00090102 CITY OF CUPERTINO
BUILDING DIVISION ' PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERM]INO.
001-Age i
OWNER'S NA,MiE 140125 RUMFORD APPLICA'UON SUB UAI I:
'HONE'. SANI I'ARY NO. CON'IROI.NO,
G C ARCHI IECUCN'GINEER: BUILDING I'EIdh11'1'JN1Y)
w_ BLDG CLECr PLUMB MECH
I._I I I I
O N= I.ICENSEDCONTRACIOR'S UeCLARArION Job Description
I hereby aliform mal I ten licensed under pm,i,ima of Chapter v anmmencing
Gv,t_u wish$onion 71XXB ter Div kion 3 of the Haim,and I'm&ssions Code,noel my license
a t^J n to full Com.al eRca a�
z a License Class Gy L Lic.« -7-3-34(o� �3�
o i u pate 9_�aw emnn.,tnd- y.,�T1,� REMOVE SHAKE, INSTALL COMP
3 u-,Fi, r\HCIIITLCI"S DF.CLAHAl10N
C w ON S I end.....d my plane 111.11 rte n,cd a,public recon], •c
a a Liana)Rofcssiuna]
n
OWNER-BUILDER c,cr,iR DECLARATION /
I hereby.Hina mal 11..Burin fn,:n the Cnoun,come:
:Air,c Low Ib: Uhl
F z i following rcamn.ttienion 01131.5.Halton,and improve.
de io demolish,
h,or:Any city o i county
x which mluire'a permit w conamct,alter,improve,demolish.or repair.ny nmanm
p6J3m prior runsinsuance.ohomcm.c,thea,plic:mtf.r xoh pontine file asigned,encment
that he isItcaetip�::,a.nln,mehrnvi.imt,m'the Cnoens,nr,IJ,c ,Law(Cnalne„) Sq. Ft. Floor Area Valu. on
b nmmeneing with Scoinn 70(XB of Division 34 the Business and Pnd'esbns Cole)
nr that he is exempt therefrom and the Iasi,for the alleged exemption.Any violation
of Sed1703 L5 by any applicant for a permit,abject,the upplicant m o civil Iemill,
orounamelnanlive ondrwdolmr,ts5au. APN Number
- Occupan p
01,as owner of the propel my employees with wages as their sole compensation.
will do the work,and the structure is nut intended or odered for sole(See.7011. �},_-_1
in, andPrefe. eeCo,l,:'luccnm,annr,L'eeaeLttwdoe,notapplytit:, -Required Inspections
deo progeny W ho buildv or improves thereon,and won Ase,such work hinucll
or through his own employees.provided that such improvements am not intended or ?05 — FRAME
offered for sale.If,hovel the building or impmvcmunt is sold within one year of u
nn't pion,'he owncf�nuilMr will have the budea of paving thin he Nd nor buikd or
mprovefor mr,su „r sale.). 307 —
INSULATION
D 1,as ownm of ilm m,cra, in e,ew,mely cmttraedng with licensed eonmannr,ro 601 — ROOF TEAR -OFF
nsvael he p,,,j,ci(See.7114.Hu,ht,,, t Pn,fessh'n,Cod,:)Tic Cmntraetn;a 602 — ROOF PLYWOOD NAT L
Lam
icense law does nm apply m an owner of properly who huilds and improve,teateon.
and who cnntmet,for such projects with a comammas)licensed pursuant m d” 603 — ROOF BATTENS
Coal..License Law.
D l:nn cxm opt maler Sce. H&P Clbr this m;jem" 604 — ROOF IN—PROGRESS
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby alfnn under penally of perjury one of the burns,ing declarationv
D I have and will maintain it Certificate of Consent at.self-insure for Wbrkds
Cantpcmatio s lnsidal Ibr by Section 3700 of le Labor Coxle, lhr rhe
perform;utce or the work for which this pennn is i„ucd.
01 have and will maintain Worker's Compensation Insuranl as regnimd by Section
3700 nl the Lamar Code,for the pa lurniance of the work for which this permit is
.steed.My N'okcr's Corn,co,ation lowrmee carrier and policy number arc
Carrier. Policy No.:
CERnIgCAI'ION Or IiXEMPTION FROM WORK12RS'
COMPENSATION INSURANCE i
('no,,anion need net he completed if the penal i,forms,hundred dollars
(SI�IXJB�or Il
•f -
f t certify that in the pardon lance of the work for which this pencil is issued.I
.hull not employ any......i in any cannery+a/p+tv o c sabjeet m the Worker,'
compensation} woof Caluor )u •I L
Applicmt /
N(H'ICETject it)the NI`L Com,v Aingtnis C i%ion%of of Labor on. .yous must
heeame h comp y the such l',Cnmpensotihis scroll
r ll shaof the famed Code,you must
O � b,newllt comply each,nee pmvi,iom or this pennn scan he seemed minted.
z
F CONthem is con LENDING AGENCY
tY. ^ nanny wRmt that them i,o construction(See
lending s.C.) icons petfnrtnance
of the work forme which this permit is issued IScc.3007.Civ.CJ _
L Q L,Mcr's Nude
= Z Lender's Address
U 0 1 certify that 1 have real this upplicatinn and state that the above informs nee i,
G.. P comet.1.gree to en:nPly with.11 dD and cmumy ordinance,and store law, eluting
C H+building construction,and hemmyamhoiec representatives of this city to enter all
} 1] the above-mentioned pn'pcnY for inspection p.r,ove,.
r y
(We)ugim m save,indcrince ind keep taintless tho City it Cuperlim,against
A liabilities,judgment,,cool, and cxpcnruv which tnuy in city way 11,ruc.gaunt said -
U 'L city in consequence or me,natio•of this perrnd. y/
Z APPLIC UNDERSth S ND WILpinion YWITH ALL NON-POINT Issued by: Date
SO'
to mut ant, nn.nod Re-roofs .
H.\ZARUOUS MATERIAL S')'let Il
Will Inc applicant in future hill occupant stn..or handle h:natdous neatcrial Type of Roof
a,dctined by de Cupenlnn Mm:lcipul Cola Ch.pkr 9.12,tum the Heald,.,,it Stlery
Cede Seclinn 25532(x)7
Ores 0 N All roofs shall be inspected prior to any roofing material being installed.
Wnlthe nppnaamIll Lame htftldingoccttpatlloo, nipntmnmde,we,v,1nB If it roof is installed without first obtaining an inspection, 1 agree to remove
emir hmatdou,air ammminam,as delined by lire Buy Arca Air Quality Minum,ctnenl
District? all new materials for inspection. Applicant understands and will comply with
CYes 0 N all non-p tet source re ons.
I have red the hmiomlaterialsy t. under Chapter 695 of he -
Calif Health 0th 6 Safe,,Cable,Sedion,25505 5531 ad 255'4.1 muderround that1/ �y
if thebld
ung don,nal currently h' 't tthtiti yrcla 'ti11y1 •
try the ! C/
oupum nl the requitewhat must he no pruc tn'x,r:i,1a o r a Cr e I u m of l
Date
O'ce,awy' Signature f Applicant -
Lane,oraammlied agenl Dote I
All roof coverings to be Class "B"or better