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01090072CITY OF CUPERTINO CONTRACTOR INFORMATION: BUILDING DIVISION PERMIT IIUILDINO ADDNIi55. - I'ERh11'I'NO, OWNIiN'S NAME: APPLICAI]ON SUR DATE PHONE. SANITARY NO. CONTROL NO. iv9 ARCHITECT/ENGINEER: i. INFO] RUILDIHGIlL BLDG ELECT' I'IIM- H 1[CII LICENSED CON FRAC'JOR'S DECLARATION Job Description Thal I ant lacnanl erprnvi'" "'d Chaffer 9(commencing I hereby affirm und wish Section7000)of Division 3 of the Businessand Professions Ctak,and my license to full li,rce unJ tll�d. License Clans Lie.N n Date S OTCLm ANCh ll be u e UECLAic I ION mcom 1 understand my Plans shall M nscA az public rtn,Na , / O ON OatREon VVV exc1.DER n the Conlr clo Licence Law for the 1 herchy al' that loon um,pn I'nmt the Contras i Co Any city orcounty reason.(Section ]U3str Hmftcrsand improve. or which requires construct, +her, improve which re or repair any tateme h lNorvh, n tie l....o Pitttoa.,i.... t nsederl,nreymro, meapionso lir Corperms a,EIea Law(xclisert that heps'o,wdpSectio to the pm.,dana.l Sq. FL Floor Area Valua$t+O ocnmmmnrsuctn.ela.War, Code) (a is with of Division 3 of the and Coital /50O legedans ion. Any vi or Sect he In exempt mtrcfrom and the Nasi, for the alleged exemption. Any violation t therefrom or that he om a of Section 7831.5 M any.pplicam I'nr u pcnnit suhj«u Sec applicant too civil penalty P3NNumber Occupancy Type firlot more than findlot ]red danars(550x). 7 / me will wages as d,drsnlc mmtiona"on. J ❑ Las evnernf properly.onny cmployces will do the murk and the amctum is not intended or offered for .sale (Sec. 7(144. Required Inspections Brame., and reare,bor, Coderrne Co.,,., n Lmcow Law deco am apply in an r of pr'pery Who folks or Impro4es thereon, and who Aces such work himself orfiredthrough his own ho bundtd that such improvements an not intended or sold within nae or nalproving hmbodde eveees. , ormretl Ibr vie. IL year rise l leive t fir burden Ilh nceb d fp B@tis J'J not build or c,nplt II "M1 of n e. improveI p try: f I ) ' as owner f theproryn5 exclusively contractingwith ficereted contractors 11, C t urs n Leis p jeer (S ]told N. a d 1 f C,., improve, leer: I I tel ISt . ufp pent 'h hlJ' p tendon � and who umtmet for such projects with a wnmdorts) licensed pursuant to the 91 Contractor's Liccnxe law. 116 P C for this reason / rD tun, venya ntNer Sec . weer �� 9(��r' as W'ONALR'S CO, PENSATION DE 'IAN L(. (A henhy a1En l under Penalty of perjury one of the following declarations: 1II ❑ 1 have unit will maintain it C>rilicntc of Consent to self inwro for Worker's I Comdivination, as pro. idol for by Section 370) of the Labor Craft, for the performance of the sod, for which this permit La issued. ❑ 1 have and will maintain Woder's Con,pen.mtenn Inwmnce, in, required by Section 370Cl fir the lahnr Cnde, fnr the ped,mnutnc of the work rat which this permit is ,sued. My Workers Cn licnsarion In,umnce carrier and Policy number um: Carrico Policy Na: ' CERTIFICATION OF EXEM1910N FROM WORKERS' COMPIiNSAI ION INSURANCE (Ther .section need not be complered if the p[nnit is for one hundred dollars (SIIXA fir he"') I acoify that in the perlbnawntt of the work liar which this permit In issued. I shall not employ any per-in in any manner m as to become subject to the Woollens' Cnmpeonadon laws of California. plate Applicant NO[ ICE TO API'LICANT. If, after making this Celt fleets of Exemption, you should become subject to the Worker's Co ldicemdan pnrvl"i m' fir list Lahnr Cn le. you must fnnhwhh comply with such provisions or this permit shall he deemed revoked. . CONS 'FRUCIION LIN OINO AUI!NCY I hereby uRrm than there is a cnmwction lending agency for the performance of the work for which the, pc.air is issued (Sec. 3197. Civ, C.) Lender's Name ' Lender's Address 1 certify that I hate read this application and state that the above information is omen. I agree to comply with all city and county ordpmnee%and %tare laws relating 1 rebuilding mnnuuwiou.nod hereby authonearapmcentativeanf this citym emerumen I the ohnvc.mcmioned prnpcny for inspection purposes. (We) a,. in save, indemnify and keel bamtlexn Sec Ciry of Cupertino agnnd l liabilhis, judgments, adv and espenws whmh only In any wary acerae ageemt said City in consequence of the granting of this permit. ' NDIRPOINT' Date SOURCEREULATI�ADt)r',C(lMl'LY\"I'HAL1,N0 SOUNCE NIU — 1signaturenrnnpraaat/ ISSIICdby: D' Re-roofs HA1A15 DISCLOS URC Win l,e applienal fir mtare Intddmg nevulwat %tart m let Ile I,amrdmt„naurnal 'type of Roof ata ddincd by the Cupclion Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 255321.17 ores V, All roofs shall be inspected prior to any Fooling material being installed. Will the .pplecantar home building oamanluse eveimnate,de.iro which If a roof is installed without first obtaining an inspection, I agree to remove unit haeanlnu%asr en at dran,as delined bythe If., Arta Air Quality Management ])iatrict,!` all new materials for inspection. Applicant understands and will comply with 6 Yea p(N1 ` all non-point source regulations. have mad. the h.umaterials requirements under Chapter (1.95 of the fJous California l lculth R Safety Code, Sections 25505, 2553 and 25534. 1 understand mat if the huilding does not currently have. repair, that it is my responsibility to notify rbc 'we” mit aof the myuircmenu which Brost he nod por ono isxuuncc of u Certihcam of °'vaf'o y _ -'� (a'L�� �— Signature of Applicant Date All roof coverings to be Class "B” or better nwnm m t r„en agent OFFICE