00090135 (2) C'TYt OFN ;UPERTINO - CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT NO. .
WNER'S NAME. Wbbo 'LICA'I IONS A � 0
i
'NDNG: /. SANITARYNO. 09" k-C) TM .
q O C ARCHITI[Cr/ENGIN HER: — BUILDING PERMIT'INFO
&L�cce _ BLDG FLECI' PLUMB NISCH
aa e
G,¢� •:. _
to
zS - 1 broth'ar
fo that IENSED am licensed CT
Provisions of Chaffer 9(commencing .lob Description-
4 t
escription4t a� whh Seutinn]I199)or Divtcionl nfthe putinccn and Profession.Codo'nad are license
e a u i' n fall fen and ellal.
� License Class Lim.a
Date Contractor REROOF/TAR AND
GRAVEL-'-'
ARCI If I'ECPS DECLARA'T'ION
O( 1 ntalecshmrl my plana.hull he uvsd as puhlie m'unl'
ye O Licensed Professional - - -
S o Kw OWNER.BUILDER DECLARATION '
u7M a, I wieby atflnu that I tio exenipi fab the C I nelu License law for the
C Z Q roll, , : Iti ti ]B31 5 B :inea J PI rat C l Any ly or..nanny
ISO which rcyaires n permit re uire%t a applicant
Permit 1 file 0 Sig any statement a°i3p prig heor is naiad porourequirc,u iiia of forC aryl... ense Laed mm"',9 '
matneiegeant,IhS rumtyrt00)ofDvim.�r,f�nfits,Itsiamole`nseLe,,uno Code Sq. Ft. Floor Area Valuation
(commencing em Starer]Will ofhe hats n 7 offie aItuede x mp ionfAny vi Code)or that he is eminpl therefrom and the boric for[liesubjects
the
applicant
Any violation '
of Section,than
5 e any applirml for a permit whjms the applicant ro a civil penalty
ofbet tmrre man fm ha.area aelmra lsslxo, - -DPN Number Dccupan`- MWJ 1,as menet of the prupenY•nnny employees with wages., compensation,
will do the work,and the wrucmre is nor intended or offered for ade(Sec.70,14, :37�34Q127R red Inspections
msinncs and Prom,si.a.Code:The Commnr
a 's License Love docs nor apply 1.on
inr of pv,smy Who build,nr improm,ve.0a,,eand who duc,such work luboelf
through his own employee..pnnidcd that such in,provememe are nor intended or
offered for sale.If,however,the beading or improvement is sold within one year of .305 — FRAME
Icompletion,the ownerhuilder will have the burden of proving that he did not build or
ntprnve for pmpoaenfsale.). •, - , , ''307 —, INSULATTON
❑Lax nor ofthe l>mpen,maexclusively 6nlmcrngwiMictmeeeommernrsIn' 601 -.ROOF TEAR OFF
onmmeaw oesno(se,.70aaBpamesnesblyaannaaMo:)Thevostheemr> fi0.2 ROOF PLYWOOD NAIL.
and wh co trac rel apply total owner orpropenY woe halide s improv,t to the
• '
and who's License
ror such projects with o centreaorls)licensed putxnm m rM1e
Contmemra urease T-ax'.' - - 603 -ROOF BATTENS -
❑lamexemprnneerser: - ,n&enortm,masa,n 60.4'- - ROOF .IN—PROCGRESS .
Owner Dale •,WORKER'SCOMPENSATION DECLARATION
ION
Ihereby aft in underpenalty ofp hiry are titnh following dcl f nes' •
Qlhae and ill Conifiethe of Consent l xalfinxrra fit,Worker', ♦ - /O( .02
C recturmt o a. provided f by Section s ko n the Labor Colic for the -
01h inn flh okfwhich this,Co . t. L -
❑Ie and will maintain W k Comfit, don carrier
ce vnrryberar Sexual
- V
37W f the Labor CW f the performance f the k for which this permit is
is ed Myy oorkr Its Co� ,rhonn lmrrun .u1�Po�l'tcy.numher urs
Cartier_ ///y'i�r+1 Policy NoW�_It Z8 -
CERTIFICATIONOFEXEMPTIONFROMWORKERS'
COMPENSATION INSURANCE -
(This section neednon bo completed if the permitisfm one hundred dollar
I crm y than in the p,don mace of die work bar which this pem,h ii IssncJ,I
'hill not omple,any person in any manner so as to heceme subject m the Andhra'
Compensation Laws of Cvlifamiv.Data
Applicant
NOTCH TO APPIICANI fl It - akin,this Cx,thfixafv,,i I n you vh ill
Obecome subject the Workers Compensation prof t Labor Crude,you must '
forth nth comply wiffistut provisions t or ths pcnmil aluall be dcemod revolawl.
r
CONSTRUCTION IrNDI he AGENCY
a thereby which
theren,eco,.miler Iced ngagency for the performance
Lu of the x'ork for whicM1 chis permit is issuW(Sec 709],Co,C.)
Lender'.Name
C.7 I cenify that l have mad this application and state that above inronnmion is
�+ F. correct 1 agree res comply with all city and county nNinances end stale laws relaying e
0 V rebuilding mnantmlon,unit herehy auntrire representwita,ri'his chy memantrym ,
>o Wthe above-mentioned properly for Inspersion purprna.
FF•t q , (we)agate m'ave,indemnify and keep harmless the City of Cupertino agaiml
tZ) liabilities,judgmentn,cow and expenses which mayin any wry azerue againm send, -
�,Z City in enmes,bame of the gmh ir,of this perm,• pp
"•' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Is$Uedb �`•1
SOURCE REGULATIONS. y: 'DaIC G
Signaturcof Appli,t t/Canbarsef - Dom Re-roofs ,
HAZARDOUS MAT'HR1ALS DISCLOSURE
Will the applicant or future building occuWm more or handle hahadou,mmcrial Type of Roof
us dcfncq by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,. inn 25512(a)p ,.
IYe,�'
C1 No All roofs shall be inspected prior to any roofing material being installed.
Il rhe applicant or future building cecupam uze eyvipmem lir devices which If a roof is installed without first obtainingan inspection, I agree to remove
emitharromrseirc, at immdacdefncrlb,lhuBuyAratAwQua1u,M,,u,cm,n P g
Di'mettK�t/Y r all new rnaterials for inspection. Applicant understands and will comply with
/ ,I, 0"h all non-point regulations,
( - I hove rend he hazardous materials requimnanu under Chapter 6.95 of the r v
Californiafleadh&SafelyC 1 Stioub,2550525517 and 255341 J and thtt Yr -
dlhch (ding Jx r nrlyh Tena t yh Yt'- y asp .blty, tify the ' _ _iYli v
pec p ut of 41 lexpreareent,which all he It mair t mance1.C n fcam of
oat/.t 2��Y atui'e-of Applicant D te�
.oen,mahmm�em Dad, All oeterings to be Class "B"or better '
OFFICE