00090108 CITY OFCUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: I'HRMI'1'Nf 1,
OW NI?R'S NAME: 3 APPLICATION SII
ONE: 2 ' x SANI'T'ARY NO. 11Afl. 1.
a Is Z ARCHITECUEN'GINEER: (83t) 637-5576 BUILDING PEItMI'IINFO
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LICENSED CGNan,ld R'S DBCLARAI'ION
Job DeSCI'IpIlO❑
I beech ffum thin nn,licans[J under x of Chu mr9lennunantin
y:, rmd„h,.. p s
4.=owith Section JlXgl of Uivi%ionJnf,he Husincss and l'r[fcwion%CnJe,unJ my license ,
a[y Jisin full Inn,and dlr
`1CC°'e`�' // "ofg9— Color.
'� SHAKE TO COME' SHINGLE_
d 'V DYtC
3+ ARCHITECI"S DECLA ATION
t—,O„5 I unJcdand my plan.,,hall he used as public record,
y z p i0 Licensed Professional /
Is.
o OWNER-BUILDER DECLARATION
m—H I hemby ultlon that I um exempt lino,,he Crn.I.COVx I La n[Law to,,he
F'Z>' following mason"(geen..703 L5.Elusion,,and Prot...kn,Gyle:Any city or county
Owhish requires ccrinam con,man.Am, p demolish.or rep y tincture
uxj3� pool , l' 4 Ill pee ,I II It tl ked.n, +mm
,hat nae licensed unterantt the provisions ofh Contractors I Charter Sy. Ft. Floor Area Valuati
(Commenting with lection 700(b of[)is room 3 of the Bu%has and Professions Code)
nae that he ix diem t hcrefrnn+nod the basis fin the alleged exemption,Any violation
of Section 7031.5 by any applicant li,r a permit subject,,he appllcarn to a civil finally
of not mom than five hundred dollars fS500). APN Number Occupy o
❑I,, `-lot deprOln'nyo my nmployx wool wages todmir tele.......tn"al
will Jo the work.and the svucme,is not immadel or offered for sale(Sec 70o.
Buxinesc and Prnfnsionn Code:The Commaor's License Law Jens not apply to an ed Inspections
r
or "Co'Who bnIIJ,m improves Jwoum,nand whO dot,saeo work himself
or Ihough his own enployeC,provided that.wnh i..ynoverm nu am inn intended or
offered for sale.IL boweser,the Wilding or impmsrmmrt is sold within one year or 305 — FRAME
in,Inoction. he owcerflnvie.i.will have the harden of proving that he dial no,hoild Or 307 — INSULATION
tprote puHws
❑Lasownerofthe pmpany.am exclusively contracting with licensed contractors m 601 — ROOF TEAR OFF
momet tee lin+Jett(Sao.70,0.lbe,iness end Proftsslo...Cl,deq'I'he G,mmoor'x
License Law does not apply In an owner of proper who hallds or improves thereon. 602 — ROOF PLYWOOD NAIL
aid who Contracts for such prC,CC s with a contractor(.)licensed Personal to the
C+ neo's 1"mCn,C Law. 603 — ROOF BATTENS
❑I ant escarp,under Sec. .B&P C lot this reason 604 — ROOF IN—PROGRESS
O"w' D;et
WORKER'S COMIIl;N5AriON DRCLARAI'ION
1 hereby affirm under penalty of p<jo y one of the following dedomtinrm
J I have and will maintain a Cenifcme of Consent to w1f-in arc for Worker'..
Coniptn%mion, as Novldcd Ilm by Sec,in1 3700 of the Labor Code, for the
fmrlhnnnnco of the work ke which Wi%poor....I i,issued.
have nad will maintain Worker',Compensation Insurance,as required by Section
]On of,he Lohor Cudt.for the "Hornum[c of the work Gtr which this pcnnit Is
:1 1MY IN rkkc&Q, rourin.wanee cmrim and Policy nunowrort:
Curricr.S . P policy 1424�5_�:f?
CEKI IHICAI ION Oil r;XEMII I'ION FROM WORKERS'
COMPENSATION INSURANCE
(Thi,action neva nal he em;...Cmd if the per it ie It and handed!dollars
IS 100)or it
I cCnily that In,hd—lomumec of thu work for which this pcnni,Is i,suod,I
shall not employ any permm in any manner w,no it,become suhjwt,o,he workers
Comp[nwtion Law,of California.Date
ApprCnm
NOHCii TO APPLICAN]".If,no,,nmking this Ctnilicme nal'Escnmtion,you should
become subject to the Wader%Compensation provisions Of the WM1sw Code,you must
Q O lI,nhwith comply with such pnrv..on,Or this .or shall be deemed revoked.
FV) CONTHUJCfION LENDING AGENCY
aI hemby of inn that here is it c[namafien fending agency for the performance
Ot'the wink Int wind,fhb punnh Is issued(Scc,3097,Civ.C.)
1Y Q Lender's Name
� 'l_ Lender's Addms,
V Q 1 to Iia,I have it this application and slam that tit atone infnrnution is
las E., correct.I agree to comply with all City and county oNmnnces and%rate laws viding ,
Q [) t++hnfldin6 cons,mution,and lit authmiic mpmsanoaka,of this City I,,enter alum
} r� the mic'e.memimmd property for inspection purposes.
Dke)agree to%ave,indemnify and keep nannies%the City of Cupertino against
lin liabilities,Iudgmarly,costs and expanses which miry in any way accrue againyt said
U Z city'in aonscgnvncc Cir the gmndng of permit.
APPLICANT UNDERSTANDS A WI.L COMM��LLYWITHALLN N 'OIM Issued by: Date "U
SOURCE REGULATIONS. �i SZ/0—V .
Signature lin Applicnm HAZARDOUS
Llan Re-roofs
HAZARDOUS ldin,OcCu, o"Oure (SURE
wluIne yTepplieanton mmmnrtal Code, lhapt nnmmeelfh natant and nmeh;I Type of Roof
as definedSee by the 32p0!no Municipal Gyle,Chapter 9.12,anA Inc Health and Salify
Colic.Section 155321x)!
0 ye, o.kie ' All roofs shall be inspected prior to any roofing material being installed.
Willfle applicant nae future building Overtrain Use equipment ordevices which If a roof is installed without first obtaining an inspection. I agree to remove
oil hnmrdnn, it comarrirmn,s a,defined hymn Buy Ana Air Quality Management
"It"Pall new materials for inspection. Applicant understands and will comply with
0Yes Lam— all non-point source regulations.
I hove n:ul ore e:,eaMna,,numndx rtgl,iro..mans r,mlet Chap,,fi95 of the
California Health IN Safety CnJe.Sections 2.1505.25533and 25534 f understand that
it the building does not currently have a mount,that i,is my mo,vi dbilty,to notify the G
ninonI Cif! marc'bell nmst he IIIc,prior to ixxu;mcc of u Cum m I
9
Signature of plicant Date
owntr Cir namorea: em— Dan All roof coverings to be Class "B" or better