00110049 (2) CITY'OF CUPERTINO
sun.onvc otvtstoN PERMIT CONTRACTOR INFORMATION
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BUILDING.k�pICJ b7 .CRAIfI CT .:., - d �. PERMIT N'017Jfi.�l],11]J
OWNER'SN h "• •' - ,� APPLICATI NSIJ ATE r elt
169 SANI ALBERT AND_ NAR,IE ' : '" ` 4t)� oL,�A10
PHONE'. - - , SANITARY NO. • CONTROL NO p
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ARCHITECT/ENGINEER:. _ - BUILDING PERMIT INFO
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_ BLDG ELECT PLUMB SHIED
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or LICENSED D CON rRACTOR S DECLARATION - -
z y 'Job Description
In nr n mmtl I d p rcI-p 9monne g .
�IOZ u� with Set ]n0o)dD ' ?oftheBo dlnfe,o :e l undmyl e ,c - • ,
" f nAlf cedefrt �OP_Y-ROOF FOAM
LiaClass `
CO L c a
Data Chabor,
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3 - ARCHITECTS DECLARATION -
1 and ernand mY plans shall he used its Public records
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F' Lic dP Professional • l
OWNER-BUILDER DECLARATION hereby affirm that 1
Cf�%.6❑ cxenpEon the Canwa-ts License bridge
followngNrcoa secton 91, laand Professions Code A.,ciytir county.
which permit l construct,aum,improve,demolish,or y - - -
-
sarrictury t.
rtau3se Prr 1 tclaim
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thapplicant
ppl tl . hPemitI Id a ten d.wt neer J
mato IFl n thep nn C t t r L :eL (Cis 9 Sq. Ft'Floor - vel tl
pier $11 ,��f?zf
from g Ins t 9man the i f0 R : ddPpf. - Cede)
of that s t talleged
he exemp hucomm and the basis for the � exem neon.An violation
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I Y
of nor more than five
by u u applicant fern permit subjmts the applicam to a civil penalty
of not nerd arae r„d nnrmrad dom.(ssom. 'A
PN Nu- -
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Occupancy Typee
` : _9J 9 "l
°1 f the larTier�r v employees jib g s theirI ,pexnt on
will d thek d dr t t t intended B d I (Set. 1044.
Bus d P f. n c d
The Contractor's License Law dapply to,rt • Required'Inspections
mvin,aTroperl,Who malkNo,raptures ha twbo1 'n work'nmself X09 -- FRAME' .
e' or through h' n employees.provided Our shimprovementst mended or - '
offered for sale.If however,the building or improsenentit. ra n i -year of • "fi7 — I MSI Il—A'T I OCtiIcompletion,m .-n m -n n ve the ire rp ovine that h e'a d ear Of
improvef purpose or le) E501 - ROnOF TEAR OFF
^+ °I,as rol(he prmlrorty,;mexcladvd,contrmdngwahlicensedannmwomtn . '+ {,,,L71 — 'ROOF RI_`fIdCIOD, MA,II...
a d toll p 1 n,ae.9044 Business I D f il 1 )Th C -t cmr's ,3 _ s -
ade 1 notion, puck a p )y n build, p 'm eon E,0 r ROOF BATTENS
,and -contracts f h projects wile co nmemr(s7 I 'tont the
Grtt t L L F;rt.4. — ROOF IN-11Rl_IGRESS Op
❑I am exemp)utderSe I-B&PCbnh,aanm ' ,
Owner Data '
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WORKER'S COMPENSA'1'ION;DECLARATION - •
,. )hereby uffirm rude,parall,ofprjury one of the folla,in,d.I
❑ I base and isill mairanCvhdlcmacf Consent t 1f)coon for Worker's
Cmunpamerion, asp,.aided for by Set 3700 of the Labor Cole for the e"
performance of the work for which ills pe n t is issued.
- ❑1 have lotwill harmataillW kc,',Cpc a I: quire.by Section a -
3704 of the Labor Code for the performance of the eras k far which this junit Is • • - t
smvd My Worker s Compensation Insurance cornerandPal yy number
� are: - . •r:' , a -
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• , CER IFICATION OP EM17TON ROM W RKLRS - '
COMPENSATION INSURANC17 -
(This section need nm be completed if the p,nod Is ler one hundred dollars
no less)
I
ceri fy that in the perinnmore of the work for belt tbh,permit is ed I
shall nm employ aty b.an in say nan to m r so a. became;object to he werkam t -
Ccmpensmion Laws of California.Dale
Applicant
NOTICF;MAPPLICANT If, rt k ,this Cedificale of Everadom,yon should
become subject mthe Weaker,C P 1 f nth LaborCd yr trust
-fonhw tb...ply with p ooh perm it shut]in I -mW mvok,& - - d” t
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W CONSTROCB]ON LENDING AGENCY
I oddity a0 rar that them is a cutnurinfirm lending agency for the performance ' '-
F>a
of and venal,f which this permit is issued(Sec.3099 Ce.C)
Q Landers Name
-� z Lender's Address - ry
C..) 0 1 vihflfY thud 1 have read this application and state that the have information is " -
ET+ ty correct Idem¢to comply mh'II car and county rInano s inal fare laws relating
C V them baking construclon dh by authorizerepresentatives f the cry to other upon
tW I g : nJ tde i
n t, I keep h t l :to Cly f C P R again,,
Cit t j da t t. sod pe finch aY'fvny y ema-ugu lit ''A - -
V Airy wsT UNDERSTANDS
of d grandma D this p a t.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
- soukcBR � — Issued � Date ' .
St ppd nt or Re-roo ar" . . '
HAZARDOUS MATERIALS DISCLOSURE
.. Wall the applicant f t b lJ nb p' t a handle harvtlous railer al Type O Roof
lir del ned by theC petl t Muateiprl Cede Chapter 412,and the lief Ith and Safety
- Cad,See,non 25532(a)2 1.
M ye, ` °No - r
' -All roofsshalfbe inspected prior.to•any roofing.material being installed:'- -
.Will theappBanl a,future cargo, entrant nor egLipment...m iceiwhich If a roof is installed without first obtaining an inspection, I•agree to remove
omit hazardous air cnnwmiumb as defined by the Hay ArmAir Quality Management
Dlstrl,P a all new materials;for inspection. Applicant understands°and will comply.with
°Y" - • s °No - all'non-point source regulations. r
- f here read and hurvrdous mwcriale dparament,mtder Charm,695'of the - v California a H Ito &Sumay Code,Serious 25505 25533 and 25534 1 mllnland that a
fthe building d t mad,have ate tmatifi yttp 'hlpt ready the ^
dap t Of,the equ'rc nts which must b t Pf.r to'sn a of a Cmll¢we of - V
oa`up°'°r a Signature o Applicant ''' Date -
owow. o � urn o te
All roof coverings to be Class a,B„ or better
OFFICE