00080152 (2) 'C171'OF CUPERTINOR ,
BUILDING DIVISION PERMITCONTRACTOR INFORMATION:
BE ILD ING ADDRESS: ' • '- - PI?RMIT NO. ,
OWNER'SNA I . APPLICTT OM00
52
HONE: IWASH1 DRIVID 5 _ SANITARY N J ^ O
W ceO C ARCHITECT/ENGINEER:` v _ .,G BUILDING PERMI'FINFO
81L BLDG ELECT PLUME NIECE
�w
y LICENSEDCIINnsedu DR'S D..air, ATION
fChapt Job Description` '
C 1 h hY Minn that lain licensed J ...... f Chaprer')(commercial,
in
t 7qN I afDnsnnlnfthe Hu P f �)CC«le,and myl nse
�e YU a Iallf nAeff� /7 /
a°LL DcIc g "vmr REROOFIy SHAKES TO 40 YEAR COMP
AKLI II I FC r•S DLCLARAI'11) "
t o 1 ny Flan-shall he a edii,mblirneenth.
oya c O Licionwril Pror fete':' I -
E OWNI It Hxe DTII DECLARATION
ContruDN
II+r`77 I hereby alfirm ilia,1 tan from Ili C ntru t 'f, c I c Low for Ilii
T.a tollowing ream, (Sect 7031.5.Ealoe d P f :'on.CW e y city s county '
S„xo
which a Permit romancer. h p d I'.h p Y t ural t '
6 3F b pr t t - tt I N mrar t f h Permit i, y ed wremem
bar lie I . Ir a IM1 pr ...
fIh C r I I or,Co e) f
Ba g vhe 71X0 mbas +F al(lie Ran +e direr.: n,rnde) Sq. Ft. Valuation'
or that io is exempt zany irritation
t it and the bane lin the alleged exemption.Any violation 1 "'
of Section7031.5ban re hundrelicamfaropennis.whjecn the applirannaacivil penalty --
nrno,maremanEvenundredaanars(s5(xt). 'Af?N Number Occup. '
.p 1,a,nwncr nl'Ilie properly,army emplaycc,with wages a,lhcir sole cnmpeuvrouti,
will Ja the work,and me stmcmre is not intended or offered for sale(Sec.71W4, ,,LL
Rusincss and Rnfc,done Code The ColamcmC,License Law does not apply to oa 1� K-' wired Inspections
or of properly Who build or improves thereon,and who since such work himself - -
sirr trough h-,own abracyac,.foulded alit such improvement,am aaintended are - -
tracalf I If, ni,eve,, lie binding . .tn t Ia within()Fie yearn 305 — FRAME
r (Ie'on the twterhu Wer will have the burden ofpr+vnh thathe did nal'build or . .
improve a for purpose of sale.), 307' — INSULATION
01,a a'owner a fine nored,amexrlas elrcontracting with recover!contractaRto 601 — ROOF TEAR OFF
m,huctthe projea(See.7044,Hutment Iml Profes,lue,Cade:)The Comintern,[.Ito', medue,notapplyidlmnwnernIPropertywholaildenrhnpooe,lhereen,
La602` ` ROOF PLYWOOD NAIL
and who contract,for such projects with a commcu ms)licensed pair mm,no the ,
Commerce,IJreau, w'. 603 - ROOF BATTENS
❑loot exempt ander Se<. .H&,,rent anis rea,n" ,604 .. ROOF IN7PROGRESS ' .
Owner Date .1 '
WORKER'S COM PENSA'I'I ON DECI.A RATION
I hereby affirm under penalty of perjury one of the following declaration,:
r 1 bout end will n einulln a Cedifiv:ue.+f Cumicnt ra xalf-re,m''for Wmker',� _
Cnmpenorner, a, auvm d far by Section 3710 of the Labor CnJe, for the a - -
performance al the work for which or,permil is issued.
�NJ7N -
have and will maintain Workers tnce,Coralsnsaron Inenras required by Section _
1 of Jet Lubar Code,for the performance of-the work for which Ibis permit is .
is,ueJ.�My WA'I'd/fW,Cempenrrsallion In.,mmac carries,/and Policy numbleraymr, -
CarinJ�///C ( U/f/� policy No.:/b7-00,6 170 %
009
CERTIFICATION OFEXEMITIONFROM WORKERS* _
- COMPENSATION INSURANCE -
(This nvenion need ne be completed it sire permit Id for one hundred dollar, b r
BI old or leszl - -
1 eenify that in the perfcmnnee of the work for which this permit is issued.I -
shnll nm employ try person III any none,w ae in bv,onrctsubjec In the Worker,' '
Ceti co,minn Laws of California.Dale j
Applicant -
NOTICE TO APPLICANT:If,rOer making this Certificate of Exemption,you should
hce subject ro the Worker's Compensation provision,of the Labor Code,you must
•Q Oom
hmbwith comply with such previsions nr Ibis permit hit I bdeemed re
e deeevoked..
Z'`.1 _
F N
CONSTRUCT NG AGENCY
1 hereby which this there is a romduerinn lending t C.) for the pedunnance
W of she work for which this pcnnir i,issued(Sec.J097,Civ.Cd _ +
Lender',Name l
. � z Lendcr'.v Addreax + ,
I rerlify that 1 have read this application and sore that the above hommauon is -
F. correct.I agree m comply with all city and county ordinances and ,are laws minting
t.7 ahaulJing counnoncion,and hereby authorise represented ves ofthis city to enterupon
�,4 the nervomcntinnalme,deny l'orinspecrion purposes.
y' y (We)agree to save, d ify and keep ham lass the City ol'C pe um ilgatnet
en liabilities,judgments costs d expenses auch may In any way accurc against said
V Z ,City in consequence ofthe grionfing offfiiv perms t
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNON•PDINT Y q
• SOURCE REGULATIONS Issuedb_ y• s e Date, .II�—L Z�(J✓�
SisnadrenfA phcsrVCommctor Date - Re-roofs t
HAZARDOUS MATERIALS DISCLOSURE definll ed
theCLicartorfmurmialCgccripant litinetortorhal eTend, ad Safe,, Type ofRoof
' os JernW by she Glperlino Municipal Cale,CM1upmr 9.12,mal the fleahh ad Safety
CnJe,Station 355Js1u)^ " -. - t
[I ye, lNe . All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which a If a roof is installed without first obtaining an inspection, 1 agree to remove
Vit,huzcAOu,nor cuntammum,s as defined by the Bay Area Air Quality Management -
isll'Ietr all new materials for inspection. Applicant understands and will comply with
GYe, �No , ' all non-point source regulation§. . '
1 h d th•hazandu-mace l a t. order Chapterfi 95 f the so /t '�
CaliforniaH Health fryC I Sections 2SSf(h 35SPan 135531.1 1 r.rand iliarJ1Y J/ -r ���fff q /�'
' he
occupant
h ' 1 , I t III 11 ywo eofa l -notifyxulor P_ v/S/V,j,t-i_` O� 'ea0 f'
ecu al the,sane eel svh�vh,must be roti pr or In ss rf f/7C�enilacat f
q�J,�//�t �r}r_O,"/_s„r„_•'�_ Signature of Applicant D to
Oluvrn-f uutht rved,g nI, Dale- ,, - All roof coverings to be Class"B•• or better -