00060018 (2) CITY OF CUPERTINO
, xun.m 2 ,otvtst ryERMIT CONTRACTOR INFORMA'T'ION:
BUILDING nDUNE55; o e�1 1A/N /`1,a PERMIT NO.
OWNFR'SNAME: (/J, 1 . 117
34 �gnlpl�,• AM APPLICATI
I'11ONE; / SANITARY NO. COVE ROI,NO.
n re0 ZOARCIIITIICT/ENGINEER: BUILDING 1'RRn11T INfO
x w_ BLDG EL1:Cr PLUMB MECH
I_--i L_I =j 1=1
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LICENSI[.CONTRACT'OR'S DECLARATION
5 I tion 7( tdrrn,mat[.at Ecem.eL under prow i,h,ns ore,Ccdca(e at,fi. w
TEAR OFF SHWPiL er'1 tom"' PLYWOOD, COMP
o,-%,Cz
Milli Section and)of Dlviainn3of the liaaincza mA i'mm,+ions Cods,and myliccnsc '
is in full knee and clomp
ce K 6 License Class Lie.q
o.u Dom Contractor
H ARCHI'I'ECI'S DFCLA1tATION [1
I understand my Plans shall be esus'as,antic mcnN, 7•
to-�r z /
i p O Licensed Profe,ounil /
e. o OWNER-BUILDER DECLARATION ^
u�Z a I heresy aRm,that 1 1,.cxempn'tern,he Cuniones C x Licenw Law fur he Imo•/1
ac%S Much
reason.(Section IDBI S,B,alter,mvl or,de toli it a, Anycoy m county \�
5 F o which its issuance,
v,cams requires
e aumuum.applier,cant
nt for such
hscrunit i or repair nay statement
65q hjalie incensed prlso sunt oche thehavtpiov al fur Contractors Licenseie a aw(ned iChanenl
footioeixncen+ithSetionmOEI)ofDiion.n3atth busine,ssandPaLawlcnaCtRa Sy. Fl. Floor Area t
(commencing with Section om and
Division J of ea business i,,,mJ PtnrAny v Cock)
or ism be is exempt therefrom a"m and the basis forme alleged nemOIL to Airy violation
of Section 703 1.5 iv troy hundred
am fora permit su„jects the npplleme o-,n civil Penalty .
or not more man hue nunerea dnna,a gsoB). Occupancy Type
01,as owner of the property.or in,emNoyees wins wages as mei,role cotnpenmdon.
will do the work,and the stmanre isnot intended or offered for sale(Sec.7feO.
Business sad PrNcs.aans code:The erotica'',Livenw Law docs a...apply to an etLlred Inspections
owner of prowny Who builds or improve%thereon,and who goes such work himself 307 — INSULATION
or,hmugb hi,own cmploy,r,,provided ohm welt im,rnvenmnh,ee nal,mended ser
Offered for wee.If,howeve,the building or improvement is sold wih in nor year of 601 — ROOF TEAR OFF
�,nple.lon,me ow,erbuildcr will have the burden af,raving than he did nut build nr
improve err purpose of sale.). 60._,�
- ROOF PLYWOOD NAIL
01.asu ne uldic,ropers'.an,cxltor,,ycounachn,wim licensed cm.amen...,o 603 - ROOF BATTENS
construct,he pmjeo(Scc.7041 Bosinew aad Profc„ions Cade)The Commaarx 604 — ROOF IN—PROGRESS
Lleunse I.uw does nu,apply loan owner of p,npcny who ballet or baa,ovcs,hacon,
and who ca tract.fur.such ,.ts with a rontmaorfs)licensed puncta.a the
a
Comms c 1t/)�Iy� M L13y❑lam m acro l µ, 1�{t.L: V 17&i'C list thin rt.rsnnOwner DataWORKER'S COMPENSATION DECLARATIONIheieM1 Binn under It f ne of the following declarations.ya pen° yo perjuryn y 0 1 have and will maintain u Cenificam of Consent m xalf-balm-lie Worker's Co,npcn+elon, us provided for by Section J7W of the Labor Coda, for me ���performance of Isework forwhich this permit is issued.01 naveand will moi noun Wader's Caa,penso,inn Isurance,m rcyuired by Srction
37M of the l.ano,Cade.far the performance of the work for which this permit is Issued.My Worker's Cmnlmnsetion Iwmnaa nvrier and Policy numberarc: _
Carrico Policy No,1
CHR'I'IPICAI ION OI'I:XEMPI'IQN FROM WORKERS'
COMPENSATION INSURANCE
rn,is section re,oil not be completed if the permit is for one hundred dollar,
($Iql)or I-,,.)
I certify than in,he perh,mence at the work for which this permit is issued,I
,hall not employ any Noun in tiny manner so its a become subject Ir the Workers'
Compensation Laws of California.Date
Applicunl
NOI'IC17 TO API'I.ICANr;If.°fur making this Cenilicme of Eserniumn•you should
seen,..subject m the Warkcr's Cmnpcn,ein l pro,Niom of tic Lou urCame.you must
C Q fonhwim comply with such provisions or this permit shall he dcerned revoked.
F ^ CONSTRUCTION I.ENDING AGENCY
CI 1 hereby affirm,hut there is a construction lending agency for the performance
of the work far which this peril is issued(Scc 5n)7,Civ.C.)
Q Lcuder'.c Name
7 z 1,ad,,'s Arid....
V I cvoil,that 1 herr o,ad mil application and state than the above information is
core t I agreeit, mpy with II c it,and county rujamances and ime law,cloning
[� mb' . , dh by authorize representatives fthis ry' ter upon �����/((11���//■L
tN6 tt
he M ti adpropeo,to,im,arcl iturI ” S 'I— V• T
F t' IK 1 g I a indemnify and k keep I the City fC peri oat against
z rahW
e I Pn,c+ h 1 > Y 'i is
V G Cito- a gm, g of Tho,conn.
^ APE r 1 ND WILL COMPLY IT I . ssuedby. Date
SOA
siga hCnnnnmtnr Dec Re-roofs
IIAZARWUS MATERIAIS DISCLOSURE '
Willln-a ppBaanno,mlum leudrl,o ,npann,lore,a handle haeallon.manorial Type of Roof
as defined by the Cupertino Municipal Code.Chapter 9.12.and ata Health and Soley
Cods. m 25512(°)^
OYes13 No
All roofs shall be inspected prior to any roofing material being installed.
Will the upph.,do,h art, l„�gnreuhamuse cyuipmemn,devie-.which If a roof is installed without first obtaining an inspection, I agree to remove
mit haaanlou.s air contaminants as defined by the Bay Arc°Air Quality Management
District' all new mit teri.ls for inspection. Applicant understands and will comply with
0 Yes 0 N all n -p nt S arc regal tions.
1 have read me hamrdaus mmcnid,',,boat,under Chapter 6.95 of me
Cnlili,rWtgEq
Cade.Buttons 25505.2350 unJ25JJ.1 undemm�d that
dtM hmc yhave tv'nont.mut itk my Vn 'h',by lis nntiryd
mcupanl hien m st be ern prior m.wane are
°OeYp°
gnature of Applicant Date
Owner or aumorited agent Date — All roof coverings to be Class •B” or better
OFFICE