00090076 (2) CITY OF CUPERTINO ` " -
BUILDING DIVISION PERMIT CONTRACTOR:INFORMATION:
BUILDING ADDR17SS: .v ' PERNIll "
OWNER'S NAME,77rO UHHH1HUE UL .41 - APPLICATIONS AYE '.' ,
ONE ., TSENG .. s' ; , SANITARY NO
pKZ ARCHITECT/ENGINEER: . BUILDINGPERMITINFO
F i E BLDG ELECT PLUMB MECH -
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Z Z y�
LICENSED CONTRACTOR S DECLARATION ON Job�Description .' r,
OZ�� therebyaffirm licamed n pr, of Chapter (d ro'b e
CW I I, tn911118) DJ,y 3 rlhe Ru a I7- r:'ypvle,y Jm)1 - - '
�zca Date elfllyyr.` I „ GGlj OV S �V ASPHALT SHINGLE REPLACE .,-WITH SAME
m Dille-�� � C I ac or Y1A rvc.
s DECLARA 110
I meersboad buyPl ne,hall teased usspr hl'cnronh
y
55wr
tit g p 0 L'e n d Pmfesenmal t
y,o OWNER BU1LDrR DCCLARA'1ION J „s ^�r I - s
nch,
the
`'S�=Ste�C❑=
following
allowing e.aso (Section qT5th Business and
P e1p .Code:
dfI gbuyer
t canounnetnywZm I afrrn that I nor atom,man, h Conari W f r
which requires a permit construct, R p e,demolish,or reptirany structure
t j y, • _ p
d
hot he
t - °
_
rcowdp :.cause the,brobuire ofJ (marournale,Li,caNe L (Chapter 9 Sq. Ft. Floor Area Valuation
(co u
nming with Section 7(xq1Yvi) dn 30 the Hue nevi and Professions Code), -
or hot he is exempt therefrom and the basis for the allegal exemption.Any vinh on. 'a' °'n s` `
of Section 70315 by any applicant for a penult subjects the applicant to a civil penalty
of not more nom five haitdrad dollar,x$500) - - AP.N Number. .. _ ",. _ -Occupal
❑I r nn P P 0 r employees with wages as their 1 ry. .aurn
will d.,tha vock,.d'Pficei C tine structure tintendedoffered f :al (saa'7044
Bane3580605 . .
s 1r I The Com roc s L re .nsI does t apply In �e�red Inspections
own r an,rty Who br ild:61'Improve,ffiloccon,and who door bmsuch wurit eelf
ort) gbh'- employees.providedthd h'improvementsare no,intended or s r
aRredfor:'I.If,n the buildo,mailan,crabor is sold imi )no yr,nof 1 305 —` FRAME
completion,theowner-builder will have h d_nrrprag mud hl'IidInuh
improvefor pnpaee3 .. ,
INSULATION '.
7111 a: airline p p ty t I t lycontracting 'do l ca'amt,inum ' 601 — -ROOF ;'TEAR .OFF�, -
contract thePrJel(Sea
7W4Boors,turIProfession,CJ )ThCt t
License L aw doedoev notapply o who conforal, I., d p n rostiwDra toproperty twho buddCor dnparoa�t��ne a 602 — ROOF PLYWOOD NAT L
cont amt r Lc ,OI 603'— ROOF BATTENS
❑last smmpt unders t&&PClx this ,a r
i '. ' ' , 604 — `ROOF, 'IN—PROGRES - '
Owner - Date a
, -WORKER'S COh1PENSATION DECLARATION r
thereby f : —
via aaqa,poorly f.p r y or the ft1da,m,,la�lmrtaaa,
❑ 1 have ad IId nC I I f 3Consent t 11' forforWorker's
paCompensation, o. p tied f h 5 S t 37110 t f h L h r COAG r th
part .....he..1Je workl hch this p t is much
❑Ihave ad 'll reentainWorker's Compeer,d IrequiredbyS t -
37001 or the Labor CoJ f the p f f tl '-as f which(]its Parent _
I, ",and.My W mhe not Im r and Poh y mb °
'Caner: sly No _V C) !
1 i.T ' r
CERTIFICAT N OF EXEMPT ION PROMWORKERS' f�.
COMPENSATION INSURANCE r ..b'�, a
( his section need not be coinpleted if the parent,f to hundred dollar,' r I v. ,
($100)or less) n
I amity that in the performance of the work for which this Benoit is issued.)dull not employ any person in any dnwmer so a,to ben ne suhjul to the Workers ..
Compensation Laws or California.Data
Applicant
NOTICE TO APPLICAN P If,after making the CeniCcone or Evion,lart.yen should
C) 0 become,ubjecno the Wei'k s Cnamerecainin provisions of the Labor Code,you masa, + n r
fotihw'Ih wnply withsuch p ' ns or ths perant shall be arsenal revokul -
F / CONST RU C'I IONLLNDING AGENCY
I hereby ufrrn Ih I them em cion lending age cy for th edam .. ' -
W
Leader',
ework for wN eh tl p n u's ivacd(Sec 1099 C v 1 '
S Q Lend .Name n ' e <
V Z
Leader's AIJ .. t
Q 1 verify that 11 till'. ppl at n dart dhldh h f t Y
W !r
correct,i agrea to comply with all any [county ordimancesend state laws relating a - '
Q,V' fre hirldin,cm,anaticar,andh eby antanize representatives of this city to enter upon
dY. Gi7 the ab tionrd p i y 1b,Jn,w,1' purposes,
(We)aBr In indemnity dk ph nl the City fC I t g ins t ''*er
fir V] Britain ocjudgments,cosis J expense'which roary in any way'accrue against said I.. .
V AR City'inconsequence of the granting of this permit'
SOP A UNDERSTSNDS AND WILL COMPLY WITH ALL NON- INT Issued by _ Date',
air
Signa a AZARD MATERIALS DISCLOSURE Reproofs .,6 -
Will mea Meant or huure building- d storeorhandlebamnlousmaterial
PP g nwap.n 'Type of Roof .
ns def nod by the Cupmnim A1unicipal Cnde.Chapter).12,anJ the'Health anJ Salety - ,., ,q'' ' -
Cod So 6hurnoyes 25532(n) .rL�No r t e
All roofs'shall�be'inspected prior to anyroofmg-material being Installed.
Will the applicant orramrchaildir,"'cuptdmo:eequipment ordesire,which If aroofisinstalled without first'obtainin an inspection, I.a reeto4emove `
emll duo conw ' ' t,.,defined by the Bay Area Air Enmity Management g g Damnab _ - all new materials'for inspection.'Applicant understands and will comply with
°Y' t e , all non-point sour'a regulations - .
1 r, ad he furnace.,national,re,wearrical, -underChapter 6,95 if the
-
California Houldin&S f f Cod S ct 125505 25533 d 25554 1 d 4 i d Ih t
if ! h n'
the M1 Id nBd at havt s
currently count, yrcp hllyt tfy tl
panttfth q t mustb tp fn's, aofv Lcn fret of //////
Occup. - _
u Signature of A pllcant.- - x, .Date
_ t_
ow a annd.ed nit D � ? .�; All to coverings to be Class"B" or better
OFFICE n 1_1'