01030095 CIT OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: - PERMIT NO.
22413 RIVERSIDE DR TRINITY GENERAL B 01030095
OWNER'S NAME: AI'I'LICATION SUB DAI'E
CHAN KENNETH T AND JULIA B 2303 GIANEVA ST .03/1.9/2001
Mop PHONE: SANITARY NO. CONTROL NO.
(408) 313-3694
Z ARCHI'rliC'I IRNUINEIiR:
IIUII.DINO PERMH IsdO
O O BLDG IiLliClPLUMB MIiCH
UE I'—t I-1 Cl IJ
G%a
FNLICENStUcoMnRncrORSDranoAnDN Job Description
I hereby allirmthat 1 am licensed under provisions of Chapter 9 fcommmncing
I- with Sect ion 700pot O......n 3ol'thu ila,inmsund Prnlccr�fynr Cdlc and myllcensc
<--antlni,r°,:eta°'r" C� � li xLQ/IJ��_ REMOVE EXISTING WOODSHACK
� I:iccnsc Cla.r
at, oaf/---3—c1—.,�0�}— .1 ECII° � j INSTALL 40 YR. COMP.
vi 5 y,m RCHI IiL1"S UCChAR ON �•D 7
t"og lumdexmndn,pian,lhallhe..ita,publ' Nn INSTALL SKYLIGHTS.
w=O O Licensed Professional
°'i OWNER-BUILDER DECLARATION
1 hereby atirnt that mm exempt Brant the Cariumbr's License Law for the
F a following re:rcom section 7031 S,@...nese and Prnfe,,iun.v Code Any city of county
,�+SG whd 4 I lniflI,c i"mr,falic,' P de I ,,—repair anyIllation,
6CCam prop t o cukrame h applicant h ,rout t flsignedal nett
man I Ip tan It th,pr o,ofthC.davetari,Liceme La.(Chapter 9 Sq. Ft. Floor Area Valuation
(common ing wnh Section 70CA)of Dmikion 3 of the Business and Professions Code)
or that he is e¢mpl therefrom and the hasis for the alleged exemption,Any violation
of Section 7031.5 by any applicant lin a permit.object,the applicant to a civil penalty
ofrt Brow than nee hundred della..($500). APN Number Occupancy Type
❑1,a,owner ofthe,Deeny,or my a l"loyer,with wage,,a,their sale c,mtpen...inn. 11 q III LA LA
wBovines,and ill do the work.,and the structure In not intended or olfcred for.ale(See.70,14.I role, ml Code:The Cummarr,License Law due,orf apply ,,an� Required Ins CCtlOns
inner of property Who builds or ingnnees thereon,and who does such work himself
or though his own employ«,.provided that such improvemmtts am not intended or 35603037. 00
offered for late.If.uo ever, he building or impmvcmcnt is sold within one year of
nmpletimn,me ownerl+uilder rill have the burden of proving that he did not build or
improv^fm pu"oe of sale.). - 5
0 —
FRAME
❑Ln,,^wheollbcpfSeeny.mnexdacs%anrmrsefittgwOCBmnxdemonlaucnfo 307 — INSULATION
ennswd meoproject(Sec.70aair Bunters and property
whoa,Code:)Thempr tv r,the o n.
License ho co fee, for Nu
hroan owner%itf a vari who licensed
improver, to the 601. — ROOF TEAR OFF '
and who emtmds for such projects with a enmmctnt(s)licensed porsmm to the
Carmemr"Licen,elaw. 602 ROOF PLYWOOD NAIL
01 ant emmpt under sen. .H&P C for this m¢wn
Owner . Date 603 - ROOF BATTENS
WORKERSC'UM19!NSAr10N DIICLAkNI ION 604 — ROOF IN—PROGRESS
1 hereby allirn under penally of perjury one of the following dedaration.e
❑ 1 have and will maintain a Ceniticam of Consent n,self-insure for Worker'. -
Compaconion, as provided for by Section 370D of the Labor Crede, for the
performance of the work for which this permit is:.wed.
❑I hive and will ntairmin Wnd.uh C...I aden)a...e ce,as mi,nned by Seen
37S)of the I.I.1 C,xle.for dieparloiria ec of me work R,r which his pentnuis
sued.My t rttmtRiR l nwranee carrier and Vol he rc
C�rtier�Polu,NA:/
CER FICA'1'ION Op EKIMMON FRONT WORKERS'
COMPENSATION INSURANCE
I this lection need Bol he cr..diled if the pertntt is for one hundred dollar,
(SM(d tit less)
I ceofy thin In the ped im ounce of the work far which firs perm:]is issued,I
shall not employ arty p,rmn in nay ttmnaer s,I a,m hca,me adjeet to the Wmkera'
Compenmion Law,of Cahfnrnir.Uam
Applicant
NOTICE TO APPLICANT:If,atter nuking this Cenilicam of limnaption,you should
Became,uhjw fn m
the Workers Compcntion provisions of Labor Ian Code.yon rrml
O O Bmhwith emnpiy wint.nh prwi.imt.or ttd,Ivaud ull he deemedrevoked
y CONS"I RUC'I ION LENDING AGENCY � -
� ' I hereby affirm that there i.s a comtrvction lending agency forthe p,.r orris nce ---
of the look bun which this permit is i...ed(Sec.3097.Civ.C.)
L Q Leader',Nnnm
Q Lender's Address
V O 1 verily that 1 have nerd 11r,applinnien and ,are the the above information is
come,,I u,re Io comply win,all shy and emna,,nnllna i,c,and,Imo laws relating
O V
or buildinge,nsvuNon,and hnrony anhorisc repreaeno c,rf 11,1,city so cncrI
the aNwo-nmminnml popcny Int innpcmion pantoses.
1�. d (We)agree msme,indenonly and keep harmless the City of Cupertino against
N liabilities,rydgnmms,costs and c,,a-,which.may is any way seems,a,aiml said
U Z Citrin consequence ohne granting of thist. :3—
APPLICANI'UNUE rN1 'A NPLY WITH ALL NON-POINr _ Issued by: r Date
7URCE REGUh �nma,11dct?�
.ty,amr,nr npltl � rt, - - - Dar Re-roofs .
HAZARDOUS MAIFRIALS DISCLOSURE
Willits uppllcanto,future bullding,ccupant.store or handle hanmdou.malomil Type of Roof .
as defined by the Cupenino Municipal Care.Chapter 9.12,and the Health and Safety
Code.Section 25532b0^
O Yes 0 N - All roofs shall be inspected prior to any roofing material being installed.
Will but applf^
' oicantrrnbuilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
ut hantnl n,.1 sur uonunninanu m d^bull by the Buy Arca Air Quality Maazgenmm
Dnales all new materials for inspection. Applicant understands and will comply with
Ayes [3No all non-point sourceregul'tions.
1 have read the h r a dous materials requirements under Chapter 6.45 of the
California Ileahh&Safety Caie.Section,25505.25533 and 25531.1 undemm�l thin
iflhe Wilding does not,mmmtly have a tenant,that it n my resprmsibiiily to notify the ••-�
occupant ol'the rat,,iremenrs w h the tact prof m iaounce of n Cludicam of
eC^p°"`'y' _ Signatur pplicant Date
All roof coverings to be Class "B" or better
Owner or ve ugcn Ilam
OFFICE