00120015 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMI F NO,
631 STENDHAL LA COSMOS ROOFING 001.20015
OWNER'S NAME APPLICATION SUB DATE.
JASHAN ROBERT -J -AND BRENDA 450 SAN ANTONIO RD 12/04/2000
PHONE: (41.5) 493-6373 SANITARY NO. CONTROL NO.
O m z ARCUITECIYENGINEER: BUILDING PERMIT INE()
O C
E BLDG ELECT PLUMB MECII
y i LICENSED CONTRACTOR'S DECLARATION
ov.e L heresy afrrrn Ina 1 on,licensed made,pmviairn ofChnpaar 9 tcraxmchg Job Description
YAC J wIIM1Scmion 91Np1 of Vivi.inn Jul he lLnincss unci l'rnfesinns Code. ImY liceme GRAVEL (4 P
"an rall rtioall T/0 TAR R GRAVEL ADD TAR R GRAJ
S Qte Licen� lu yYW ( Lic.p %e
3 a N Dateca
N/ V—— cnm,acou
O ARCHITECT'S DECLARAIION
w 1 anaerwand my Plans shall Iw nsed as pnnlic....o a
ca
o LicenwJ Pmlc...iamd
°' OWNER-BUILDER DECLARATION
v1=' 1 hereby effort Inas I am twat
nml from the Commcuri s license Llw for the
following reason.rsectian 9011L5,Bosincsa and irmfcssmrs Gde:Any city or county
I S o
which c,mr,,a,,,rna1 t bet. toon, 1 .loh,or elpe,any loi,bare
to 3 pr far I t Iso y In pl I'ca,I I Tcmri,
it. l I l nclnem
matne is wernedparvandt the poolf,jons oftn Coramicam,Lce: Lo (Clue re Sy. Ft. Floor Area
Bsmunencmg with SectionMIKE of Division 3 n1 the Hmsiness and I'mfoaons Csdm
or that he is exempt thcrdronl and the ham,fol,he alleged exemption.Any v,obnion
of Section 9031.5 by any epplieant on o permit subjects the appficnn,to a civil pcoalty ,
of a , me latofivehundreddollan65dth, APN Number Occupancy Type '
37542028. 00
❑llmowner ofthendthe y,ormy I,am
wage,te hairsole c (See.70,14,
will all the work,and the xw ram h not i tor, or mimed far sale(Secs],,act
miof and P y Who
code:drop ort th or's.and
od dna,nm work
h m a„ Required Inspections
owner ofhhisow cuff
csorirtndecltatsuch,andwhndocsmenworkhimself 305 — FRAME
far through his awn lawevcecs,pmviJed Incl such icemen is of are not(mended or
offered far sae.If.erwcver.rhell Inge t e l improvement of pmm Ix.old within re you of 307 — I NSI-LLAT I ON
i.nprovef,,mnwo,(Itmice,wuhavelhenmdenarpmninxmalnadid mmbuild<rr 601 — ROOF TEAR OFF
,,hrnve rnr pugnnc or)die).
❑I,asrot the property,am exeWsim
cely contracting with licensed commer,1. 602 — ROOF PLYWOOD NAIL
n000cl she Fajen Sec.]014,Business and pmresxmns Code:1 To,Clartrani
U,enw Lawdncsaolapvy to an nwne,of properly was mldMm improve,moot 603 — ROOF BATTENS
;,ad who cmantnn ror such pn,Jects will, a rnm,n"a'(0 lisenud Pmream,l to h` 604 — ROOF' TN—PROGRESS
Committee,Lieeak Lw.
EI1 am exempt under Sac. .B.&I'C for this rtaxm
()wnc Lac
ENS
WORKIiR's COMI'I!NSA'1'IDN UECLARAI'IUN /
1 herby o fir under penally fat perjury intent the following dedwatiom:
r]IC have coin wilt mailnain a Cby Se ti of Cannan w ve Latsa Ito,Wnrl.the
have
int,, wi pn aia"i for far Section o C...o of the ilbi Gkar for he .
Irc'rformance of the work for which this peril is issued.
have and will maimain W'orker's Cnmpensmion In...o e,us required by Section
9106 ofthe Labor Code,for the nefloroarri ofthe work for which thin permitis
iemed.lily Wurker't nua,rsalma Insurance cancer had PolicY,mmbaareq� '
Carrico policy No S 7/—Q /Z"
CHRTIFICA'I'ION 01:EXEMPTION FROM WORKERS'
C.ONIPENSA'I'[ON INSURANCE
(This wctina faced mol be completed if the pcm,it is far one hundred dollars
61101 or tenet
1 acrifr tont Ia he performance it he work far which Ia'n peril is heed.1
shall not employ any person in any almoner so as to become whhcl,o the Worker(
Compensation I:,ws of C•olifomia.Dae
Applicant
N<mCE'r0 APPLICANT:IL after making his Cenifeate of ho'na ,ion,Ynu should
become)abject to he Wol4r'n C...ownenlion pmlol.-of the I'ma,code.yrs"mast -
Q 0 tonhwih comply with such provision,or his peril.shall be declined revoked.
'L
f•' y CONSere ka cONLENDI NO AGENCY
K > I ark or which
hot there iss csucd(See, lending urgency In,the perforanee
W L the work or which O,is Pcnnit is ln>ueJ(sec.}119].Civ.C.)
y 0 Leader',Name
Q L 1<nckr's Address
U O I cenify that l have rend this application unit sane thus he above inflonution is
ell sec,.I ax,ee wcomply with all city and county or bvanea daso
d lo lows relining r
O U m,Wilding anwrom i a.and nerebYzmhorisc repinscmmives of this city m enter upon
the aMvon,emioned pmpmry for inspection mapoas.
2, (We)agree to save, admi nify and keep harmless the City of Cupertino og um,f
N liahilin-.Ind6lncnn.civ,,:,fad n,ca ,which may in any way a¢'roc again'said �
U Z Clry in aonsnmcnce of the granting n n111"10.
^
APP N6 )WILL COMPI WITLIALLNONP Issued by: Date (/
SOURCE REGULATIONS, � IL"
Signammol Appliunt/Cnla rave. Fltnc— Re-roofs
HAZARDOUS AIA)HRIAI,S DISCLOSURE
WJl,bc appfcamor future budding aavpaa,carom hm,dle hammomnlnaedm Type of Roof
as defined by the Cupcmnn Municipal Code.Chapter 9.11.and he Heaeh aml safety
Code,Section 25531m11' /
❑Yen -GSNu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or mere Inti lding occupant uses mpnmm or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emitemit haN
oaous air contaminants av ddiawby the Bay Wren Air Quality Managementrun,
Di'litia"? • LIiT/ all new materials for inspection. Applicant understands and will comply with
EI Yes all non-point source regulations.
1 have mad he hty Code materials 505.25nenla under Chapter 6.95 id the - /
Cahebail Heahhlitot currently
Seniors 15565.15533 umd25534.lundemm�d the /Z ./ Vt7
Iftnehnilainhe dors m. em,enllyna,frot beiI,�,h'I to.0my respnnsinili,yarnmify anc it - S'
oceapam nl'the n'yw,�rocnn which tauµ%V'— riur m innuunm nl''n Ccrtilicmc of
eeu„°"ey' j y//'�j� Signature til'App cant Date
owne,orand...a«� `1hat, _j All roof coverings to be Class"B"or better
OFFICE