00100011 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUu.DIN'GADDRI:.'.. _— _ LOS GATOS ROOFT.NG PERMrcNo. 00100017.
Oui NAMEi:POON TSO F AND LAI C TRUSTEE 1771 SMITH AVE APPLICATIONsuq®}t03/2000
PHONH: (408) 398-1233 SANITARY NO. CON'1Rf11,N0,
ARCHI'I'FCTnFNGINEER: BUILDING PERMI IINFO
❑O❑ BLDG ELLC'I' PLUMB MCCH
CSN� LICIthS[DCONI RACnOR'SDECLARATR)N Job Description
:o I hereby n m,mallnmucen,eennderpm.i,irm>nrcnaptervlenm,Mneing REPLACE EXISTING WOOD 'SHAKES
with Section 701X1)of Dl,Won 3 of the Hmirl,,and Prol'ewion+Colin.and my license
F`L_L^C.�Jit full Ione and etfat.
5 ¢ Licence CluesLlua
p 6 U [)am C....me,Ul
F a g ARCHITEM'S DECLARATION
I anderdand my pl n -h II he used Pubic record,
xi:�pp
Licensed Pf - 'I
ao�y OWNERRUIIOI?R DICL1RAI SON
f1 I by fl d p, thef ions :Code. I cer,he -
t-E2 filo Arc - (S , 70n15 B .'v JP f s 'Ay city crummy
E p wb'cM1 bapire,.Pefruit, con,later.alm,improve,J n bush.or repair say structure
ce
c,3 prior to, . .also ,happlicant f .ueh pe tit f life signal statement
E. ,hath licensed pursuant, the powismas Elithc nt ,e%License Law(Chapter9 Sq. Ft. Floor AreaYaluation $0
(n„dn g i S et 7,XXp f D ',it 3 f theI n d P I ,Code) �.J
or ,at he is caomnm
p, , rm troand Inc ha.iv Ibr the tdls8cd cxcmp,um.Any vlDlalion
of Seeaon 7031.5 by any applicant to,a pEmi slubmu the appliar,Ina civil..small, .
of no,mom pmt rive bundred dollars($5tXD. APN Z9113TENIF9073. 00 Occupancy Type
01,as owner of the propcoy.or my employee•with wages as their sole comPonvton.
will do the work,and the umcmre is no,intended n,offered for sale(Sea 70.14.
Bort boil P
orofe..iva,Cnde:'rhe c.,.,manrorP.IJ„7tm Lnw doe.,a,,,apply h,as 305 — F�(�red Inspections
Bi�`nI pmreny WhD build,or Intpn,su,,hereon.,Ind who dne..um,wink himself
(,.through his own employees provided mitt such improvement,are not amended or 307 — INSULATION
offered file sale.If,however.the building or improvement is old within one year of
completion.the owner-builder rill have tire burden of proving that he did no,build or 601 — ROOF TEAR OFF
improve fill pnm"`nl"a'`')' 602 — ROOF PLYWOOD NAIL
❑1.as owner.,Iron.......eny.nmv,cb,.i ,ly=IImmlagwO,I.....meDn'r'ct "r 603 — ROOF BATTENS
Lim.rnc,,h,p^,]ee,(sill.7(94.H-ar,,and Prn,e„ion.Code:)The Comrnaor's
cense Law,d«s ma apply 1. a.,wner Di property vino build.Dr improve,thereon, 604- — ROOF IN—PROGRESS
and who contracts for mal,Project,with a commorml licensed amount,o,he
Contractors Limens law.
01 met c,empt under Scc. .B&P C into,recon
Owner
W'ORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declaration.:
❑ 1 have and willuse timain a ecni0num of Conten, u, oll:insure for Wider'.
Cmnpcn,minn, as pvided for by SendDn 37M ,I Iho Labor Coda ka dm
pco'onnance of,he work orouch thio I,conn Is icwed.
01 have and will maintain W'ader's Cnmpcmation Insurance,as required by Section
37111 of the Lvbv Chile,for,he performance of the work far which this permit is.
.wed.My Workers Compensmion Insurance carrier and Policy number are:
Carrier: Polity No,
CERTIPICAnON OF EXEMPT[ON FROM WORKERS'
COMPENSATION INSURANCE
('Ibis section Neal not b,completed if the Penni,is for one hundred dollars
($IXB or loss)
I evit y For in,he p:ftranmsv of,he work for 11lcM1 Wil..molt is issued.1
shall not employ any person in any manner,o a,to became subject,o the Worker.'
Campenmtion law,of Ci lifomiu.Dam
Applicant
NOTLF TO APPLICANT:If,after making this Certifcam of Eaemp,ion,you should
hcnm wbincu.,theWnrI,—Cmnl<ma,ion pmvl.ion,of the I.abor Crede,yon mow
Q 0 .....
toohwitscu....1,with ouch provision,nr this onatn shall rte d,c ed mvnked.
z CONSTRUCTION LENDING AGENCY
a > 1 hereby affair the,there is a construction lending agency for the perfommnm '
W of the work for Is hill,this Fermi,is iso d(Src_YN7.Civ.C.)
r, ❑ L=ock'.,Name
L,^ Z Leader',Address
U 1coolly that l have read this application and state that the above iolurndion is
ti E. correct.1 agree to comply with all city and county ordinances and wmc laws alining
C U to building construction.and hereby authorim repmrsaraivevnf,his cfly emeruryn
rdie anove.tnentDned prouny for inspection purpose..ME (We)ugacmo.cool andeifyand keen h:rt,, it the City orrione nn , end
'G City Mica judgments,S the gain=sponse i wean nutty In any sexy accrue agninY,sold
C.) Z APPLICANT UNDERSTANDS
the of WI WILL
O
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON PoINT Issuedb Date
SOURCE REGULATIONS.
Slgnuuuo of Applin alCon oto owe Re-roofs
HAZARDOUS MA'S I;RIALS DISCLOSURE
willme appncam ,,mora haddro,oceupam more Dr handle ha,andou,nta,edal Type of Roof
as def ley by the Cupertino Monlcilml Code.Chapter 9.12.and the Health and Safety
Code,Section 255324x'
0 Yes ON. All roofs shall be inspected prior to any roofing material being installed.
wid meanplicamnt'form.ehuddn”occupm,le.eegwFtnem.,rdevi=D.whi,h If a roof is installed without first obtaining an inspection, I agree to remove
..tit haZilous air cuntnntinan,,as dolined by,he illy Area Air pualoy Munngenmm
Distill?
❑Nn all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
1 have read,he hamrdom materials requirements under Chapter 695 of the
Cablino a Hoahh&Safety Calc,Sec,iuns 25505.25533and 25534 1 monstand that
if the huild'n,g docs no,causally huva a h
eart., at a Is an ,p
y snn.ihillty to nrnily,ho
cupam of,he requireamnn which amu Ise reef prior b itwunen of a Cenilicme al
OCCCp't°Cy' Signature of Applicant Date
ownur.,r atnhad.ed agent ()areAll roof coverings to be Class "B" or better