00060025 (2) bW4 - KUUF lIV—F'KUUKt55
' CITY OF CUPERTINO -
BUILDINQDIVISION ,PERMIT. CONTRACTOR INFORMATION:'
BUILDIN=ADDRESS. e I `t PERMIT NO.
s
Gn"'Pil ROOFING
OWNBR'S M1A E: �• - . ! " ' - - APPLICATION SOB DATE
ONG. , u SANITARAN16 REB AN ANTGN16 'RD__ Y �95 .NO.
MOO ARCHITECIJINGINEER;, i - r - BUILDING PLRMI'IINFO
-
BLDG ELECT- � PLUMB' , MVCL
LICENSED CONTRACTORS DI CI ARAIION
z'S�+ n n amrm m I 1 r J ata ` - - lob Description
CZE
y pr ren rl qt s s' �' . .
'rims I nl(x»nID 3 tine en Jr r.- .e de,md,yl n - n - ,
a S 's fur I crl�q ,�x .
�C�a Lic CI C.i� L .p� •Z"`0
° Da, Cot emr T/0 TWO LAYERS C. SHINGLES, ADD 30 LB" FEL
ca w to ARCHI rt.CI'S DLCLARATI N
d lana try plans rRn;neJn, nnrore...d, 40 YEAR' ELN COMP SHINGI ES
w 5 0 0 L'c n.ed Ple :.cional •'
OWNER-BUILDER DECLARATION, `
Ihrly orf rm lhtl am esompl( areC I I I Law or the `
f= < full 0 g (S t ]031 5'B J I f C d Any ly ounly
f f ❑ wh h 4 P t i st I II p J I l'h p' , t&lure '
Prot t al q d ppl' tl n ournt fl 'g Jstatement"
math licensed In a the lawflims.f'h C rdi 1 L (Chapter 9 Sq. Ft. PIOOG,ACea l Ya]Uat1011"
(Commencing with Section7010)of Division 3 ft Bu. Iprofessions C d) _
or that he is exempt Ihercrrom and the busis for the alleged exemption Any viol i n '
of Section 7031.5 by any applicant f formal sq c the pl h are(it a rivil penalty -
. of ant mme than Five h dred dollars($500) APN Number Occu enc T'pe ,
El T.aaowmerofinep p ty tiny employee,with wages as lh ,ole eompeummn. -
63Y7Q1y
will do the imirk,and the tracttracom I n t Lnlcndnl or offered far! (See 7044, -
Business and Professions Code:The Com I L Law does not apply to;In RRequired-Inspections r
wno,of p,.,,Iy WhoI ld:e mprovea income saeµm Irev FavIt work himself, .30
369260 . 01ZI � +
or mmngh his own en pl y-: provided that,act, armo,inuouts meant intended or r - -
efle ed for side If,however,the building or improvement is v Id w iflan one year of
notnplmmn.meawnerb IJ•r will have the burden of prong that he did nm build or y. ,
eg r pdrp v til,ale.). 305 .—• FRAME
o Va,uvms,afffic property, ung with roe,eaI 307 — T NSUI_AT I IN
u h J t f (S ]044 B e P and fisc Cuda:))Tb Contractor',
taqn
1 :3
eeLnwildi,notapplyloanomeropropertywhebnld mpdwa,gaireon. 601 , — ROOF TEAR OFF
and who inandirls r h projects with ontractorCg licensed p ;iI t the
Cn I etre 602 ROOF PLYWOOD NAIL.
❑I,n exe npl anamsa. t` Bmrcarthis reaam . 603 — ROOF.•BRTTENS
..Dale - _ `' 604. •ROOF ,IN-PROGRESS .
WORKER'S COMPENSATION DECLARKIION , '-
P 1 hereby afford under penahy of perjury one of the followingliwromitiow; ,., - 1,• '
, 11 and serif I CnfI fC It If Wk {
Co p t : provided I by Section 37001 f theLabor Code, r m
performance of flw work f M1 I In':p I 1. '
a and will mandome W k Cmirmaredifor 1,surrairce,as requ red by Section
3100 of the larsiu C,
sale,for the istifiroureare of thew,k f h i This permit is •� '
issued,My Worke,,C p t ,Insurance urrer,nd policy umber an.
r
Canter: jj�{X'E y Nm; FROM g 9 d t7
CERTIFICATIONXHON TINS FROM WORKERS' - . -
COMPENSATION INSURANCE -
re as dma need not ri .
f c I t ¢anti lilted it the permit hundred p -
r
lSurtU or Inas,) , - - � •. ,
I eulify that in Il11 p;,96ionave of he walk f hi h this tomain is issued,I , ";v' ..
alien not emery any per...a n any mama .a m become subject to die worker, ,
Co pe i Law,of Calif in Data
Applicant
NOfICETOAPPIICANT',U.-aftU.-affor makingth' CerifieceofP 'pt' y h Id
Z becomesubjecit.theW k Compensation priu'sto (if the Labor Code,you trust:
C forthwith comply with such provisions milas perntsholl bcdcapasl revoked.' [� - I�, ,/- u•
7. 7
F^ :0� CONSTRUCTION IENDINGAGENCY
a I n.by dI rm that them construction 1 nd11g agency forth pe for n J ,
W of
kf, h''h fts�prorrir i,'Sanod(Sc 3097.Us.C,) u, , - •!,
Lend .Name
Lc Address 1
w0 F[)a 'cum t I greeto c-um'ply II III n city
did county,nd mon tieb onate laws feeling
rob Bring
r t t o and hehY authorize representativesf
-
this IY I t p ` .. [/'••�(�/,/{],�/y/ .
,x [� the ab ve tier d
(w) 6 I save,
E. � d fy and keep haninloSS the City tCpt gait - »
i..rZ iahiCty ] I6 t t i p h h Y'nary ) tie ag.i nst auJ
V Cly au.'uwce of Ih runt ng of Oi s p t -
APPLICANTU A SAND WILL JOMPLY WRHALL NO POI
SOURCE RP s _-Issued by: p• »
signemrcn _ppucawcnn
to
- - - Da Re-roofs
IIAZA DOI1S MATERIALS DISCLOSURE
: wud,eappleam n b tie g w Lt rhandleh,iroadmis material ". Type of Roof�
a,dideednymeColNu Municipal code,Chapter 9.12,and dre Heald,and Safety t r' a•°
Code,Seeman 25532a1 - - - - •r . - '• .
°Y . r , ' n All roofs-sfiall be inspected prior to any roofi
ng'ma teria]•being installed:
Will the apgi I it-r t n Id gnmmmpa�t n.e rgtrl me I ie awn n' If a roof is installed without first obtainingan ins ection;I agree to remove '
enol h J s a cot ms as refund b)the Bol Arc n A'-Quality Manage ent : P g
ra.deta all new materials for inspection. Applicant understands and will comply with
°Yea ,! '�it r, - tall non-point source regulations. - -
I ha e read theN mat uff 1 c nu undo Chapter 6J5 1 the { °
California Hoedds&SkftyC leg t s2550525533 d25534I and...d lthr, f,
fmclairldiri,dra,,reamurrenti,h audiant, hatt :myrel bi lity to notifylh _
Oman' I T h L wh eh et he t l or i f con Owl¢ r '1 - S
ce p n u " ,
„'Signature of Apphca It Date.
own n anmmi+. agent ..•AIL roof coyerings'to be Class "B" or.better
- 'r OFFICE - , r.-