00120011 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING AT1.11";i8 SUTHERLAND AV PERMIT 1,10.0012001. 1
rwNl:RsuArN,I+INTZ KENNETH A AND LINDA R nrrucnnorj,`1�10'y./_:000
PHONE SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
p Q 0 ARCIIITLCI'/IiNGIFlilik: L I:I.I°el' PLUMB MUCH
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0 5 N LICENSED CON'TRACTOR'S DECLARATION
=c 1 hercny aftirnm mol 1 a,mm licensed node.pmvis:ame,,it Charter 9(contrailJob,Description ,
F'31_04 winmSeadun7b)(AofDiv' ampofineli m�.m
edPonro...mCote. SHAKE TO 30L'B FELT
ill full forte!and Of cal.ill
5 `d¢ Licenoc class Lica
Ione I'mcormal
ARC,I 111 lie[ S DF_CLARA ION
t=°5 I mwer.mand air pram ensu rte avid::.,Pamir m«,rds //
y3i I/
a a ° Lmc°n,cd Yrofessinnul
a a Oat I am exempU o DUCe Contractor's
/
=' I greeny (Sect that 1 ran exempt from the Cessions o Licemc law for the ; /;o
wich billowing ineoo.wrinion]loll S,Business and
ove,de um Coot:Any city or county
mor i requires a c,also to comw0.cher,improve.demolish, file
repair any structure
w (bar hems komod,mm�r I,,irecmavlvi applicant for Coli pmmru oca:t,Law(Chapter
aj— h;nnei.lieen.alsecliatlnill)of nnneennlnone,,eer:aeLc,,iompn9 Sq. FLFloor Area Valu¢llpQiO
lu ingwimSccl....lgndI'eh n3"rmc lou, n,nion.A n.Ctalrl
olein
or las,heel. nmpf Jany aim"and the Mail r sthe alleged[ticcsmnpioo.Any viPenalty
ofnon nun, Iran
veanyapplicantlinaPenni,nunjuts Ike applicant Inocivil penalty
nlmf marc"man five nundmddou,r.IsStroh APq' ut�t� 9. 00 Occupancy Type
JJ
O 1,as oche work,and
theproperty,o lu employee,wird wares offered
olidf sole le(Sec.
7[ion,
will ne me cork,ani the ode: T e is not intended en a Low for sale(Secy to an
holiness and Pry,Who a Code: rovev taor'..unit W law d«,not apply to an 305 — FRA�uired Inspections
owner or h his ow Who builds or improve.thereon, r Who does such work himself
othrough his own empmyces,provided that such improvements enen,i, arc not intended of —
nneeee for sole u;niwurur,n:e nnuding or immmprovnar,ml is sold whom nor year it 307 'I NSULAT I ON
im,pletion,me owner.l,nnderwill hav�enide harden of provmg,hm he did not build m 501. — ROOF TEAR OFF
amnwe for pmmo,e ofaade),
01,a,w none pof,c0ly.uclelaa.ivay small will,reea;,ed lonmclo, 602 — ROOF PLYWOOD NAII—
camMlmct the project(Sea.7044.Buenos and Pndission,C.Al,J Itic C'ontractor''. 603 — ROOF BATTENS
Liecov:law does not apply to an owner of property who build,or improves fhecom
and who contract,rot such pnjenv with a central licensed pursuant to the 604 — ROOF IN—PROGRESS
Comrecmes LitS m t law.
01 It,racmpt unser see. ,B h P C roe his mason
0.act Date
WORKER'S COMPENSATION DECLARATION
I hereby alfran muter penally ofperjury one of one billowing dcdarafions:
`�• Cl I hue std will loaLloido a Ce lllicanc ul Conceal to w16mwre fa Worker's
ComprnreJnn, ao pmvideJ for by Section 3]N if the Labor Code, for the
perhonnernee of he work for which this permit is lowed.
have and will maintain Worker's Cimpenvfinn Insurance,as required by Section
.]IMI of the IaMa Curb.lot he performance of me work for which his permit is
issued.Aly//W�nrkC/s CnmpenwtiotAl rycrcarrier anddr�•Policy nnunbei am.^:,�Aq
Carrier:./'1NPJL�(C•4md Policy Nu:
CERTIFICATION OP EXEMPTION FROM WORKERS'
COMPENSAI ION INSURANCE
(',This.ecfiun need not he cn,a,pleaH if the pail,is for tae hunched dollars s
151011,",less.)
I certify that in the perfi mence of oho work for which this permit is issued 1
shall not employ any ill in any reamer so as nm harms objet to the Will
Congxmvtion laws of California rate
Applicant
NOTICE TO APPLICANT:IL after making this Cenificas of Hsemptics.you should
necnnm object lithe Workro s Com,mmtinn pro,more,of the Labor Code,you mmm
Q O lon vith comply with such pmvioioro in this permit shall be deemed revoked.
z
CONS eRUCIreisa UN LENDING AG agco,
a' NCY
Ibereny at son fherriss aa,'uunal(Sax. 097,gageawy for the purliammnce
W .11 Lea he oak it,,which his)at it is lnwacd(Sax.3097,Cie.G)
[a
Leader's Addm
7 z Name
IxnJcr's AJdrcss
U Q 1 ceniry that I have mad this application and state that he above information is
I it [.. cornet.I agree to comply with all city and county tuitional and stale laws relating
Q U m,fuilding construction.anti hereby outhorim reprawmatives ofthio city in enter upon
the mhvcm almiscd po),ny for inspection purposo.
F•, a
(WO.,me to.ave,indemnify and kip harmless the City or Cupric"against
M liabilities,ludgmens.cove and exiNo se,which may in any way accrue against said
U Z city in conseque"ce of the erasing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued bv- DatcP � �.
SOURCE REGULA]'IONS. Y'
Slgnwurc"f AppllcxnhCnn,mnoa' Dale Re-roof
HAZARDOUS MAI URIA1 S DISCLOSURE
Will the applicant or tumid building occupant store or handle hv:Wous mal Type of Roof
as Jelinal by the Cupertino Municipal Code.Chapter 9.1?,and the Heads and Safety
Cale.Section 255320)'!
0Yes A All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or hire Mmildingrvcuream use equipment or device.which If a roof is installed without first obtaining an inspection. 1 agree to remove
snit leourdnus air conemiwnM1 as relined by he Bay Arta Air Oadi,y Menngement
uklrin] `', all new materials for in.lection. pplicant understands and will comply with
E)Y,, /I7kN`' all no o' t sours re h f v.
I has mad the havat pfd tx .,'Icial.mquirmn.of,under Clmalno 6r95 if the
Cnlilind( he
Safity L sky Seen'my 155 5, _ and 2 534. uuJerewnd,hat
itit the hnm cuncn0y h:rv'c'fnm tl , nye 'limy us notify the - do
the bnircmems w 'b u.f of a Cenilicss of
°Cups I afore of Applicant Date
ovine tamorredagent n All roof coverings to be Class ••B•' or better
OFFICE