00080161 (2)CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BL+u.DING utwst0N PERMIT
BUILDING ADDRESS: wPERMIT
Is
NO.
°`°"E"'SNAV6323 BLANEY.CT
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DONE RIGHT ROOFTNU ROOF
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PHONE. HSU CHUM-HISUNG AND LIH'G
1.129 LONG FEL[SANITARY
ee 61MU410.
ARCHITEC (ENGINEER:(408)
377-87'77
BUILDING PERMIT INFO
„
RLDG ELECT PLUMB MECH ,
LICENSED D CONTRAC FORS DECLARATION
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Job De$crl ion,
I li by fl lam l a„landed i. ,I CI u 9 an t o ,g
w'0 S , 7000) J to,B , of tMfl ' I f `
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III (orecn 1 :21yv
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Dat`
ARCHITECT'S DECLARATION
40.)EA�C�OMP
T/OFF PLYWOOD — 40
I undersmneew dams shall he used as public record,
[AccusedP fi
fWNFR RDI CARAI
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11 by I I l 2 einra III CIIelo tile
- Business-" v
lil g set 91nL5 JI f.� Code: t, ntY
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w inch deviants o poloolit In ransomer, .1111 taproot,Ir h, .1 replan an,ImIldrove
prior tI e. also rcyuirvs the applicant fix such permit to file a signed seenent
Sy. Ft.,FIOor Area
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that he is lianscl..... lnIt) the provisions of We ConBanors License Lane (Chapter 9
(commencing with Seuion,W TWO Division] of the Business and Professions Cada
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or that he is exempt Ibcrefmm and the haxis for the al lcFnl exemption. Any violation
of Section 703 1.5 by any applicant for apcomil,sujece; the applicant to a civil penalty
of not mare than five hundred dollmit55Wl - -
APN Number
OCCLIA.UL t5)3PA)e
C1, it, oanerot lhcpmperty, drmY crackly., in, wnge,ass lheirsule csnhpcnst to
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will do the work, and the slrnnure its do, imeudcd rel ollernl for rule (Sec. ,Mm,
Basin... and rn,rsvimto Code: 'I'he G,nbumx'd Lnern,e Law does nu nrply to it,
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-36 932 411 6.111quired Inspections
d,vacr eI property Who build, or improves thereon, end who due, such work bllnsolf
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er through his own empkiyees. provided that such ingnnvcmen¢ are not intended lir
offered for sale. If, ho ocode the building or improv hent iv said within one year of
completion, the owner-huilderwiR have the burden of rnvingthat he did nor build or
305 -- FRAME ,
im,wa fear puryme of,. e.L
307 — INSULRTION ”
exclusively contracting with licensed
111. its owner of the pSee,
construct the project 7(am Connore 'i
The
.601 — ROOF TEAR OFF ,
ownerotandcu,whos id, or pr reprove, thcrxnn,
Llecase Law does nm ,m roam owner MPn,pcnywan
61T2 — PLYWOOD NAI
doY
mal wctorsLrnets rLode 1, foetal, wile a nmrlletmcl Handed p,lxsllnrlt m me
it,lird or,n
'ROOF r -L .
cnnamexe l.<en.OLSet
am exempramner sort � ,BxaPe for this reti.nm
603 '— ROOF BATTENS,
owner Date
604•• — ROOF IN—PROGRESS
WORKEWS COMPENSATION DECLARATION
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1 hereby affirm under penalty of perim, one of the following declarations:
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] I have and will detrain a Certificate of Consent m self -,ovum for Worker's
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'onlpensation, no p e idrd for by Section 3700 of �Ihe Labor Code, for the
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lerGumunce mf the woxk ton which Il,is permit I, Io4neds.
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.Q I have and will nuirmin Worker's &a,emselien Insurance, as required by Section
AW of ,he.L bur xllr for the perfn,mance of the work forfor�
issued. My``W ellShcion umnce Currie J}y(kI' be
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13 /1
Carl U Poliry No.:
,
--CERTIFICATIONOFEXEMPFION ROMWORKERS'
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COMPENSATION INSURANCE
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('[his seen nn Hemi nm be completed II the pannil'Ix for one hundred delblrs
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1 certify had in the ilerormunee of the and, for which this permit is issued, 1
shall not employ any proven in any manner m as to become subject,u, the Workers
Cnmpcnmtion Laws of California. Dale
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject o the Worker's Compensation grew sinus of the labor Code, you must
forthwith comply with such provisions or this permit shell M deemed revoked
CONS' IRUM ION LENDI NO AGIiNCY„
herehya1Rnn taut Iherc Ixu constnidinn lending agency fonhe perfnrmm�ec
of the work fir which Ibis pcnnh is issued (Sec. 91197, Civ, C,)
Lender's Name
Lender's Address
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1 certify that 1 have read this application and nate Ihu, the above information is
euro. I agree u, comply with all city and aunty ordinances and ,are lax. relating
to building construction, and hereby catheter representatives of Nis city to enter upon
the above-mentioned propenY for inspection pnrpnses,
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(We) agree m save. actually and keep harmless the City ofCuparde, against
liabilities i cipardo,. i perse, well, ,at, in any wily gaina vE I
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City d g t' g ,this p
APPLIC ER STANDS AND WILL COMPLY WIT ON I
SOUR GL TIONS/t
ISstledb
by: Date
Sib drureofApplicant/Cnmmnor Dme
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the opplicam or fatum building ode.,som stem or handle honorary.. evencritil
Type of Roof '
as dcfined by the Cupeninu Municipal Code, Chapter 9.12, and the Health sal Safety.
Cndc, Section 25572(a)f
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EYes 0 N
All roofs shall be inspected prior to any roofing' material being installed.
WiBmerpliGent,ta onerehailaimce
go,paitlureeq,r'Iprnenit,rdeviee,wmcb
If a roof is installed without first obtaining an inspection, I agree to remove
ani, hooddlims air contaminants as deft red by the Bary Arca Air Quality Manng0lant
)iadelp - ,
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;all new mat cls for inspection. Applicant understands and will comply with
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13 Yes 11 No
idl t s urce regulations.. .
1 have the hwidmus materials mquiremcmts tinder 6.95 the
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Califumia Health&Safny'ode Sutinns 25505, 255JJ and 2551m.l undcrswnd that
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if the building envy havea¢nant, tam it iv my mponsibilitymnrnify the
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occupant of yup lots which must Ix, met prior to issuance of a Codi of
0Gric i
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Signature of Applicant », Date
All ro"of.coverings to be Class, "`Br' or better '
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Owl a aulhorlZeJ agclll � Date