00080018 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
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COWNER'SN 1II�TI 9 .., �•c3 AI'PI,ICATI( .', ❑ FI
I•'Af] j'I.11+1(i AND CHIJAhI t9r?/r_?Cr1(dL)
iONI:': SANI'I'AItY No. CrIN'BOI.NO.
ore]_ ARCUIILC'I/fRGINLIio. BUILDINGPERM11 INFO
au O C BLDG ELECTPLUMB MECII
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b yv' LICfiNSrucO,vrRAcroKSDECLARATION Job Description
OO G he
Z m,• Iherebyaffirm c1nm otthe Raloom ounvi.mnvofC,Cude9nd mmrnang
mww wilts adone(and of Dlviuion lr,f the Pwincss unA,,coca jO�CrWc, my license I
is in full form and effect/ ��`��ss 1/ 2Z �rie� 1-I_Y .. _ .
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ARCIII'I'LCI"S DIiC1.AItA ION
I,mdcnl:md my pion. nodi he used as public records
Wa,
o t Liccncad Pndc..ional
S sOWNGWBUILDER DECLARATION
v I hrrcny ullirm char I um v'xcnnrl Ind,Iba Cnnvnnor'n Liccnvc Law fur 111, '
C 7< following maven.(Section 7031.5.Rnsinces and Pndessiom Code:Any city or county
Y x O which requires a permit m amstrua,.Ime Indmo..Jen olivh,ar repair any relmre
ce 3� prior to it,i,suuncu,„hors,16m.,the applkaeforsurw
ch permit to filcanignedsemem '
mwhe is licemed pnrmanuothe mvisiomuf the Commome,Limnve law(Chapter 9 Sq. Ft. Floor Area \G I u
leummenring with Seaton 7000)of Division 3 of rho Busincav and Pml'c,.iom Codr) .Q Y•j (d
I),Ihot he in c,orad therefrom and the basis fnr the alleged exemption.Any violation
officiation 7031.5 by any applicant lin a permit subjects the applicant to a civil penalty �y
ennot nom lmmFvehundrmldollars($5ol), AP3'�,�;I ''�i.'fJf] Occupancy Type
❑h us owner ill the Prn,i my ennpluyecx w,in wrtg,,a.their Aule cotnpemmin 0,
w'i1I do the work and the amnure is not intended nr offered For role(Sec.7014,
Bmi.css and 11ro4,,ionsCuslermc Condor,,License Law doe..,ot apply ,,anPl�-L
,,.. R luired Inspections
toxcerot propery who bolds or hnpwo.cx thereon.and who dues such nark himself • ;3f%5 .._ FROa
or through his own employers,provided that such improvmnents arc not intended Our -- e.
corned In,Bela.II.however nuc buhhing on hopmvemenl is sold within one ye:rz nr .3(%17 :L' ON
completion,
completion,the owner,builder will have the burden of proving that he did not build or _
impro"Ah'n"col'.calv.). E,01 kIJ01 TEAR OFF
01.as,wner of modem,amexclwively contracting with l iccnud eccurs"ur.to6'C:1?3 -- 'RUfaf' G'I_YWf:1UI) PIA:I.1
t the project(See.7044.Ihnfnms and rrnfc,,i.m,Code)'rnc Contractor. 60 —• FiOROOFBATTENS
i........�iceme Law roes not appy'd,an owner of ps,orty n'ho builds or in,penxex thereon.
h
and. who cos m,such nnjmt.wane a contract(,,(,)) boomedboomedpurxnnm to me 6044 -- fi(7C3F' 11,1....l'-'hilJ(iiFiF:.:S(•y
a nntc,Lkmuc Law.
❑1 am exempt under sec. •B k P C Inc flik reasyn
owner Date
WORKER'S C0MPCNS6rION DECLARATION
I hereby diirm under penalty of perjury one of the following dcclarallonc.
7 1 have and will nminmin a Corifcme of Cmeent to xIri...re Int Worker's
'umlcmvatin 0, us mooliJ for by Suction 3700 of the Luhor Code, to, the
performance of the work for which this permit is issued. 0 ,
❑I have and will n,aimain N'urkcr's Gnnprns:nion Insurance,m requited by Section
37fi)of the Labor Code.for the periormance of the work ler which this rcrmh is
IvsuaL M��••kky�/f�ke(rs ConnpcJ}}��� nun n lumnce da t P`oliry/norma,,a u;
Policy No
rn.�jj—Q O a r
CRRfIPICATION OP EXEbIM ION FROM PORKERS'
COMPENSnnON INSURANCE
(Ibis vection need not he completed if the permit is for one hundred millers
($Rkq ar less) _
I cenify that in the performance III the work Ii,r which this Isrmit is Issued.I
'nil not anploy any partum in any manor,m,a,. y.onomu je[I m the Workcn'
Cpph 1i lion i..Ila II' P��
nprlicam /�
N(TnCETO PPLI(:ANr:l[a to making t ,s�-ill Cenih`cetc of Exemption,you should
becmne subject n the Worker•+Conformation provisions of the labor Calc,you now,
Q O I lo,th comply with such far...ion.or this mano.bull be deemed revoked.
C(INSIRUC'I'ION LIiNDINO AGENCY ,
' I hereby alien that them is a convection lending agency for the performance
fd of the work toe which this pennu is Lmu,d(Sec 3097,Cis.C.)
1 Q Lender'.,Nuns,
_ 'L Lcndcr's Address
U 0 I cenify that 1 have read this application and state that the aMve informdion is ,
tz ;: correct.I.gree m comply with.11<cry and county ortGnm—and store law,rebating
Q U to building comrmetiocand hereby anmodm representatives ofthis city to emit upon
the abve
omemioned Pou,ni for impraion pu",sc,.
`tom. L (We)agree msavw indo is coin keen han,nn"Re Cityofenpenino.gnina
OA Iiahilitics,joul,ameN,coos and oapemes which may in any wdy accrue against,did
U u City in ronaquence of the gmming of,his purmif
` APPLICANT UNDIiRSTANDS]]]]]]ND WILL COMPLY WIT.ALLN/P^NP,OINT IssUedb Date �
V SOU -irApp"T ONS / Da00 y'
Signuunm or APplicantlCommnor '—'-D]ar� Re-roofs
IIAL1RDOUS Is Ii"U\LS DISCLs"ToE
Will the applicant or ruwre buildingsx'ctoc Dore ne handle hawNuus mdencl Type of Roof
as debneJ by the Cupcninn Momelopul Chapter 9.12.and rhe Bad.,and Safely
Cn Ic.Section 25532(u17
o}'e• All roofs shall be inspected prior to any roofing material being installed.
9.511 the applicant or pompe building occupant use equipment or device,which If a roof is installed without first obtaining an inspection. I agree to remove
mit huaNuus air mnmminanrs asdyl nod by the Bucy Arco Air Quality cloo,cnent
Dinbicr! / n all new materials for inspection. Applicant understands and will comply with
0 ye, r all non-point source regulations.
1 have read the haserduus materials equincri is victor Chapter 6,95 of the
Califomi.Nuulrh&sul'ety Calc.Schoch,25505.25533 and 25534.I had...I d Doo
it the IniI ding docs no currently have a tammt,that it is my msprommil ity to unify the
ecup.nt of the regoimmem%whic mer prim h,issuance ill a Ccnircde of
oily y�-- p
�4�Z�/�. D� Ori Signature of Applicant Dale
i nrrnftl tan,t„i.eangent U Kate - All roof coverings to be Class••13" or better