00090150 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
RUILDING ADDRIisiS: I• IV,111 NO. 60-6p O/,5-0�XTCRJo2 �
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APPLICATION NAN1882KIM ST 7- Smir� 4vim 00 150
PUONEse � 9SSANIfARYNo .
0LERNERROBGrRT T c1� }
O aez ARCHITEC'DENGINEER: - RIJUXING NIRA411 NFO
hoc . 1 08 — .3S8-1233 D ELIiCI' PLUME CH
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S LICENSED CONTRACfOR'S DECLARATION Job Description
0. u n Ih'rebvlifmm mal l am licensed under prmi.ion:of Chaper9 leonmmneing
OJ zn w with Seninn 71(X1 of Disision 3ofthe liwine"anEl•rdcuions Cole.1 dub lie
I 'm bell lircn:nd effect
Y case
��z< Lieen.ec,xy_ /`G3_9 Lie.»
Som" nate_ /-'ti—•S/b comraaor_ K Rtoai
��a, ANCIIITECI'S DECLARAI'IO SOaorioeu Woo. SHAKE TO CELOTEX PRESIDENTIAL I//DYQ)
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I I understand my plans nh;dl hu used m public rc nl
atS O LL LiccmN Prom.sinnal
OWNER-BUILDER DECI.A :TION
I hereby allinn 111:11 1 a rapt li'oen aara,aa' Liam,Low for the
fZQ fnllnwin,mumn.(Section 7131!5 eRunincs unJ mm,sions Coln:Anyehymcuuney
Ewhich require%a psunit to comma',,alter,improve,demolish,or regularly sy ommm
S — pratfalls c at y the f much 'Dt flea belt cement
it, that he I' i namI dueImon, ifll C I' , ACIale Law(Chapter 9
marl s Mill Se I' 70(11 fD + ,of he Basin.,,' ds t ,. sCode) Sq. Ft. Floor Area gValuyation —
m mat he is evempt therefrom and the basis for the alleged exemption.Any iolmion 7 p �Z
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally
Anor narethan live hundred dollms($5dd). APN Number Occupal�c �•
01,m owner of the propend,of my cmpLgecs with wages av dmi,vole eon+pe l,rumn. s��
will du the work,and the mracwre is nal intruded or offered fm sale(Si 7DIy
na,aaU+and Prom,i+mv Code ]be Ca;+lmaar.l.iaeme Law due,na,apply m atm3`'191 r�@?4. H iced Inspections
mr of properly Who build,or improves thereon,ail who doe:such work hlmwlf
through his own employes.provided Ina,such improvements arc not intended in
offered far role If lum'ever.the building a imprevemem is sold within one year of
nnnpledon.me ownothuimer will have the burvelofpraline mal he Aid amt wild 305 - FRAME
mprnvc for putpn,c ol'sale.). .
OLa,awmer Wlhc pmpery,vane.masivey comment,aim licensed eaalmaurm a, 307 — INSULATION
nsauet he nobler(See 7(144,Imo .and Prafex, rx Code:)*Me Contractor:. 601. - ROOF TEAR OFF
Liiuaa
ndc Law does ran apply ,un wneenl pm�ny will) im
builds or pmvev Inercnn,
and who cantmcls for much project,with a contractors)licensed pa mor to the 602 — ROOF PLYWOOD NAIL
Commcaw',License Law.
Cl I an,esmnp male,Seem .a K Pe mrmi-eamm 603 — ROOF BATTENS
owner Dm' 604 — ROOF IN—PROGRESS
WORKER'S COMPENSATION DECLARATION
1 hamby altwo under penalty otpnpo,ono of tial following deelarat loam',
3 I have and will maintain a Cenilinm of Concern m self-insure far Worker's
mper,ation, r. provided for by Section 3700 of the labor Code. for ,he /
Iw11 Hnnnnmu ot'ran work lin which Ihi,pcmmit is'osacd. 0
I have and will maintain Worker's Gmmpcnsmion In.uranee.as required by Section
3 X of the labor Code,for the performance of the work for which this permit is
imwaA.My Worker's Conpc vullnn munenm curler uad Pulµy number urc:
4MSR.I Cfi.(� /�07
carve - Paho,cyNa,Nr..: S�RADL3$ !_ /O
CERTIpICAT10N Of I?a E11PTION_FROM WORKERS'
COMPENSATION INSURANCE a
(This section need not be completed if the panni,is for one hundred dollen
IS 100)of lead
I ecnify than In the perfmmatne of the work lin which this rmil Is l,.tard.1
,hall not employ any wo im in any manner so us r+became subject to the Workers
Compensation law,of Culifornio.Dale
Applivarn
NOI'ICE'Ii)APPLICANT",IL aIle..nuking thin<irmlficen of lixcnrytian,yon shmdd
hccom'subject,o the WorAcr',Cnmpn,minn provisions of me LnAa Cole.You nmv
O 2 fordwieh comply with such provisions or this permit shall he teemed revoked.
r Z) CONS'IIIUCTION LENDINGAGENCY
1 hereby affirm that them in a construction lending agency for the performance
W of the wank for which this pmmit i,i.wmd(Sec.3097.Civ.C.)
L A Lander',Name
a Z Isndcr'.,Addasa
V 1 certify that 1 have teal this application and,tate that nm above information is
4. [.. correct.i agree to comply with all city and county ordinances and state laws relating
O [) to handling umm tia nd hereby nnthorim arm cntmrves of this any m eater ain't ..
the ahovcmcneancd propend fm ify and keep
hmrnec
E„ G
(We)agree m save,indemnify and keep humtlein the way rCamengainstino ai
VI Ilahllirics, d mix,cuss and expj//(nws C� iy,A�'�n It way accrue against said
Ciire t �naaf@e"' int/arI ,l/
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?A4A"
` UNDERSTA >S N LL NON-p INT Issued by: Date
I Apnlic;mtJc'a�nmTor II00 Re-roofs
MARPOUS MAITRIALS DISCLOSURE
l dee applicant of future budding occupant store or handle Incallo,material Type of Roofby the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Sccrion 255320)?
0 YP5 N° ' All roofs shall be inspected prior to any roofing material being installed.
. ltheapplicantort ire miming occupant use eyuipmemnrJevimmwhich If a roof is installed without first obtaining rot inspection, I agree to remove
emit hxeanlno.air...in nirmmsm deired by 0c illy At.Air Quality blanognnent
,Nma7 ig
ria1, for inspection. pplicam understands and will comply with
0Ye9 �n I have read nate hazardous nwecrlm.rnlolrenu•ms tender Chapter fi95 of the
Cvlilaniu I II;JIh h$utely Code.Scala m255o5,25533unJ25534. undelslnnJthi /l,if the bel decmnm corm ly ave t t, hill it is... ..parrotilily lonmify th `�accup of he require nal ch m m i..mnce of a C in 11; fOccOApplicant Dale
o>~ �naum—a„d as=r� uae All roof coverings to be Class`B'+ or better
OFFICE