00100105 CITY OF CUPERTINO
BUILVING 111"annPERMIT CONTRACTOR INFORMATION:
BUILDINGAD�_R SS: P12Rbil'1'NO.
1�100trvya
OWNER'SNMS1V`t)l�-N LEA C APPLICAI ION SUB DAIIi
PHONE.. SANITARY NO. CONTROL No.
\RCHn'ECT/IhN(i1NLEN: BUILD]NG I PLUM'I'INPO
5 BLDG CI' PLUMB MliCfl
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y a%
Z S N K LICENSED CONTRACTOR'S DECLARATION SHAKES TO
P m O 1 hero,aflinn tom 1 am licensed under prosisinns nl CM1upter 9(commencing
S W wilhSec;Innvanna WDlvisio 3nfibclluninc,vandl'ml'cxsioneC c,unJnrylieunsm
je d is n rod force;mal ci h'¢_ L /l Z
z < License t'I;w.. C-- 39 Lie. S_
><o a nate_`0_/.6�eo Co
=�_
W a.a rARCHITIiCf'S DECLARATION
F' /
'—'fig Imuled dny pl hIIW mJ i blc < N.
C'y' �S
w6p0 Licensed 1fic,a 'll
o�y OwNf R dUn DER DECLARATION /
n, 1) I m ton11,1,I I70 ,ar, II ( ¢Codr: I.;comb,
1 folio b a st cit 70131511 'nos J V 1':.' is C d 'A Y n mns,u re
z,x p which requires a permit to cnngrve6 otter,improve,Janolinh or repair any structure
ca Cam prior to in issuance.aim mauiics the applicant for such permit o file a signed Nudennad
Inalheislicen.edpmtamanttothe pmlimansofthecnmmel�.ueense Law(Chapter 9 Sy. Ft. Floor Area Valuation
(commencing with Section 700)of Div inion 3,d the Busi no and Pndcssinns Code)
n,that he in exempt themrrom and the basis for the alleged exemption.Any vmotion
Is—
,if S,non 7031.5 by any applicant fora penal a.hjcc,,the apprcam In a civil penalty
mmol more han live am,hc l mown,(55000 A1)N^ i1iTer Occupancy Type
C Las owner of Ion po,any,m my c,a,Iayem with wages as hearsale emnpcnr o,no.
will do the work.sod he m,,O c is no.Intended of offered in,,sale(Sec.71114. (coons
—
Butes and Professions Cale:The Contractor's License law docs not apply w,an
u
r of property Who Wilds or improves hexon.and who dues such wadmse
hilf 307 -
roirr through his own employees.i molded tot such impmvements are not intended lir
Nfercd fox sale,u;however,the building or improvement is sold within one year Of 601 — ROOF TEAR OFF
nnpledon,me ovonor-mmdcr will have ibe humcn of proving Thal he dol mol blind Or 602 — ROOF PLYWOOD NAIL
improve for Purpusc of mule.).
602
maroon,am exclu.ivelY contracting with licensed contmama" 603 — ROOF BATTENS
Lconstruct nine project(See.IRW,Business and Professions Code:)The Contractor. 604 — ROOF IN—PROGRESS
icense Law docs not apply to an owner of trope",who Wilds or improves Beacon.
and who contracts for such projects with a ruminations) Bremee pursuant u,the _
Contra cmr's Ixonm La-
0 1 at axm,ml nndrr Sec. .li k P C NO his reoron -
Owner Dov"
WORKER'S CONVIRs SATION DECLARATION
I hexhy alEm,under penally of perjury one of the following declamtions:
0 1 have ant) will nainmin a Certilicme of Consent arm self-insure tor Worker's
Compensation, is. provided far by Section 3700 of the Labor Code, for the
pedor;nu toe 01 the work lin whim Ihis pumdl is iwunt
yl have and will mainmin worker's Compemmion Insurance,as required by Soodon
3710 of the Iatmr Calc,far the performance of the work lin which this penal is
iswed.My-ukery Compe�yr1inp Insurance carver and policy another aux::
Canner_ `L�^J Policy Na: ®� //•
CI!RI IIICATION 0I7[7hMpTION FROM WORKERS' '
COMI'IiNSKI'ION INSURANCE
H his section need not he completed if he retail is for one hundred dollars
(5100)ser Ins.)
1 certify that in the perfommnce of the work for which his per"it is issued.I
shall not employ any person in any manner so an to,bi subject to tim Workers'
Campemation Laws ol'California.Dole
Appel oral
SOTICETOAI'I'I,ICANTlLalicrmnkinglh'd Cenidcamonixcmptii you should '
beenme%aurb,uhc Worker'sComncnwlion pmvixions of doe Labor Coe,ami malt -
Qfnnbwilh comply with.such provisions or this tenni)shall he,deemed revoked.
Fi CONSTRUCTION LENDING AGENCY
aI hcmhy v1i m that them is it conswaion lending agency for performance
h
or e work for which his pc nn I is issncd(see 3097.Civ,C.)
(ds Q Lcndcr's Naha
v7 Z Lcndcrs Address
V O 1 candy that I have mad this application and smte that the above infornmlion is
4er (.. onect 1 agree at comply with all city and county ordinances and state laws relating
V to Wilding construction.and hereby authorize repellumimv of his city to enter upm
} k7 the W t J p pens 1 inspection Parlors.
.
t„� y (so )ei,cou,s J fy d keeph the Cit)ofC peon".b not
to liabilities putlaurall. a n t cs,bs hi,ii may in:mY a, gain., mid V
U Z City I cold g'• Ing of thispcanl,
^ APPLICANIU 'RST ISANUWILTCOMPLYWITHALLNONPOINT 1 Date
soullcE Rr .no Issued by:
Signiumn AppLcanl/camrncmr ]late Re-roofs
I w7ARD0US MATERIALS DISCLOSURE
Will the atpream oa future Wilding moup istore,re or handle hv, m
ardi wcred Type of Roof
a,defined by the Cats nioo Municipal Code,Chapter 9.12,and the Health and Safety ,
Code.Socdon 25532Cp?,
CYe. 0N All roofs shall be inspected prior to any rooting material being installed.
Wim IhcuppI-.1 orlum ehailiinpacapamuser,ripmemor letienwbich If a roof is installed without first obtaining an inspection. I agree to remove
emit ha"ro nus air comammmnts as defined by the tiny Arta Air Quality hlangansid
Dinaiell all new materials for inspection. Applicant understands and will comply with
❑Yes [],No all non-point source regulations.
Ilra I1- .zarvot,ar,kti,riab. d '..cutouts t do,Chaine,r)s or the
'alit ' n x 111 &S fry Code,S Y 255115 25531 J 2.1520 1 n l -.I d lam /(//�— 1(9-14
fin b W' bd n dyl t i
fl 'I : Y P ,dolit,I Lily the
em n1 v
cupathe re4uixme/is soh no must be met print m,issuance of a Con can of
Oecutemey. M� / Signature of Applicant Date
ownerar malleolrea�ag(e�a'I �— b .ate All roof coverings to be Class `•B•' or better
OFFICE