00090137 (2) CITY f OFNCU;ERTINO CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT SO
OWNERS NAME:10284 ORANGE AV APPLICA'1'IONSUJLQ75}ji90137
PHONE. CONTROL NO.
SANITARY
RTLURI B RAND ET L SANITARY NO. 091/Q21/2000
�p-LO ARCIII'I'I'CIIIiNGIWiHR'. BUILDING I'ERMI'f INTO
u_ BLDG 171ACI I'LUMIt MECB
Naw CI
Z O m Z IJCIiNS171)CONTRACTORS Df:CLARATION - Job Description
O 2 m I hereby affirm that l am Imerued under poo mons of Chapter 9(commencing
with Section 7000)
of Divvoi 3 of In,BasincxanJ Pmfia,,inns Gde.aoJ my license
sdi is in full forte and effect.
at se Liceme Clan Lie.N-
3 LL O Dam Contractor
t-LL o t, necxlTEcr's nrcl.nan'rum DEMO OF SFDWL
j 1 undersmnd my,phos shall Ire used as public..No
25 25 Liccnacd Professional
OWNER-BUILDER DECLARRI'ION
u� ut I Wrehy affirm that 1 at exempt Imre the Cunvaaor'n License Law far the
I Z r following mown.IScction 7031.5.Bu.inas and Inds icons Codri Any ,,y or county '
x O which require,a permit us venxoum,after,impmvc,demolish,or mini,any dricurre
W
5°° pr'a't a :' Iso y th ppl v e l p llt l 'g Leat
lersent
Iluelt Ip noa tl Ihe t x III Co ra',1 I (Cheek) Si Ft. Floor Area Valuation
(conmmnumg wllh Section 7000)o1D,i,riot 3ol'I he lin .NI'rfil—on.Code)
,,
or Sul he is exempt therefrom and me banix Int the subject,
de, exemption .il l reminn
of Senio17031.5 nv unr,applicant fire permit x(tltjv'ela the applicant¢...ivil penally
a1 ran roam malt hie hundred danara(gslg). APN Number Occupan4y6 yp a
01.nsowneradmc propcny or my employeeswilh wages so.mch,olecompenemion. 3 �DrO
will do the work,and the araaure is not intended or offered for sale(Sec.76LL.
Business and 1'mfce,ime,Code:The Cnmracua's Licenw law doe.,nm apply 10 an 357]9@3]Re�6red Inspections
oves
matter of property Who builds or imprthereon,and who does such work himself
or mraugh his own employees,provided that such improvemcnu are our intended or
offered for sole.If,however,the huilJing or improvement is add within one year of
completion.the owner-builder will have the burden of proving that he did not Wild or NO ASSIGNED INSPECTIONS
impmvc for rmai c uLsalcJ.
)(1,as owner of the prapeny,am excle ively contracting with licensed com iI it,
u Ixtram the project(Sec,7044.From— at Pro lex.rolls Once.) The Contractors
License Law dwI tell apple to in,aware of prol arty vole)hulldx or improves thereon.
and who cmnrnrw be such projects elm it wnttmnorls) ho,cansed pursuant m The
Cmmncuds I:IrrnsI,Law.
❑I nm un/toJ,In uufn I Sec. .B N 1'C for his reason
Ou'ner�^ wWOdot '•S COAIPDate SeNsoxioN I(Ya 000
I hereby affirm under penalty of perjury,one of the following declarations. t
❑ 1 have and will maintain a Cemficaro of Consent RI oalf-insure for W'orker's
Con.ps ne.tfair as provided for by Saar 3710 of the labor Codefm the
sadvar marc of me work for which too penton is issued.
I
❑1 have:her will maintain Worker's Comvance of t ,work f a required by Section
voteof me Lxhm Code,for the pensurncec rr the work for which this permie i.
..wttL My Walker Compensation Insurance carrier and policy number are: -
Carries: Policy Na: -
CFRTH;iCA'1'ION OF EXEMPT ION FROM WORKERS'
COMI'EN'SA•I'ION INSURANCE ,
('Phis semina need not be counialmed if the permit is lin one hundred dollars
ISHg)or lic"T -
1 cenify that in the performance of the work bur which this permit is issued.I
shall not employ any person In any manner on as to become subject at the Workers'
Compensation laws of C,lifnmiu.Data
Applicant
NOTICE TO APPLICANT:If,aper making this Canificate of Exemption.you should
become subject to the Workcds Compensation provi.iom of the labor Code,you must
O O forthwith comply wise m<h proviunns or mis permit shall rte deemed mvokeJ.
r U) CONSTRUCTION LENDING AGENCY
a 71 hereby allimt thauhere is it econstruction lending agency for rhe performance
of the work for which this penair is issued(Sec,307,Civ.C.)
Tendo',Name .
r7 Z Imdur',Address
V O 1 certify drat I hate read this application and stale drat me above information i,.
Lr:, e,,.I agree to cnt ply with all city and county onlinanecs and erne Iawt relating
O U ser o
mh�ihh-onati need property
beri aumorim rep,asenmtivuud thl,city menmr upon ,
} 0. (hc nM(We) voompcnfnr insprdkeph...or.,
t„o S es judgme ro euvc indentndesperi vola hm may
in he Ci a yf Cartaus,against
against
W liabilities.sequence.v,cosec and i esofthi whirh may in any way acerae again.sail
f) Z AiPPLICA TUNDERSTANDS me granting D mis pe CO •� e{ /ss /t
SOURCE REGULATIONSAND WILL COMPLY WITH ALL NON-MINT Issued by: -� Date <� ^V V
Signature of AIdicontlCommttu, Dme Re-roofs
IIAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore Wading occupant stem or handle hazardous material Type of Roof
its JefmvJ by the Cupertino Municipal Code,Chapter 9,12.and the Health and Safety
Code,Section 25512(x)!
Cl Ya, I CNo All roofs shall be inspected prior to any roofing material being installed.
Will fire nIrlicamn,moan nrrddhlg nrcapam sea agaipaical or ch,,va=whirh If a roof is installed,without first obtaining an inspection, I agree to remove
ntit namxlons air soot o gourd,"definer by the Ila,Arca Air Q urlay Mann......(
Uialrim9 all new materials for inspection. Applicant understands and will comply with
❑Ya 0 N all non-point source regulations.
I have read the hazardous materials mquinforcr is under Chapter 6.95 or rhe
California Haohh k Safety Code Sections 25505.25533 and 25534.1 9ndenm d that
if me huilJing docs nm currently have attained,mat it Me,responsibility to notify the
(occupant of the requirements which muse be met prior at issuance of a Conmficme of
OccepancYR Signature of Applicant Date
Owner or authorized agent Data- All roof coverings to be Class "B•• or better
OFFICE