00080144 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMI"f NO,
OWNERS NANIIi0247 WILLUT APPLICA'rION,U i A I;
79-g�
ONE: MOORE LARRY L AN s,wn"nRYNc. co, .. .
CHITIiCUENGINEER: BUILDING PERMIT'INIFO
HLIX11 IiLECT PLUMB MEC11LICENSEDCUNawd and R'SDECLARATION Job Description
Q1 Int..70 unon that um offolati under pnrvivionS ml Chapter v(conmenensenseenon 7n1a)nn)faiaan 3 osteo Btl,ane..amt rmre.,d,,,,.c„rte•n dl„y reel,wnin Glu famecense Lie WxoG Date °` Contin m, , oRE
—ROOF
R 11'nicr'S DECLAR,
5��LLny O g 1 under.mnd my pinnn shall he used as public mi -
Ire+i o O Liccood Pmfcaiunal
a. ca OW NERdi UII.DEIt DECI,AltA'I'ION
'+ I herby a0irn that I am excnnpa tem be Colltraelor.,hicc,we law to,rhe .
tollnwing reams.(Serino 7031.5.Busincsn and Pml'essiols C do Any city or anunty
E O xhieh requires a permit m construct.ulme improve.denudish,or rtpmw any suunure
S32 prior m its issuance.also requires the applicant for such pemn
aio file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7001)of Division J of the Business and P..le,ions Cute)
o,thin he is exempt thctefmm and the basis for the alloyed esenaptimo.Any vinlutinn
of Section 71315 by any applenut rani Ia'+,nit subiab the applicant ,,a ,,it Bandy
If stat moat than for hundred dollam(650), APN Number OCCU a C ” y e
01,as owner or the ptopeny,or my employees with wages as their sole compensation.
will do the work,and the structure is not intended or offered for sale ISec.7014, .6�5 ,J
Business and Professions Code:,ne ] •K Contractor's License Law does not apply to an 4 fired Inspections
lor of propany Who builds of improver thereon,and who don such work himself
t through his nor employers.provided thal such impmacments Ire nal intended or
uttered far rode fir,I level,the hniming or nnpmvemenl is sold within one year of 305' — FRAME
nmplmion,Ilia owner-builder will Iulve the harden lib proving that he did out build or
inapm.e hrprq,r.e rr.de). 307 — INSULATION
01.as owner of the pmpen):ata calusirely contracting with licensed conametors to 601 — ROOF TEAR OFF '
,mum the project ISec 7044,Business and Professions GWe:)The Commemr's
License Law docs not apply no on ow net of property w'ho build:o,improves 0,e con. 602 — ROOF PLYWOOD NA I L
mid who conlmclo for such projects with a col ral,ons)licensed pmHmnl to he
contmnors l.,"w 1.aw. 603 — ROOF BATTENS
n len cxmnpl miler See. .b&PC lin 116,reason 604 — ROOF IN—PROGRESS
Owner Date .
WORKER'S COSIPI NSATION DECLARATION
I locrothy affirin under penalty lty f pert f the following declanitions.
7 1 U,c I J will ancoolun a Condricale If Cranwon b—oll-ni,ent f -Wodcr's
Can 1r,aloai. ;I. ..... died t by let 3701 ol the La1 Code, Iia the
�peHo
YI leve and will maimwin Worker's Compensation Insurance,as required by Section O
37W of the Labs Code,for the performance of the work for which this permit is _ V
Issued.My Workers Comptnsmioa Insurance currier anti Policy number arc:
carrie,:S 7iQ ICA uM cy NO: J }K� �
ChItIIPICA PION or AI DOPI'IONRANC WORKERS'
COh11'IiNSAi'IOM1'iNSUNANCIi
(This union need nor he c ademd if the penal is for one marvel dollars
(51 W)lir Icas.7
1 vorlify that in the ile,b)nmmce of the work lot whit his lernit Is issa d,1
nhldl ten mnploy luny parse,Ill any mmmcr,ra:is m bmnmt sahjecl m the WorkeN
Colnpcnsalit Laws of Cdifnna la Dam
Applicant
NOTICE 10 APPLICANT:If.after making this Ceniticme of Exemption.you should
became Subject m,the W'crkrr's Compensation provisions orate labor Cale.you must
'Q Q foMwsth comply with such pmvnions no this perms shin he deemed revoked.
F CONSTRUCT ION LENDING AGENCY
I homily allinn that teem is it eunswcta n killing agency vu the perlbnnine,
A the work to,,which this permit is i....of(See.3097.Ci¢C.)
y Q lender's Name
G G Lender's Address
U C I certify that I have mail this application and stale that the above automation is
kis E.. coma 1 note to comply with all city and county ordinances and state lawn elating
C (j nn htilding construction.and hereby ralhorim represcnwlives of this city to enter upon
y the ahe"neullonWm
pt �
ny lin lnsmlon purpoms.
ff....tt 0. tvtwin agree a save,indclnuit'y and keep lmtndcex the City of Cupettinn against
fr h liabilities,judgments,costs and nptn.ws which may in any way accost against nail /
U Z City in ouequence of the granung of this .it.
APP NT UNDERSTANDS ANDj��}II'ILL COMPLY WITH ALL NOW/POINT Issued b (. Date ^u��
S ,R i :G LATI NS y'
Sig lir i tBpi, can'Ciman lot U:nc Re-roofs
IIALAROil MATIiRIALS DISChOSURE
Will the uppllcanlrn ranic roiling nttairma xlwi nr handle luvanbux m.mnal Type of Roof
us dclinvd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda pvill 2553'(.)4 El No
All roofs shall be inspected prior to any roofing material being installed.
Will the appreamorfuture building occupant use equipment ordevices which If a roof is installed without first obtaining an inspection. I agree to remove
m it Nordin,air co,,at ro to It,defined by the Bay Area Air Quality hRmngtmenl
nei,lricloYL n N all new alerials for inspection. Applicant understands and will comply with
all n point source regulations.
I have read the haaad.......annal,requirements under Chapter 6.95 ab the
California Health R Safety Cole,Sections 25505.25573 and 25534.1 undtrond that
ifthe building Joey not currently hove a mnum.that's is my mpunsibilitym notify the
occupan 1 the requirements which must be met prior to issuance of a Certificate of
,.,,at
�C S nature of Appli ant Date
Ow rendaopled.,,a, Y V` Dme All roof coverings to be Class "B"or better