01020012 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRF"_SS: PERMI'n NO.
10409 JOHNSON � ,fir 01020012
OWNER'S NAME: APPLICATION SUB DATE
WILLIAMS ,3o WVAV vl 02/05/2001
PHONE.: SANITARY NO. COM KOI.NO.
MQ O ARCHITECT/IiNGIN'EHR: BUILDING l'CIi MIT INFO
si m❑ LD ELECT PLUMB MECH
G< NJ IJ
LICENSEDCONTRACTOR'S DECLARAHON Job DESGPI Ion
OO Z 4� hereby antro than I nor licoawcd under pnwlsiorx of Chanter m(cnnmleneing -
E nI.ka wishSection7q)(nniDivlxbn3ofbeBufincssum1Professaan,Code.andmylicanv i.fall fREROOF TAR AND GRAVEL
fame ad effect.
ffia License class Lic.a
3 w y Dam Convector
H O Q ARCHI'ITCI"S DECLARA'T'ION
1 unden and my plans shall be used as public it
w O O Licenced l'o,mssinnal
c a OWNER-BUILDER DECLARATION
1 hereby affirm That 1 am excntpl from the Contractor',Llccnm Law,for the
F L a following reason.(Section 7031.5.Business and Professions Chile Any city or county
`F O which requires a permit In convect,alter,improve,danolisR or repair any structure -
o, prior to nth
s issuance,also requires e npplirun liar sneh pcnnit nulileasipned stuten¢In
c. that be is hrvnxal,unl..hml n.,she nowlxionool0te Cnmmcmra.imoc Ltlw(Chapter n Sq. FL Floor Area valuat
(commencing with Section Von of Division 3 ol'the Km%irat and Prolevviom Code) V3 00
an that he is exempt therefrom and tire basis for the alleged exemption.Ane violation
of section 7031.5 by any applicant for it permit subjects the apdicam to a civil penalty
of n.I more than Eve mand ed dolma(sstxn. APN Number Occupancy Type
0 I,m owner of the pmpeny,or on,employees with.,is as Meir sour eal.npensation. 37518044. 00 *
will do the work,and the amachine is nm intended sur affcmd far sale flee.70bl.
Buxme%s and Pmm%x ion.Code:llne Commetnrx License Law dues not apply to an Required Inspections -
owner ofproperty Who build,(itan,nee,the rea...iIwhodoassuch work h1m"If 305 — FRAME
or through his own employees,provided that.such imprnvctientt are not intsmod or
oBeml for sale.B.however.the twilding or improvement is sold within one year of 307 — INSULATION
Impletion,the owner-builder will have the burden of proving that he did not build or
a u'rovefornamo.am.me.), 601 — ROOF TEAR OFF
13 1.asnxncrofthe pmpen,,amexeltowelycontracting with licensed contractors m 602 — ROOF PLYWOOD NAIL
e
mtmct the pnxjcct(See.704al.Business mal Tot ..e..... Code:)The Contractor's
i MeesLaw doe not apply it)an owner of property who mhild,or impn,ax thereon, 603 — ROOF BATTENS
cnd who contra 1,far ouch pr Jac s with a umo-ucnngy Iicunsod pnnuan,a,Ihe
mnrmclor's license Law'. 604 — ROOF IN—PROGRESS
❑1 am exempt under Sec. .II&P C for this maw.
Owner Date
.WORKER'S COMPENSATION DECI.ARAI ION
IMrehy afhnn under pewhy of pe jury one of the follow ingdeclarations: /� O
• O I hase and will n innoin u Cenifeum of Conscm ,,melf insum lit Worker's /
Ooopensaliun, os provided lar by Section 3700 of the Labor Coda for the
,it unnamce of the work lit which thin permit is isstnxt
01 have and will.nainlam Worker's Cit apensminn Imurama as required by Section
3710 of.he Lahor Code,to,Inc perlmmn:oeu of fire work h.r which Ihia Icrmit is
ipx
trod.My Wndcr's Con.pensation Insurance cmriar and Policy number arc r /t,I w7
Caribr: 7� G rTt�'v'!PnhcyNn.: SV� 'gra-flo
cpRTI PICA)ION OF hx FM"ION FROM WOR KERS
COM 11ENSA I ON INSURANCE ,
(Innis section need oat be completed if the permit is for one hundred dolmas
IS IpB or Icss.)
I cenily that in the perlltmuncc of the work liar which this permit is issued,I
shall not employ any person in any manner so as to become abject to the Woken'
Compematinn Laws of California.Date
APphc..I
NOI'IC1i"TO AI'PLICAN Iq It,attar uwking this'Certificate of Esanpta n,you should
Q Obecame subject to the Workers Cmv,.envuion pmvisinn.,of the Iain Code,you must
fanbwitb comply with such provisions or this pemhit,hal)be deemed revoked.
G —
re CONSem i,it
LENDING n AGENCY
a > hnohy Which this there is a oamd s ion Icndi ng agency for Inc perfannanec
,it work lit whieM1 this permit is IxsuN(See.31187.Ci,C.1
LC Lender's Nmnc
7 Lender:.,Address '
Iecoitymnt l hive real this ap.Titmitin:tm1"mom,the akom infamnaton is .
eormct.I agree to comply with all city and county onlinanees and slate laws relating
Q U to building ajoamejon,and hereby uuthndm representatives of this city to enter upon
{J:
the.b.wc-mcmllmred IF perry far inspection purpnm.
Fya (We)agreoit)aoe,.mmn,dfy and kceF bamncathe 01yof"Cuperflnl agninxl
N liabilities,judgnwnts,anus and-..µ.see which may in any way accrue against said
V Z City in consequence of the granting of this permit.
�o APPI.ICANT UNDERSTANDS AND WILL CO YWITH ALL NON-PO Yrs Issued bv: Date
"RCES( NCF. B_ILATIOryC �� Y'
LAN —L Z 0
ApplicanVCo tar late Re-roofs
HAZA DOUS MATERIALS DISCLOSURE;
w5n the appheam or,mom bmldoi,oxcupa>,am ar handle hauNoos mindd" -Type of Roof
n dem,cd by she C,npenino Municipal Code,Chapfe.9.14,and me IlcahM1 and SAity
Code.Section 25532(n)'f
OYcs 0 N . All roofs shall be inspected prior to any roofing material being installed.
Will the;111131 ml num nnIII ing nttap..m me cut.ipmam ar nevle°s x'h,ch If a roof is installed without first obtaining an inspection, I agree to remove
coil huxanlon,air cormonioum,m defined by the tiny Arca Air Quality Management
• District. all new materials for inspection. Applicant understands and will comply with
°Yes °Nth all non-point source regulations.
I has cad the by ml.. wmmnaw ode
ti:ds mi,e. , , .Cooper 6,45 nl 111, x
Culifionia lke llh&Suli tv CbdeL Sectiono25505,2 533 and 25S3J.I undunnuW than
if the building doxy nm csnen0y 6av :Infant.that in isoyrespmsihility"'hmify
occupant of the requimmmrim which ansa b en prior uh olocowc of a Comfiche of
Occ ncY.
AL
plicanl Date
Date All roof coverings to be Class "B" or better
OFFICE