00060164 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BU I LOING ADDRESS: rERN11'r NO.
OWNER'sNAV67@@ LA RODA DR APPLIC,11
PHUNE: BRIAN EDWARDS/CYNTHIA LI T SAN rrnuv
O ARCHITECHENGINFER: - BUILDING PRRNUI INFO
BLDG h:LECf PI_ILUMB AIECH
.�V I.ICEN'SIzDCON1'RACI I IR'S DECLARAIION Job Description
°z:p 1 hereby 41rm mal I am licensed under provisions mf Chapter J am,uoenunic _
F=Fa with Section 7")of Disisdn 3 office Business and Pmfesnion,Cd..and my licen+e
is in fill force mdel{{yy, B
c license Clus. V Luc,a��I
�(3ill LF Dale_ib,
2B;_ Contractor<•nn •+ o ,_ TERMITE REPAIR/ELECTRICAL UPGRADE
W
ARC It ECI"S IIF,CLARArlON
C ° undcraanl in,Plans.hull M1c and as puhuc nand,
i pz Licensed I'mfcs.ional
OWNI.11,es IpER DECLARATION
m o u 1 hereby,(Sect that 11. exempt Inn,the Comment's :Any'c Law for the -
t-= following massa(Section7onItr t,alter. and Pmliwrrolicode:Any chy menumy
ria p which set,miaapermit toconstruct,a alter,impmvc,denmlusl,ore a signny,hnnre
e. barhnslicermnaa,,.a, ,,lismevi,inaenl for permitEmile a.ignedammmcm s
thatnaticcensd Putman mlhe pmadm,snl coinnlrnnra Licenx law(ChapterCoe) q, I'l. OOr rice Valuation
or that he is a wilt f the mit)Iran d the bait n 3 ohne Ruslnca and inin Any v Code)
m dial he to cae,npt m.+eunm and the nnsi.Dori rob auegen exempann Any vimadon
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally
ser not more man rive han lred dollar.Mfg)) A m r Occupz e
0 I,a.Owner or the property.sr my employees with wage%as their sole compensation.
will do the work,and the amaure is nn,intended or offered for sale(Sec 7014,
Basic r,,and pmres,s,n,ns,('Ode:'Ihe,Coca teno,Li....c Law does,nor apply it,an ., @43.l�tQ�uired Inspections
owner of property Who builds or improves thereon,and who dons such work hi inch
or though his own employees,provided that such imprammucht am not intended or
offered for sale.B;however,the budding or impoorn cnt is.old within ane rearm @4 — ROUGH ELECTRICAL
completion.tire ownerrbuilder will have the burden of proving that he did not build nr v
ingovemrprpron ofsalc). 501 — FINAL ELECTRICAL ENERGY
01,axawnmmhepmlmny.sencxedusuvelyesmmillm,wisenormal CmlmecC,lo S@5' — FINAL ELECTRICAL
constmcl the project(Sec.7014.Business and Professions Cade:)The Contractor's
License Law dmua nua apply it,an owner of progeny who builds or improves thereon.
and who contract,for.vch prnFas with a ni lavonO) Vermeil putun it to the
Conoaaors License Law.
01 nm exempt anile,See. ,B le I'C for'his reawm
Owner Dae
WORKER'S COMPENSM[ON DECLARATION
I hercny,flim,a.&-,penalty oI pt mite al the lidlowing deelmara o
Cl I have and will muimuin n Ccnilicinc of Cu wrier m self-imam for Worker's
p - _
Comcn..lion. a, provided for by Section 371X1 of the Lubar Cale. Peri me
performatae ofthe work for which this permit is issued.
01 have wd all mainmin Worker',Compemanno In...ance,as reyulred by Schon s
37(k of the Luther Chile.for the performance of the work for which this permit is
wucd.My Worker',Cc ifenxatisn Inwtimevarier and I'ol icy mark,are:
camens$S/}TE ru N A Policy Nn.: 2i3s�o autT coo n72
CERTIFICNOON OF EXEMPTION IBONI WORKERS'.
COMPENSArIONINSUItANCU
(This,eci inn need not he completed if the permit is for one hundred dollar,
NI0O)or Ill,,.) '
I certify that in the performance of the work for which this permit is issued.1
,hill noI....ploy uny per.mn in any nwi act e'..o, ,,sit.subject In he Wo ke.%'
Compensation Laws of California.Date
Applicant
NOFIC17'1'0 APPLICANT:If,dlcr making this Cortical,of Exemption,you should
balance object m Inc Work,,,Campcn,atlon p....Won,0 do,Labor Code,you mol
Q O kohlovith comply wit web pruvuauons or this p.it lball be deemed revoked..
z
(•' CONthem is cone,ION LENDING AGENCY
FL 7 the for which this thereins csnswait, Ieruld6agency fnnM perfi,hancc
attic work for which Ihie Imrmit is issued(Set,3097,Civ.C.)
L Q Lender',Nmoc
� Z Leader AJJtnn .
U C -I codify ihet I have Iced this n,liculio i and some that the Dhow inl [inun la
[si [.. rea.I again m comply with.11 city and empty cadmiu c,and anile laws at
Q U wo building construction,and hereby anchorite apm%enmtivev ofthis city wo cater upon '
'y Wthe unovomcnlloncd pmpcny rot aNscl i purpmcx.
[... a. (We)agreeit,save,indenmidy and keep hannlros the City of Cupeninn agoinsl
W lilibilitit judgment,coax and expenses which may in any way acerae against said
U z City in ci neyue f me prune chit.
APPLICANT D STAN,, A_,"'N" L C MP Y WITH ALL NON-POINT _ r 3��
SODRCER uL olds.(' _ o Issued by: Date
Mgnnurc t�d App .pnVG,ri-eraser — D:ne Re-roofs O
IIA]ARDOUS MATIiNIALS N:CLf)SURE
Will the applicant or Inure building Occupant mre or handle Battalions material Type of Roof
as dernd by the Cupertino Mtmicipid Code,chapter 9.12,and the I Icdlh unit safety
Code.Section 255326a)^
0ye, /0 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfuture l,wildingaccupamuse equipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazandows air contumn¢
iwas defined by the Bay Ama Air Quality Management
Emmet all new materials for inspection. Applicant understands and will comply with
[Iver, _591n all non-point source regulations.
I lime read the kv:Wnu,materualx muniren,ents under Chapter 695 of the
California Ilcallh Fs Safe,,Code,Seaiom 255115,25533 and 25534.1 undcwland that
it the building daps nut contently have a mount,that it is my,eeptm.thilly ur notify the
ixeupant niltheft-Doren, is/�yMIryy/4ne't hev a,Pro ui i,. emit,of a CerjmG elm of
Occupancy'
Try b-Z3`o0 Signature of Applicant Date
Ots or aw ri rig, r Dam roof coverings to be Class `B"or better