 have read the hmn.dnm materials requirements under Chapter 6.95 of the
California Health&Safety Coda Sections 25505;25533 and 25534,1 understand that
ifthe Wilding d«sum mormly have a mnanl.lhal it is my resp.nsibilitym notify the - -
occupant of the requirements whiah'mu,l be, at prior m issuance of it Cenificme of
Signature of Applicant Date
'' ow.lt,ma�morineeagtm - Orm All roof coverings to be Class "B" or better
OFFICE -
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