00090118 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HU HAA NG ADDRESS, PERMIT NO.
OWNER'S NAME: APPIACAI'ION SUIT DNHH
D
L 4@99
19
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FF-y LICENSED CONTRACT'OR'S DECLARATION Job Description
pO�I 1 hereby rtirm thus 1 ton licensed under mokion of Chapter 9(commencing
with so,bm 700o of Divan 3 nl'the Buxinexx and I4nfvuin o Cndc,and my
FnC�
S y y-I is (ail force and c
x p d 6 I:iccnve Cl / .1_
ante 9 /x/00 conhdrv,r_��
LL O ARCIIITF,CI"S DRCLARA
1 made, and my plum shill nc used as pundit 'c nix s
oo LirersJ are.,innal REPAIR ROOF LINE
OWNER BUILDER DECLARATION
1 hereby affrm to.,1 an,a empt fan,the Contractor's license Law fur the
1-=a following reason.(Section 9(U 1.5.Business and Pafeaions Code:Any city or county
o wlaim requires a permit to constmct.neer,improve,deb ulixh,or repair any structure
prior re its isnavnnt ta
ee,clan rcyuircx the aPrI cor snot icrrnito,file a dgned statenean
=5� that he is licensed personal to the previsions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation'
communcing with Section 7000)of Div kion 3 of the Bminesx and i'ndessinns Ede)
or that he is exempt therefrom and the basis lin the alleged exemption.Any viola inn
of Section 9031.5 by any applicant for a perait subjecN the applicant to a civil penalty
of a,,(Imum moa five ha almd,lapa,S( 000. APN Number Occupancy Type
01,as owner m the papeny,or myemployees with wages as their sole compensation.
will do the wore,aM the stfucture is nut intended or offered for sale(Sec.90.14.
Bualnes,can Profession,C,dc: rhe Contractors License Law does rant apply la an Required Inspections
r of property Who holds or improves thereon.and who does such work himself
onhroogll his awn cnpWycea.p,,r dod ilia sash hnprnve ttentx are nor Intended or
offema liar sale.If.hours.,the bu0d'll,g o.....pmsemmtt is xmd within one,-ear of 31.64201 5. 0021
completion,the ownc,li ilder will have the burden ofpaving that he did not build or
apmse Eu par aace of alc.)
0 Las owner of the property,an exclusively contacting with licensed contractors to 305 — FRAME
en
onstnml the prnjcm Sec.9M4,nmilaro amt Pref MOIn Cn lr.)The Contractor n 07 — INSULATION
i.i«arc ns no
Law dans apply e,an owner ofroerty ppwn .m mrudimprove,mrota ''.�
and who ommel,for such poneas with a eantmctad,licensed prsaard to he 601 — ROOF TEAR OFF
Contrac'tor's d.icenxc law.
0 l am exempt under Sec. .It&P C Rn this reason 602 — ROOF PLYWOOD NAIL
Owns WORKER'S COMPCNSNI ION DECLARATION 603 — ROOF BATTENS
I hereby Bunn ander panalty of erjoi y one onhe fallowing drdaradons: 604 — ROOF IN—PROGRESS
I I have and will maintain a Certificate of Consent in.self-insure for Worker's
mpensatio s pavided for by Sectio, 39(q of the Labor Cade, lin the
pertormuna of mite work for which this permit is issued.
(31 huvc and will all nrker'x Con,pematinn Insurance,as Obtained by Seddon /
39U9 of the Umbar Code.for the performance of the and,for which this permit is
issued.My Walker c Contpensatina Insurance carrier and Polity number are:
Carries Policy No, O
CE RTi FICAq'ION OP EKENHIIdON FROM Wo RK1iRS' J
COMPENSATION INSURANCE
This section need not he completed if the pennn is for one hundred dollars s
($100)nr less.)
I scally(hat in the performance of the work for which this pemut is isxucd.I
hall nm m,Ir u y Parma in any Inannr t he I subject d,de Warkerd
camprnsah,n - n al fain a �'
nppucnm_ _ a(rt -
N'mICETf AI'I'LIC '1': v[tc,no Ingtlf Cc tiOcvtnof Es,,i on you should
Incomes, jecnn the varkers Compensation provision,of the labor Cale.you must
Q O I'onhwlte emnply with each pr,viJans m this prone¢hall nc ducmcd revakcd,
V]
CONSTRUCTION LENDING AGENCY
1 herahy aI'Orn find them is a c.mstrnetion lending agency tor the performance
fine work far which this permit is issued(Sec.3099,Civ.C)
(� LmdeC,Nome
7 z Leml,is AJMrss
V 1 certify that I have read this application and state that he above information is
W FI correct.I agree a,emnply with 1,11 coy and cumty onllntmees a state laws relw'mg
U m building construction.and hereby arm...m repmsereaurs of this city',,enterupon
r1] the ahav-mcmtoned propene for impeainn pugmcn.
F6r (We)ugmc"' "e.i udnnuil'y it I keep harmless the City of C riraoagdhna
to liabilities,Judgments,anus and expenses which nine in any wry creme against said
U z City int ennsegncncc anhe grating of thin Pc.it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNON-POINT Issued by: C- `"` Date
SOURCE REGULATIONS.
S'Ignauncaf npplic ICmnracmr Due Re-roofs
HAZARDOUS SbMERIAIS DISCLOSURE
win me appdeam err future h ldfing arcupant stem or handle ha udim,materml Type of Roof
as refund by the Cupertino Municipal Code,Chapter 9.12.and die Health and Sufcry
CredoS
a n 25532(W Vite ❑No
All roofs shall be inspected prior to any roofing material being installed.
Will the ap,l,c.a or future(wildin,Overpaid use equipment or all which 11'a roof is installed without first obtaining an inspection, I agree to remove
aril Inonrduns ter cunantinanu as defined by the Bay Arca Air Quality Management
)oldro all new materials for inspection. Applicant understands and will comply with
G Yea ON. all non-point source regulations.
Ie read the eve,dous maenads d,rylmmcmn trader Chapter 6.95 of the
Colhvrnla Health&Safety Code.Sections 25505.2.5513 and 25534.1 undersand that
It the,b lding dove not uc rcolly nava a tenant,tem it N ay n+rym,lbillty m notilr the
mveuIt plot the mgalmmbnn which masa be ton prior to issuance of t Ccnilicme of
ctrl cavy.nna rt acrd ?are 0gnatm of pplicant Date
— All roof coverings to be Class `B" or better
Lo
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