01080094 CITY N
PERUNO
PERMIT CONTRACTOR INFORMATION:
B�L2y485RRANCHO VENTURA ST MAX BROWN CONSTRUCTION P010800094
TM CHANG 702 S DANIEL WY OP8Gf20f 20A0E1
PI10NE:
(408) 260-1260 SANITARY NO. CONTROL NO.
q-Z ARCHITECT/ENGINECR: BUILDING PERMIT INFO
'sC y FF BLDG ELECT PLUMB MECH
a u U 7 J
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i LICENSED CONTRACTOR'S DECLARATION Job Description
n h� 1 hertby affirm that 1 am licensed under provisions of Chapter 9(commencingo,,liis REROOF . p
r•.,E=w is in fll Pone and effect. onJnf the Business and ProrcaSinns Cole.ones mylicense
y I is in tbu fora and<Bem. REMOVE SHAKES
m a License ass Lit.M6
E.
Date cantmmar INSTALL 11 1/2 " PLYWOOD NEW COMP.
w 3 a G ARCIIITE DECLARATION
r u 0 4 1 undenl d y M1all as puM1l cads
c.a. Liffe .
K o OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Conn..,',License Law fur the
F z>' folbning reason.(Section 7031.5.Business and Professions Code:Any city or county,
Iso which requires a pennh to construct,alcor,improve,dnnolob,or repair any stmcwrc
a 3'° prior tottaissuarc<.also or,mossthe applicant for.such,smad taftle asigned statement - --that he is licensed purriount to the prossionsofthe Conarastim's License Law(Chafmrs) Sq. Ft. Floor-Area ,
(commencing with Section 700(b of Division 3 of the Business and Prof..tars Cartel $120tqiduation._ .
or that he is exempt thinafrmn'and the hasis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a permit subjects thevpplicam m a civil perally
of not more than ave hundred dollars(5500) 3 5 7,011rb f$90090 Occupancy Type
❑1,as owner of the propeay.or my employees with wages as their sole compensation.
will do the work.and the swsure is not intended or offered for sale Ism.7041 305 — FRAME Required Inspections
"
Businessmid Professions Cola The Combacwr's License Law does not apply to an tl p `
owner of property Who builds or improves thereon.and who does such work himself 307 — INSULATION
or through his own amployees,pbo pled but such improvements art not intended or ._ .. _..
oltered for sale.If,however,the building or improvement is sold within to year of - 601 - ROOF -TEAR -OFF --
improve far po owee f,alcer will bre-e the bollen of proving that he did nest hand esti 602 — ROOF PLYWOOD NAIL
my r mu:
❑I of the i pony n exdtowcl,cm gwithaccrmejcaudommin 603___ ROOF BATTENS .. .. .. '11 . ._
construct thproject(S 70,14,Business antiProfessionsCod<)TheContratm,s 604 — ROOF IN—PROGRESS
License Law does nor apply to an owner of property who Wilds or Improves thereon.
and who contras fosuch projects with a easternmost licensed .an,as he . . .. _ ... .. ._ .
Contract.,r License Law. I .
❑lam exempt under Secs IB&PCfar his.,on " ' - "-"• ^�Y
owner Date
WORKERS COMI•ENSATION DECLARATION /
I hereby afasm under penahy or Perjury one of the following declarations: l 0/
O 1 have and will maintain a Certificate of Consent m self-inmte for worker's
Cmnpcnation, as provided for by Scotian 37W of the Lada Come. for the
performance of the.,,,it for which this permit is i.umeJ.
❑1 have and will maintain Worker's Compenmtion Insurance.as required by Section
3700 of the Lawn Code,for the performance of the work for which this permit is
issued My Worker's C p< -t n Insurance curer anti Policy number arc.
Carr cr Policy No " •. '
RTIF CA TIONOFE%ION,.IONRANC ORKF.RS'
. .':' COMPENSATION INSURANCE: • . . .. _..,.__-. . .......... ....... .. .. .. . ......
(Thi<sectian sad nm b„completed if the permit is fm otm hoMl dollars
IS VXb or lexs.)
.. .. ._ ..... "l .... _ ..
1«mpl y any the n in any man f the work fb come thin pemtit a Worker' „ t
`Com not employ any peals m any mu as m become subject m the Workers' '
Compcnmfinn Laws of Calilinnlu'Dat¢nn
Applicant
NOTICE TO APPLICANT:If,afmr narking this Certificate of Exemption,you should "
became subject m the Worker,Compcns:nion provisions of the Lubar Cole,you must'
Q O forthwith comply with such provisions or this permit shall b<occurred revoked. —
Fi.ra ''-"" - CONSTRUCTION LENDING AGENCY
' 1 hereby atfmn that there is a ennstmefion lending agency for the performance
of the work for which this permit is i.imcd(Secs 3M7/Civ,C.)
a.Q Lenders Name .
Q Z Lntder's Address
V 0 1 certify Wat I have mad this application and smm that the above information is
Gs. P m
coes.1 agree to comply with all city and county ordinances and state laws relating
'Q U fo building consfmction.and hereby authorize representatives of this city to enter upon
W the aWsena,mioned prorerty fm noteor on'to",
L
Wo agree to save,indemnify and keep harmlasthe City sof Cupertino against
V] liabilities,jnagmenla,costs and expense,which may in any way rectae against said
V Z City in consequence of the graming.of Ihisp roar_
SOUkG. E DNnER. S DS AM 'LL COMPLY WITH ALL NON INT Issued by: Date
Sigmwre of Applican for oat Re-roofs
wri RDOUS MATERIALS DISCLOSURE
vrtant�r
_. \v'm mearfomrenuilmng occupant stare m handle nanmleu.m:nedal Type of Roof ..- ..
esdf dbY th CMrt nes blanc pal CW Ch pt 9.1 Jd H Ifh JSafsy r -�... •.. .:. . ..
Code Smt on 2551 (al" - -
_
E3 yes " r. All roofs shall be inspected.prior to any ioofing,.material being.installed. .
Will thn't,pplicant or mitre building occupant usec,I utpurcedordevices which If a roof is installed without first obtaining an inspection, I agree'to remove
ininutheriantirritoomourairourn, ac def dby the Bay ArtaA Q lily\lanagemem
District t - all new materials for inspection..Applicant understands and will comply with
x \IL"° all non point source regulations._ .1.,
I h ve read the ama; , s on,entill mr.inerrem,arder Chapter 6.95 of the
CII 'a Health&Safety Codi Sections 25505 5533 and 25.534.1 understand that
_ ifthe building does notcurrend'v have a tenant,that is my responsibility to notify the
occmthanired.,nut
quiteme hich must be m t prior m issonnce of a Cenifcale of
yry/ 2.01Signature ofApplicant DateCo ( Man, All roof coverings to be Class"B" or better
,. OFFICE . .