00062068CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
I'ERMH No.
OWNER'S6R : `O
APPLICAI'
1DONE, _ CARL — HNU ly1RRL1RXi--',"
SANII'AR Eef. .No.
2 ARCHITECT?:NGINEER:
—
BUILDING PIZRMI'IINFO
O
BLDG euscr PLUME Mbal
i LICENSED CONTc,c]unOR'SDECLARATION
Job Description
I hereby aRirm the(I am Itched under provision. of Chapter 9 (commencing
uQi wish Scutinn 70(llp of UivisivaJ afrhtnminc,,uual i'mfh.iuns Cude. and ns.hrnn.ce
is In full mine and effcct.
iai`e°= - 3"g c ups.",—ROOF
ARCH ITEC-rS DECLARA PION
j lord—modury plans shall be wed h public mcurd,
JLicemed Pndcssionnl
OWNER-BUILDER DUCLARAI'[ON
I hereby mu muand 1 an, exnnpl fmm the Conlmcmr's License Law for the
following rewun. (St 7031.5. [1 nen, and 11 re,,mm, Code: Any city ur roomy
pwhich n cors, a permit In tonMrvd, aunt, impfma detnolkh, ir repair any dractom
prior to its issuance, alto requires the alrylicam for such permit to file a signed,taRmrnl
Sq. Ft. Floor Area
ation
— Ih:n he is lieen"dansurI"'hepmvmon, of Our 0 Ira,lor, Licche Law (Chapter 9
Iromnheneing bisection 7(XXp of Division 3 wl'the Bueinen and Mvfnrions Code)
,
or that be is exempt therefnmh and the b:uis for the alleged exemption. Any vinlution
of Section 7031,5 by tn,y ^PPGcum hn a l,crn t subject, the agq+Iimwt to u civil pctudty
- APN Number
pe
of not mate than rive hundred dollars(SSap.
„QC
O I. as owner of ren pmpcmy, or my cn+pinyees win+ wage, as their sol=u,mlbecou ho'
32615102. 0 9l:quired Inspections
wdl do the wink, and the .tmeum i, not intended or offered for .ale (Sec. 70,W.
business oml Pmm..loh Code:'I'IN Cootmctor's Liaun,= law does not :p,ply or an
wider of pmpeny Who build, or tuipmv=s thenen, and who docs such work himself
or through his own employeesprovided that such improvements are not intended or
'
offered far side It. M1mwe..r. the building,, impm.emem I, sold with lu eon year of
305 — FRAME
completion. the owner-Wilder will have the burden of proving that he did not build or
mpmveorpor,soc if 1,10.
307 — INSULATION
O 1, at owner of pmperry. am exclusively contracing with licensed contractors m
601 — ROOF TEAR OFF
nrctrueI Ito pn+j=ct (Sec lo-our,, Itiucand Prol'es,,uns Cudc6'fire Comrueror',
pve.thereon.
Licen,eUsedoe.ootapplymanownerofpmpenywhohuumorimm
602 — ROOF PLYWOOD NAIL
and who contracts Isar ouch projects with u mmmeortk) licensed pursuant to the
License law'.
603 — ROOF BATTENS
commmn I
01 am exempt under set. . B & P c for (his reason
604 — ROOF IN—PROGRESS
Owner Date
WORKER'S COhIPIiNSA'1'ION DECLARATION
I herebyaffirm under penalty of perjury one of the following declarations:
] 1 base and will maintain u Ceniliad= of Consent to self-incur= tar Worker'.
_
ompeha(ion, as provided for by Section 3701 of the Luba Cede, for the
-
perfnnnum, or he work tut which this nnit i. issued.
❑ I have and will maintain Worker's Compensation Insurance as required by Section
370(1 ol'the Lnhor Cude, for tire set bu nntnce wf the work for which tI ks permit in
issued. My (Wo kei[c,Com n%atiou Imumbec garner andpolicymm�her are
r0
'
Carrier_
C E K IIps. C AT OF EXV%IP 10 N— O\f WONSKO S�
COMPENSATION INSURANCE
frhis section need our be completed if the permit is for one hundred dollars
WHO sur le")
I cenify that in the pertomwnce of the work fid which (his permit is issued, 1
shall ant employ any penvn in any manner,, as Is, wee nm subject lin the Workem,
Comis nmtion Laws of California. Darn
,
Applirma
NOTICE 10 APPLICANT: If after nuking this Certificate of Exemption, you .should
becoom subject nth the Worker, compensation too kions of the tabor Code. yew mus
r
bah, bli comply with such provisions sur this pcnnit had be dcnncd revoked.
O CONSTRUCIION LENDING AGENCY
I bereby ici inn that them in a cwwtmetion lending agency lin the peffor o m.
of the work for which this permit is issued (See. YNI. Civ. C.)
] Lender\Name
-
Under's Address
y1 eerily that I has= read This application and stem that the obese intormmion IS
sec(. I agree to compwith all city and county ordinances and crate laws relating
m building co ournetinn. tm l he,ehy nuthorim repmeetmnivnv of this city in enter c,n
,
(he Cho-merumned lou,ny for ihp=ction pugmnc
y(We) agree In rve, indemnify and keep harmless the City of Cup=nino against
n liolubties, judgments. costs and expenses which may in tory wary accrue agxilwxmil
t\
L City in consequence of the ginning of this permit.
APPLICANT UNDERSTANDS ND LC9MPL/,Y./1 HALL NON PO
SOURCE REGULATIONS. ��� //N/—N/2.%/
Issued byDate `
Slgnwurc of Applicano ;,am 1�/Cs ('_Y I7 Dam
Re-roofs
HA%ARDOUS GRIALh UISCLOSURI3
wdl he:,pputantm minor Wilding octopim store or handle har.rdeu, material
Type of Roof
as relined by the Cupertino Municp,d Code, Chapter 9,12, and the Iictdrh and suety
Code, Section 25532wr ❑ Na+
El ye,
All roofs shall be inspected prior to any roofing material being installed,
Will the a,licanrormtomWilding oteupantuor mpmenlmde, ichwhich
If a roof is installed without first obtaining an inspection, 1 agree to remove
.,it M1uuvdoux sir amumaimmu ar delin=d by the Pay Arca Aar Walt, Mor"cu rent
all new materials for inspection. Applicant understands and will comply with
mric(7
0 Ye. 0N
all non-point source regulations.
I Imva mad the loo-dnh mmedol, requirements under Chapter 695 of the
Cull4 to llc;drh&Safc,y GXlc. Svetiunx 255115, 25533 and 23531:1 wdcmtund thin
if the building dots no, curmilly base a marinl, that it i, my respntaihil fly to notlly the
socupern of the re4ulmancoN which must be me( prior u+ issuance of a Cenilicam of
i)ccupancy.
Signature of A licant Date
All roof coverings to be Class "B" or better
.are,orauthr+drtdagnh, Date
Lq7�