00080154 CITYBUIoFNcuPERTNNo CONTRACTOR INFORMATION:
PERMIT
lid ILDING ADDRISS: PERMIT NO,
OWNER'S NANh:472 - - - APPLICAI'ION.I A '•-
ZONE: \IM YONGSOO1:11,10AROER 1I
SANI'1'ARYN(. C(1.
C ARCHI1FC'T`ENGINI;rR: v — BUILDING PERMITINFO
lihl%'i [LIiCT PLUMB MliCll
U -
Z��7 LICENSED C'ONTRACFOR'S DECL\RA7'ION - Job Description
v I In mby affirm that l am licensad under Noviaions of Chapter 9(commencing p
�rz with Section 7000)of Divi.inn3uf the liu.i....a..I Professions Cidc/and my license
iu t'ulll'otcc an II•t
�1. ii«n%eclax% — Li1.« 22 73 REMOVE SHAKES, INSTALL 1/2 CD X GLYWOOC
x 9 a O Dnte _ _ �a-o— Contractor
ce 5 a as ARCIII'rECr'S DECLARATION
twig Iuadcl.In:da,ypinn.anJlhenwd:LpnnliemamJ. FELT, LIGHTWEIGHT CLAY TILE
ani p O Licensed ProfessionalM OWNIiRiBOILDER DECLARATION
e =v 1 hereby affirm'I'm 1 ton oxanan tram the Cn immmr's Liceme I.uw fur that
F Z a following mown.(Semon 7031.5,Bmhws%and Pmfcssiun.Codc:Any city or county
fo which req pc nim nw
c . ct hen' ,p J IIh p sram
y, c -
61j2 ma I. Iry 4 .tit PPIi<mf ch pc a fl 6 J.ttmens
Irtn tl rat tt m p ,n, r n c t t 'eL 1 (cn pr,9 Sy. Ft. Floor Area Valuation
(commencing with Section 70hi at Drom..o 3 of teat Bu'n111and I'...aWra%Cn]I)
or that he is exump,Iherefmo,and the basis fur the alleged csempdon.Any Imlmion
Of Section 703 L5 by any applicant for a Permit subjects the applicant to a civil penalty
art not Imre man five I,uadmtl dolim,(5500,. APN Number Occupancy Type
oLasnwurrofthe prnper,ori„yaaployee,with w.,u,a,mei-olea...1penxatim,. $12621
will Jo the work,and he,tmantre is not intended tar altered for alc(Sec.7044.
13.,11111%and Pruhe,,imn Code:The Contractor',Liccnw,Law dues not apply to an Required Inspections
r ahmn
rt proper,who build.m ,4ne, ,crenn,tlad won dins\ace work bimwtlr 36624057. 00
as,through hit own eagbycee.provhlcd that Inch hnpnwlmem,am not inteadcd or
offered on sale.IL howcseo the building or improvement is,old within one year of
completion,the owner-builder will have the burden of proving that he did not!wild or
moms ser partro""I,al'.). 305 — FRAME
01.a,owner Of pmpenr.amexchi%ind,emnmming with licensed contmai"to 307 — INSULATION
Linstruct the project(Scc.TM4,Bminca and 1'ndcssionre Cade:)The Contructur's
ininw Law doe,non apply to to,awmrIr prop«1y who h"hd,m impnw",maroon. 601 — ROOF TEAR OFF
and who contracts for such projects wit),a contmcmr s)accused pursuam to the
Contmctnrs License Law. 602 — ROOF PLYWOOD NAIL '
❑I on exempt ander Sec. .H A,P C for this reason 603 — ROOF BATTENS
WORKER'SCOMPENSATION DECLARATION 604 — ROOF IN—PROGRESS
I boron,"mini ander p a Ce of I+,'Jury ono:watt itlilbwing dedfor Wor:
C I bine and will maintain t Certificate of Cement Il uladyer for Worker
ComP•.11vt ion, a% provided fir by Section 3700 of the LaWr Cole, for she
perfnnnuucl ill see work for which mli%permit i1 mated
❑I has the
will Lobar Code.n or the Pe fo mance 01 t e work f r whit thi ny Section
37W of,heorker Cale,for the Performance of the work for which mire pcm,it in
lowed,MA'Y nWn,n,,`,A'cr'x Gnnpcn%atinn Inwrancl carrier anti Policy numhe��r••��arep:
CNlee_"aAJ folic,Na.:
H I'l1ICATION OF EXEMPT[ON FROM WORKERS'
COMPENSATION INSURANCE Q/
I'Ibis section need not be completed if the permit is for one hundred dollar,
($100)or Ie")
I"Tiny that in Inc perbnname al the work for which at,pooh is i„ued,i
mill not employ any pcnon in any manner so a%In necnme subject in the WorkccJ -
Compensation Laws of California.Date
Applin at
N'OI IC17,'10 APPLICANT:IL;deer making this Certificate at Extn,ption.San d a:dd
necotm aubjen m the Work,,Campen,anor pravisianl of the Inbar Cade,yon man '
O C forthwith comply with auto provision,or this pcm,it shall bo dmmcd revoked.
Z
p_J CONS'I'RLUION LENDING AGENCY
Ihereby alliin,that there is a contortion lconingtgeney for the l,courmnnce
of the work for which this permit is issued(Sec.3097•Civ.C.)
❑ Lcudcr're Name
= 7 bunch,',AdJes,
U 1 comity that I have mad this application and state thin the anove information is
G. E..
comet.I agree to comply with all city and county ordinances and%tate laws relating
0 C.1 mhulldingcongn¢tlnn,and bcrchy authorize representatives ofthis city to enter upon
} rya the m.wounersuined autwa,In,impcnion or %I,.
F-' 6, Date)agree in save.indemnify and kelp hannle,s the City of Cupemno again,
Z) liabilities,judgmenn,cis%and cxpen%cs which may in any way aerate against said
U Z City Ia consequence of the gron ing of this permit.
^ APPLICANT LINO RSTANDSANDWILLCOMPLYWITHALLNONJ%OINT SOURC
Issued by: Date L
51k ffliu
Sigautom Applimnr/Comm,uu 6- Date Re-roofs
HALIRDOUS MAI TRIALS DISCLOSURE
Will the applicant or lutum huilding tccupanrttore ar handle harandur.numeral Type of Roof
are
defined by the Cupertino municipal Cude.Chapter 9.I],aad the lmalm aad safety
Code.Scodor 25534(.)7
❑Vere ❑No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it noadmis air c"numinann as defined by the Bay Area Air Quality Management
ismer) all new materials for inspection. Applicant understands and will comply with
0Y,, ON. all non-point source regulations.
have mad the hvmdous materials rcyuimn3ns under 4.1 l 6.95 of the
it he build iHoUlthn,do AC Sal Codle.Suctions 25505.2,9533to k ni nd 4553,.1 nn%Ic„mud that
tithe anilOf t aces nils onrt,amend,hove a mount,tett it is to issuance Oility a niftily,of ��-D
he
occupant of she u ems which moat M met prior m issuance of a Certificate of .
�ig %tore of Applicant Date
Qlk1L2_ ZZ a4
J aathnri.,�d agent Date All roof coverings to be Class "B" or better