01040127 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING A DURESS: PERMITNO.
20565 VALLEY REEN OR 01.040127
OWNER'S NAME APPLICATION SUR DATE
04/23/2001
I'HONH; SANITARY NO. CONTROL NO.
kCOceQ ARCHI'I'FC'r/IiNOINHER: BUILDING P17RMIT INFO HLU(I E.Ecl PLUMB MECII
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LICENSED C(IN'BACI'UIt'S DECLAItAIION Job Description
ZOZ_C Iw71,0)of[)is lam of
Ravines,
s provisionsof CharsrY a,,license
p_rw wilM1 Sectym]qMR nrll'i on3af lncHmina'anJ 1'mfcxinn,CrNe and myliarnx
Y J o INtrforce an, I
�� a .1 «Hi 4 OVERLAY B. U. R. W/DUSOLOST SINGLE FLY
o a Comtacun
v 3
ARCHI rECr'S I3ECLn! ]ON- MEMBRANE—REROOF
L` 5 undemmed any plan,'hall be used an puhlie neon s
ce o Liccmed Profcainel
a ce w OWNER BUILDER DECLARATION
I hereby affirm that I um exempt(raze the C'ontraclnr'r License Live for the
C Z following reason.(Section 7031.5•Besides,and Profession,CuJc:Any city oreounty
ce
ad x C which requires a permll to comvinn,alter improve.Jemolsh,torturer any structured 3 prior I Lu y to II pI I'Cu t f I p 't l l g l rnenmm
met lm is licensedpursuant m pnni%ic)nsc)fffieCt)tireicitirsLicenw LawoChorNcr9 Sy. Ft. Floor Area S/ alu-tion
(Com g lh Section 701)(IofDro to B_ ass and P, r. :Coo
,it that he's uscmpl.headomt I I Inc ba,i,Far nae;dl.ged exempt sat.Arty violmima
of Section 7031.5 by any applicant kers permit raccl,the applicant to a eivll penalty
of no,mom than five hundredoRm(S5g). APN Number
❑L: ohne prnpe,ty.o my employ„ who wage us thnh...le c..;„pen 7
will do the work.and the viniculture i,not intended or offend for sale(See,70cTI,
Business and 14ofe,.ion,Cade:The Contractor'%License Law Jnea not apply to an 3261004 : d Inspections /
of properr properly Who buildemprap thereu
on,and who Josuch—ark hinnelr
,r do i,h hl,own employee,.mordoJ It.. .,It ampsvcnent,arc our inurtded lir
offered for sale.If,hoxessa,the building or improvement is sold within one year of
iomplotion,the owner-M1udder will have Inc burden(of posing that he did not build or 305 — FRAME
mprove for pmpo,u of sale.).
❑I..'owncronhe reaper,as c,dshely commcd.g won licensee c ommfa,1. 307 — INSULATION
Lconstruct the project(Sec.7044,Rroine”and professions Corc) Tire Contractor's 601 — ROOF TEAR OFF
icense Law dux out apply I,,un owner til'progeny who Inifds n,imp,ovcs Incrcm,
and who conferee for such project,with a contractoral licensed pursumn to the 602 — ROOF PLYWOOD NAIL
Cannortwinecen� se, 603 — ROOF BATTENS
aw
C1 .mcorm tcusersee. .Rmrerrills mason
owner Dale 604 — ROOF IN—PROGRESS
WORKER'S COMPHNSn'nON UECLARn'I ION
I hereby affirm under penalty of perjury one(if the following declamations:
.48 ❑ I have nus will oatutain a Certiliozae of Consent to elf-inxu,e for Worker', .
Coup, tion, as providal for by Suction 371X1 of the Labor Codc, for rhe
rfommarec of I u for which this permil is issued.
1 have un �muinwin Wrrkar'a Caau,r,xtion Insurance.as mquined by Salon
J]q) ur LaMn Code.for the perhanuncc of the stork for which this permit is
I"u fy Workers Compensation insurance carrier and Policy number are:
__Policy No.:CoP_IF61
CI:It ipicATION of:rxuldvr1ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need nut be completed if the pennil is for ane hundred dollars
(E I(0)or less.)
I eerily that in the performance of the work for which rhi,permit is Issued,I
shall not employ any pawn,in any manner m as to become subject to the Workers'
Cmnp,n.atin i Lows of California.Dote
Applicant
NDrICE TO APPLICANT:If,after making this Ccnl5c:ne of Exennuion,you should
to subject to the Worker's Cnmpenwlion prwisinns of the Labor Cade,you must
Q Q Iknlbw;th comply win such pot ,anus lir this per x11 shall be dccnurd revoked.
Z
F`
CONSTRUCTION aco LENDING AGENCY
' I hereby amen that trio i..s a aril(S . lending09 , agency far the performance
of the work for which this perntir it i.a,ua1(Sec.909].Co.cCJ
y `p Lder: re
5 � LeneaAddress
der',AdJ ,s
V O 1 uedily that I hmn w.d this application and visa,that the idswe Inittrnmtinn.i..
IL F correct.1 agree to comply x'ith all city and county ordinances andante laws slating
U In buildingcmtmclion,and hereby authorize representatives of this city n)enter upon
the uM1nvensminned pop„ry fur in,paerwn pma",
F A. (We).,.,a.me,indemnify and keep lunules the Cilyol Cnpeninoagelns,
(n liabilities,judgments,costs and expemcs which may in any way accrue against said
C..7
4: City In tonnupmnce ol'the grunting of mi,pcmait. �k
APPLICANTUNDERSTANDSANDWILL MPLYWrrnAL�L/NO/]S�I'(II Issued by: � Date
CE REOUL Y/ O/ yi
signau,re m'npp 'a ,,a aor f nae Re-roofs � .
It 7A UOUS MAI FRIAUS OISCLOSURH
Will Ilse applicant or future budding occulmm store or handle banm4m,material Type of Roof
:d ddiued by the Calicoiso Muaicied Code.Chuprcr 9.12,Ana the I led o road Safely
Calc uma !
25592(.)'
D
All roofs shall be inspected prior to any roofing material being installed.
Will tneopphatmorlm;,r.building occults muse cgwpmeato,do,,r,,both If a roof is installed without first obtaining an inspection, I agree to remove
emit named....sir cumeminana,a,delined by the Bar Arca Air Quality Management
. Di...I,,' all new materials for inspection. Applicant understands and will comply with
0Ycs err_ all non-point Source regulations.
1 have read the hazardous material,try.irearem,under Chapter 6.95 of the
Califomin[Icahn k Safety Code Seen t,255(15.25533 and 25534.1 understand that
nn,ho dingdocs not critically havua truant.that d is i;y,c,ry,mibil it,mnmlfy the - �-3/4, —
i
axupam d tM mynimmc '<h must met prior u,isunnee of a c nil icas of
Oce YY.. rel�o,� Signature of Applic lit Date
ox.ne,F n,,,]d rate�/ All roof coverings to be Class `B"or better .
OFFICE