05030219 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CUNTI2ACT()ItNIATI°
BUILDING ADDRESS: SUMMIT REMODELING PEaMIT NGb 5030219
OWNER'S NAME: PERMIT ISSUE DATE
41WE: SANITARY Ke OL NO.
ARCHITECTIENGINEER: a BLDG BUILDING PERMIT INFO
ELP.Cr PLUMB MECH
e r 0 0
�i mOS LICENSED CONTRACTOR'S DECLARATION Job DescriptioA ,p
I heroby of ton that 1 am licensed under previsions of Chapter 9(commencing !1
with Section IF=)of Divlaion 3 of the Business and Profession Code.and my license is
° kfunmataedtrtta / REMOVE (E) DECK FRAME ROOF w<' '
j Z Lictna CI Loo.R
Dam Comnmar
ARCHITECTS DECLARATION tf
1 understand my plans shall As used As public rernNsh
u. Licensed Professional O 6gr ` wa/
m
OWNER-BUILDER DECLARATION
E I hereby.(firm mal 11. exempt from G r Conlns Co e:A License taw for the y
o O following requires
a(Stento 713 1.5,Business and Re,do Professions Cade:Any oily ser county
$ which ro9uires•permit re ores the alar,ntProw,dembllsh,or repair anY structure
I
poor missluuanaermentin tea theapplicantof forsuch Conracmit m Lion.Laedeuamcnl WI�D t]Vh
£=£gyp
that he is licensed Ferment in the Provisions of the Conuacmri LRrona law(Chapter Sq.F[. Floor Area
d IX he is esem M Secdrom and the but&for of ren Bwiruand on.Anynu Code)of
'x $ Net k a eampt therefrom and the bait for Ne ai1cgW exemption.Any vlolatim of
Section 7031.5 by any applicant for a permit subjects the appileant m a civil penally of 3 y, ?!D*@ro 0 Occupancy Type
not mon than ave hundred dollars($500).
1,u awnu of Ne propmy,ser my emplaytes with waW u reek sole wmpewnon,
will do the wart,and ice strctre isnotinaMed&offered foraaie(See.70".Bwinew Required Inspections
and Professions Cade:The Contramis Liane law does not apply m an owner of 9 P
property who builds orimprovesdam on,and who does suchwarthimselfor through his
own employees,provided t uwch improvem rms an,notinanded croaefed forsak.if,
however.the building or impronment is sold within me year of compledm,the owner-
builder will have the burden of proving than he did ret Wild or improve for puryrc of
sale.).
❑1,as Owner of the property am exclusively contracting with Oared counemrs to
comment the project(Sec.7010,Business and Professions Code)The ContramYs U-
sena law don not apply m an owner of property who Wilds or improm thereon,ad.
who contracts for such projects with a eontrai ar(s)licensed pursuant in the Contramfs
License taw.
❑lamesemptunder See .BkPCforthisfeuon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby&M m under penaity of perjury one of the following dalentior:
❑1 hire and will maintain aCeAOntaf Consent to selfMruufe forWObefaCompen-
workfr whichded for by Section 77000(the labor Code.fm the performance of de
work rens which this permit is issued.
❑1 hove and will maintem Work es Compeemlon Irurana,as mquired by Section
7700 of the tabor Code,for the performance of the work for which Nis permit is lssmA. '
My Worker ComPe Goo In note carior and Policy a Cis)
Ca ' yn� Policy FROM
CERTIFICATE rCOMPENSATION
ON FROM WORKERS'
COMPENSATION INSURANCE
(nd1 F%tion red not be compinad ifthe Permit Is forma hundred dollen f HN)
ser sees.)
I certify that in the performance of the wM for which this Permit I,issrd,I shall not
employ any person in any manoran see An become subject m the Workcfi Compensation
Laws of CaO boflL Date
Applicant
NOTICE TO APPLICANT:IL aftr making this Ceniaaa of Eamirtim,you should
become subjm on ren Wahee's Compenudon provisions of the Liver Code,you most
.J 0 rOnhwire comply with such pavisinr°r this permit Mail be domed rowked.
'Z
,s y CONSTRUCTION LENDING AGENCY
[.r Ihereby.M.that time is.construction lending agency for the perfermnee of
C,7 the work for which this permit ls issued(Sec.3097,Civ.C.)
CN.
0 Lendees N _
7 z lomans. Address /
U O 1 unify,that 1 low,rued this Application and sot that dt AWw informal].a S
0 correct.l ayes c comply with all uth end county ntatnanaa and sus lawn relating a
Q V Wildingmioned ion,and hereby uthodarooses, roof than city mentor upon the
Da alww.(We)are Property for indemnify
Purposes
iL es,ju ogres m row.ad exper and trip harmku de City of Cupmdna again
IZIZ incoidequenc ofheensu tndexperuwhich may in Anyway acoe against aid City
U Z APPLICANT
oNDERSTAND4nji Of ls pe ma
^ APPLICANT NDERSTAND WILL COMPLY WITH A NON-POINT Issued by:9 Date
SOUR R LAS. T i/ser
cJ f/ J Re-roofs
amreof AppliaZdConuamr as
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will de applicant or future Wilding next pan[storo or fondle hauNou material
A
deOrd by de Cupertino Municipal COM.Chapter 9.11.And the Health and Safety
cade.Section 25551(a)7y All roofs shall be inspected prior to any roofing material being installed.
❑Yes 4No
Will tun applicant or/future Wading nauwm as NuipmMl Or dtvi%i which If a roof is installed without first obtaining an inspection,I agree to remove
:Zna
hanAos airconWnlnuLL as de0rd by the Bay Ams Air Quality Management all new materials for inspection.
ict7
❑Ya NoI have read Ne hu materials requimmems under Chapter 6.93 of seColifof-
al"SfmyCle.Shims 25505.25533 aha 25334.l undemand dwlithe Wilding
t cruron0Y haw•tenant.that it ls responsibility m runty dt oceupanl of the
regmromco must be ° aCcrnfieaa panty., Signature of Applicant Date
or uthoriad agent D, All roof coverings to be Class nBn or better