00100147 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
xUILPf'(t ADDRESS: .. P17RMIT NO.
OWNER'S NAME _ .. Tisl'C APPLICAT MI
10316 VIRGINIA SWAN PL z.r,...'S MMI47
• PHONE: SANITARY O
BATRA TARSAIM L AND ARLINA 1771 SMITH AVE 1��20� 1�5bN
(�[ CIII'ITCr/ENGIN'EER: BUILDING PERMIT INTO
�LL (408) 398-12 33 CLECI' PLUME MI CH
F<w .I LI IJ 1-1
jLICENSED CONTRACrOR's DI;CI.ARAIION Job Description
O L a'❑ I hembv a07na mat into lircnved under pmwisium'til Clmm..9(moa ancing
tw with Senior 7lMMpof Division 3 fthc Businnaand Prolessi...Gmc,endurylimew
a p is infalllass and cBcct. !Z
s z a Lima Clan. L39 Isis.a T Q�
6e. Data_�Q_,j(L—p.o_ Contractor F-YT
°Heap 'srn;cLnun o t/TLO.V REMOVE SHAKES INSTAL_ FELT OSB
— a I undca"and my plan.sl h ...las pal h c co SN(_.
� r
SpbO Licensed Professional (fee LJ
a. -BUILDER DECLARATION `T
uai to to I hereby albn I ore swop,from the Cnnlracmr's License Law for Inc
~�6 fmlawin,a....
a l In 7031.5.Mucin s and Professions Code:Any city or count,
<F❑ aslfii,hmq (itnict.alipdrinclis) piriny%iru,turI,
wC P Lir 1,'. al y m PPI'' I p 't t 1 1 g I,I t ,c n
s main 1 dp . tt n P I Ilia Contractor':I L (Cnper9 Sy. Ft. Floor Area Valuation \
(,ormorwin,L,nth Section 7000) 1 Division I fthex canand!Profession,Cole) .(
urban he n esmnp,mcrcfmm cad the basis lin the alleged exemption.An,violation
of Section 7031.5 by any applicant for a permit subjects the apt am to a civil penalty
of not more than five hundred dol6a(8500), APN Number Ocggapgl14
O pe
❑I,;rvown"ollnc prep:°,,Lar mycmpinyecs win,wagese,dbk,wlc coin,ensmiun, b11VJ
will do the work,and the xlruclum is not immuded or uttered Ibr sale(See.71144,
business and rroessn,as rtme:'rne a,,nlmmmrN urcnse Law d«,not apps,loanquired Inspections
ownerPe
odu
c%property Who builds Lir improves thereon,and who dseuch work himself 31.646007. W
or through his own employees,provided that.such improvements am not intended or
offered far sale.If,however.the(wilding Lir improvement N sold within one year of
vcompletion,the owner-builder will have the burden of proving that nu did not build Lar
,proelor par.... of„1de.l. 305 — FRAME
❑1.astrainer or me promay.amexmmdvly contracting with licensed contractor.10 307 — INSULATION
construct the project(Sea.7044.business Land Profession,Code:) Me Contrueor's
License Law d«s not aPNY in an owner ofprmpnny who builds or improves the(,., 601 — ROOF TEAR OFF
and who contact..for,urn Project,with a eontmema»licensed p....at In th` 602 — ROOF PLYWOOD NAIL /
0,aaContrn,s, Lircnnc law,
❑1a;m mxel;ny render sees .x.Krcfor his rcax°a 603 — ROOF BATTENS /
°xncrDat° 604 — ROOF IN—PROGRESS
WORKIiR'S COMPENlA'I'I(lN IIIiCLARAl10N
1 hereby m rto under penalty of perjury one of the following declarations:
I have and will inainkait a Canifcmo of Conserv mSall-insure for Wicker's
Conhpaomlon, as provided I'or by Swoon 371X1 of me Lubar Gula for its
performance of the work for which dos permit in issued.
1 have mW will maintain Worker's Comlmnsa,ion Insurance,as required by Section
370()It the Iabor Code,for the perommake Lithe work for which this pe-,I,is
i.aved A15Wader's Cunynn.ti;A
Inseurance currier and Policy number am:
CurriAi eA-1 e:�Nt._C�CL._6OImy Nm.: _� Z-x+(p
CERTIFICATION OFEXEMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
phis section need net be romplcroJ if the permit is for one hundred dollars
Is Ian or le".)
I cc+dty mat-in Ihaw L,mmna of nm bark for which this permit Is LsneJ.I
shall out employ Laay tk , any mono ,Is to become sar,ac lOn the Wnrka,d
Compensation laws I, ram.Data �t7—
Applicant
N(mCG'IOAYI' Exemption,you should
becomsubject the Worker's Compensation provisions or the Labor Code,you must
C Oe Ermwih comply with wch provislmss ur oris panni,shall bedeuinhm revoked.
F `
CONS'rRUC'1'IONLE DINGAGENCY
} I Leahy a09ma that them is o camtraa lending agency far the pvrforimncc
'If the work for Is hich this Pemm is issued(Sec.MILD.Civ.C.)
1 Q Lender's Name
.5. z Leader',Address
V 0 I cknily 1hm l W—cud this;;p,lwan I and sam,loo Ilia nMrve Ial ra ion is
Fs. E... correct,I agree ,,comply with all city an I county n,Jinznaa.and sedm laws riming
C U to Wilding construction.and hcrebv remorim lisp,esenmtivesofihis city to c,nerupten
} f4,; the aMvcmentioned pmparty far iapellon purposes.
y (We). , o save,inde um,and keep harmless the City of Cupenmo agoin.0 ,
m liebilitics.I�Iuutg,,, N.case and asperses which;nay in any way,serve against.void
V G Goy inr dsewlu roof 0c grnmin,of 1s c til. —�1—� - i\ �� /1 ^��
APP( AN” NDER5TANU'B J .1 :(l LY WITH ALL NON-POIN'P Issued by: 1 °a' Date / V (-J
an aid PPtemt/Carractur Dme Re-roofs
HAZARDOUS MATERAI S DISCLOSURE
Will the applicant or limo,Milling occupant store or handle hvaNtws material Type of Roof
;is dclineJ by the Ca,rfi ;;l4ura fkA Cale,Chapter 9.12,and the I Icahn Lord Safety
Code.S,claon 25532(u)'1 Ne
I�J�l�1.' All roofs shall be inspected prior to any roofing material being installed.
• Will the apPliramorfmmabuildingocrupmnusectImpmemordcviceswhich If a roof is installed without first obtaining an inspection, I agree to remove
emit hmair ,main
innnts m defined by he Nay Area Air purity Mmmgemket
District all new te't rials for inspect}' plicant understands and will comply with
°vas "° all n -pot source rvru fo
I have read the hnmrdouv mactimx n lificu rots under Chapter 6.95 0l the
Cali1'r,mia llrahh.g Salary Code
tions 255°5.25533 anA 255]4.1 unJcrsmnJ ma �Qd
7Iffle bit IJi nm currall amu n,.thm it is my rezrymsibility to notify the /Q �aQ
tnapam , c rtquiremcm w :h ma , to issuance of a Certificate of
ore j 'gnature of Applicant Date
/O^2o�a
o o nnmod,ed apaid - Dalc All roof coverings io be Class `B"or better -
OFFICE