01010059 (2) . CITY OF CUPERTINO. ,. I "✓ -
sotLbtNc DrvrsIONpERMIT' CONTRACTOR INFORMATION
BUILDINGAUDRess` . - - .f%)7.f) � Li:�D'
:(.gSil'`i-7 U)ITIHI:iRUEY I...A
OWNER'SNAME - AP SOB DATE.
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a`nr`Fr_ rlraFMA 1= r:::r nl
• PHONE: o - - SANITARY NO. CONTROL NO.
❑eeZ ARCH)fECTHNGINF;ER: BUILDING NERMI'I'INPO
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,Wr LDO ELECT PLUMB` 'MECH 6� J CJ I_1 LI s
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LICENSED CONTRACTORS DECLARATION.
Job Description
z I hereby mrr,t that I . a ap fehamar9 monneg -
r
E, "wth Section 7000)ofDivision 3oftheBu and ProE„ m,Code and rayl
m a to mu fere an rr LL..I'14ll:)OX) TO 40 YEYR GAF' .
E Llceme CI ., Lic,k -
ce3 ContmDECLARntnr_ ONA _. .
_ ARCHITECT S I
C loode,,vandony plots shall named ,uhIicenr1,
5y r
-u]
cLies ad Pfanal
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OWNER-BUILDER DECLARATION
w= i hominy ufft a t 1 pI I the C
u 'l ' L for hc
hollowing .(5 f 7031.5.0 ProfessionsC d:A y city aunt
which nSacol r a pper Inod Ih PYamdum
c. poen I t issuance,alsorequiresapplicantef nil It hes 6 Itumem'(coG :rip t,,n _ ro Contractors Le Law i(Circle,9 a .F. . Floor-
'Area
(commencing
eatoo w .n0 Division the 1Icobseoi) - '
- , _
Valu-ation
or tha,heisexcnToIn.e1rerand lc Na...hu. RatiraepriorAny violation
of Section 7031,5 by any 'aforap tsubjects me applicant acvI lwnolly
of not more manlive hundred dollars(9500)
,
,
AP.N Number', •' Occupancy Type
❑LaowneroftheI ? o,
proper r,arn,r nntpeoyaa,wpm wages a.meiraolecompenamion, .3�H �r.Ide.,.)t „Calf%) -will e n k 1 m a , pintended B ru is . " Required Inspections
• 1 Th istI :C e L JI Spey.man a
Buind.i f : C
owner fProperty Wh build. improves therear.and whodoes work ourself 3f):`ri f"FifTIE
or through his wn emplaycc,.p- led that such improvements am no,Intended nr
offered f sale,If,Ira vicar me baldingimprovement is told within one year rr ;3Cd"% ... J:bl:nt.11...61'T];Olrl -
^
completion,the ownerfbu ldcr will have the burden of proving phut he did oat build or a
itnpt„va purpnaao k',G1 I'.T.)O- 1E6R OFF
711.in,m,no,of the pmpe,lb at c.ceas v ly contracting with l trn,ater •60c2 ROOFI-'LYWHM)
NOD..
onst n theproject(sea Jou.Businessd Profession,e r) I Couturiersconstruct I does net apply l aner,f, pay who build,or in as themes, 60" ROOF LAITENS
andh I:f 1 , 7 I with a c t Yor(al licensed purti2an t do +..,...::fC.r� -
Cobr r, Licen.eI..., 6W. .... .IsOOI .I:hl f-9if:)Gm .,ra
❑I at,,exam,:under Seo. - .II&P C for'his moon
`
Owner
WORKER'S COMPENLNSAHON DECLARATION
Ihereby affillo n.,Ia,,rrlly f,rbr,ymwoflhm loll ,d 1 I
O I [lose and,vill mention ;i Certificate oI Consent If for Worker's
Co p t n : pnoiderl for by Section 3700 of the Label Code; for the ^ I
Performance ftl work lot hich this perrout L- -
- O1 have and will admin Workers Compensation Insurance,as required by Section V a
3700 of the Labor Code,foe me performance of the work for which Has permit Is -
sued.My Worker's Compensation Insurance carrier and Policy number arc: ,
Carrier: No.
- N Ilcy
' CER IP Af1�ENfMON M M WORKh� :RS i
COMPENSATION INS {2ANQ _'t•" (.9746 0.d
' /✓/+'fPo ho, t,
(This rection need nal be'coo plomd if the,count,s ounce hundred dollar,
ess - `
(SIIXI)nr l .)
a I ee map rt e p f to f_ k f II p h
_ shall not employ any person'n any noon rus n bae c,a rte sub)ecl wmee WoderF
Comicant ion Wwc rl Culil'ornin.Datar '
APPllrnm _ - - .. 1,•- . . �
NOTICE TOAPPLICANT BE after making this Ceni ,aile of Exemption.you should
baccou,sahlicrato theta leads Com,co,aticla am,kinnofSheL barCode yo Host
Z� Qforthwith nilly with ip sonhp 't-.LullhaAcemal rooked. _ '
^F CONS TROCHONLENDINGAGENCV
a ' I hereby affirm that Isere is a conswnion leading agency for the pedorm...cc
or the work fur which thin permit is issncd(Sec.3097,Civ.CJ - - +
Q Lender',Nnrs.'
z Lender's Address „
n.
V Q �, 1 certify mat I have read this tpplicmion end eme thw the alwve n..actions
FT+ '�.t crms,1.I agree to comply,wim all city and county"ordinances and smile laws relating - e' _
'C) CJ mIsebuildin"') Ivtnion,and hereby authorize mprencat Ives of this city w enter upon - p.
W h f ted p p Iy f p I n p .
[ra
(Wa)agree troye,ind unify andkeep ilh hart in any w
Imay. the City ICn fog 'I ,. ^ _•
ay
6,7 z City in card,nonooftTA S g Ithis WILpermit. -
APPLICAN UNDERSTANDS AND WIILCOMPLY WITH ALL,NON-P(11NT • u
sgkyRcc auL Ns ' , �I /��B� - Issued by: Date,,
Stgnatum f A,juenmJConnasmr — --( 4---,e t- Re-roofs -
HAZARDOUS MATERIALSDISCLOSURE - - -
Will"otos,,licura Intent building oannpamnorce,handle haaemon,mannim Type ofRoof .
m debnW by the Cuperino Munlcipul Cade,Chapter 9:12,tad the ficnlih nnJ Safety -.Code, -
Section 25532I'a) . v . • y" ..
,DuosirAll roofs shall be inspected prior to any rooting material being'installed.
Won pplaro I future laing ooenpmdble wu p t e oo,wmeh If a roof is installed without first'obtainin ins ectiort agree to,remove
Ered bya nay Am,Air Q'Itr Mure,oneat -sta . . g an P g
• Didn't, : all new materials for inspection' Applicant understands and will comply with
E)U,V ° all non pain 'aorta regulations.
t h e a I rh Intention, I nd Charter 6.9.9 I the
Callf r Health lth&Safety C do Seances 25505 25531 d 25534 1understand thin t '
flnob Id' not renl'y tenant,II t t'. y .pu M1I'tyt notify th ' '
" .
relp.a h I hmnastb tp' ,tr sa fa Cmfwte of - -
�Occupo n _ -
. /�7•�.� Signator f Applicdnt : Date _
aathermed ager _ nate All roof coverings to be Class B" or better
'OFFICE