00093306 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: a 1
Ill SANITARYNO. APPLICATION SUBMITTAL DATE
ER; " E" 1078 OWBROOK Y MAX BROWN CONST c
40 "HONG:'
I 702 S DANIEL WY 09/14/2000
AR ECI'/ENGINEER BULDING PERMIT INFO x
300 (408)260-1260
�d
F• i LICENSED CONIBACfOR'S DECLARATION Job Description
O N— I hereby anthem mal 1 ann licensed under provision of Chapter 9(mmmeming P
O4—�
P=Ce with Section]000)ofDiviaion3ofNe Business and professions Code.and myyliccnu is
Of $� in full force ands . �T �Q�
Of
w< [,on m Lil.. 1 IV ,_ PCs,-..�
Dam C°nummr /77"'kkl..���� D SHINGLE I�'0 OMPOS T I01
ARCHFrECrS DECLARATION&erns a� �� (� (,2.,WOOD J
$ , 1 undenund my plena shall,used.public records K4(.T'�' (d5 1 a— Dl V"'0_'y1_&/O✓��
�Y
rc
SS.CC o a licemd RorneimW
OWNER-BUILDER DECLARATION
C z a 1 hereby rgipn,hat 1 em exempt from Ne Cad.. License Lew,fon the
7=n following reaann.(Section 1031.5,Business it R
pess ofeisionr Code:Any city n county
to3 a which requires•permit m croswn,deer,improve.demolish,al rcpev any u— Sq. Ft. Floor Area Valuation
prior to its i......also requires the applicant(much permit to Ill..signed autem ad
that he is licensed punuant to the provision of the Commanders License Law(Cbmsm 9
(cix.nn,with Smile.71)Nh of Division 3 of the Bwimn and Plefessiom Code)or sane ApN Number Oceu 'ryI
haand,he is'newt therefrom Ne balleged 0.for the alleewmpfirn.Any violation of P y 'J Pe
Section 10313 by any applicant fn a permit subjects t,applicant m•Civil pmalry of 3 b •Z2 n:,) Ie., --
pm some,than rive hundred dollua(S500).
Laamam'.furepmped,..yempinymawithwages.theiraolednmpenr,anon. Required Inspections '
will m the work.andme ruunure if not macrale iornaew for We(Sm.100a.finsimas 36922037. 00
and Professions Code:The Contractor',Lima.law don ret apply to an.a -
prepeny who builds or improv.thereon.load who deer,such work himrelf or Mough
his own employees,provided that such improvement,are not intended or oB.cO for
We.If,however.the building.,improvemen,isroll wimm np year of dn"ttinlion.the .305 — FRAME
ower-Willer will lave I,holders
or proven,that heed not wile or widows for For.
pnewwe.). 307 — INSULATION
❑1,as owner of t,pr°pert,am esd.Ovely conhmting with loaned comments a 601 — ROOF TEAR OFF
camirm.the prejeel(Sec.]DK,Bmsaid d Profeuhms Code)Thm
The Conmmb Lt
CO.law dm,amt apply ofanowm,ofpropnywWWRdaorimp°..ronenn.and! 602 — ROOF PLYWOOD NAIL
who contracts for such projects with aconvactm(,)Idmud pmnt
rsuant to CUraxm s
Licen"Law. 603-- ROOF BATTENS
❑l and exempt under Sm. ,B&P C for this reason 604 — ROOF IN—PROGRESS
Ower Dee / ,
WORKER'S COMPENSATION DECLARATION we
I hereby affirm under penally mf perjury arc of the follmving dmlmdow.
Ihive and will for by eCmi/Gale of Comethm aloe.fortfor Worked Compere /)(/
worn..provided fon mi Section 3]00 of the Later Code,for the pedmmurcc of the 7
work have
which rola permit is issued.
X7(1 have end will maintain c Iskn'a Compensation Irk for hi h required by Section
/
of the lvswc
my Wmare6saW�r pCewayk+.far
ylme perfoamryanmce of rix work for which this—pTer�mXit pis issued
Carrie G^+f'IfY tIL(s)/Y O- Policy Nlorylu (S /t1tt—W
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi,smtinn need ren,wmpletnd ifma pemtit is forom hundred dollen(5100)
or lass.)
I minty this,in the pdo.,of the work for which this permit is issued.I shall
not employ any person in my manacle° ry
as to becoaaubjmuu me rt
w° en'Compn-
latinnlaws°fCelifo u,Dec [•t•IU (�(J
Applicant IOl1l}riV/��NYRe
NOME TO AP CAM':IL after making this Cenifiwte of Exempun,you should
,come mbjmt to the Workers Compensation previsions,of the labor Code,you most
forthwith comply with such provisions of his persalt shall,decided revoked.
CONSTRUCnON LENDING AGENCY
O Q I hereby d5on that mart is a constmctiom lending agency for me performance
Z 2 me work for which his permit is invited(Sex.309],Civ.C.)
ladle/,Name
f Lendeex Address
[]] , I emify mu o
1 have rll this applicatins,"m
on and at the above information is
d 17Co.,.I.gree to comply with all city and Gouty ordinance,and state laws relating to
7 Z building concoction,and hereby...bon.rtpaef,Gives of this city 1.mer upon me
V 0 lobove.memiomd paopeny for inspection puryofc,.
Lp. F. (we),IOm On save.indemnity and kap harmleas t,City of Cnpmino elision
O U liabilities,judgments.costs and espouser which my in my way ammo against said City
>a Wan con,equence of the grating of this permit.
[� d APPLICAN'l UNDI: NDS AND WILL.COMPLY WITH ALL NUN.IroIhT
h SOUL ' REf.ULAT S.
t.7 coon Sigw re of ApplieamtContactor De"
HAZARDOUS MATERIALS DISCLOSURE
Weil the epplicand or mere Wilding Occupant fete or handle hawndaus material Re-roofs
w defined by the Cupertino Mumdif^I Code.Clupmr 9.12.,"the Heilm and Safety T e of Roof
Code,Section 255311%)] / yP
❑Yes �j
Will me Byplicwt or future Wildingmdgp.nt use equipment or de.ie.which All roofs shall be inspected prior to any roofing material being
emit hewrdous air eonourivnls.,defined by the Bey Area Ail Quality Mmagement installed. If a roof is Installed without first obtaining an inspection
malt]
❑Yes INC'"�// I agree to remove all new materials for inspection. Applicant
I have dead me harardawe materials reyuirtmenb under Clupmrfi95 of the Cali- underst ads and will comply with all non point source regulations.
IUmu Health��S..25�5,2"3 53y mp25534.IedarsfandmatIfthe
ingf'ity rtsponsidlirymn.ifY me m'upwt0 suame afe mifin"nf OcIgnalure of Ap ican[ Date
Owner or authorized agent Date
All roof coverings to be Class"B"or better
OFFICE