00060193 (2) ='CITV.OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
.a LDINO ADDRESS; PERMIT No
199:75 PRICE Allr
OWNER'S NAME: OD /MVV A APPLICAI'lON,1 A
.ZONE: POGHYLSK! T449MP9 T AMP 14 !TO SH SANIIAIiY NU, Cr0 Il, ).
1 '
G s 2 ARCHI'rECTXNGINEER: BUILDING PERMIT INFO
Iv00 HI.DG ELECT PLUMB MECH
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LICENSEDCONTRACIOR'SDECLARATION Job Description
_C 1 hereby affirm tM1m I a,n licensed under provixinns nl Chapter9(commencing
F=Cup with Sacrinn](XX))uf UivisionJolthc Busirmsx and Pndfssions CoJ<.and mylicen.c
`4".a is in lid( lass and ellict. __
z a
License Class Lic,p SG
o � Dwf ,.omfaerI" I CONVERSION/SHAKE TO 40 YR COMP, PRESID
w 3 u y ARCIIITEC'I"S UIiCLARA O.
" g I anJemm�a my Nans anau b<a.fd rs pabhe mfoma
w6pyLicensed Pf I
%% th,I a asea DI It..I CLARXI Coun,IOY
6 W=LL ng son. d 170 pelt thee l' I . L I r lhe
t=m
following (S ri ]III 15 Business J P . r. C xt e y ly mnq
S S C which y p 'It construct. II i J m :h p' Y.t cturc
3 priono ns rawvwc,also mywms the appl,cam for such permit m file a srgrrcJ zmtemem
Nathe is licensed pursuant to the pmvisionsoftne ComraHols License Law(Chapter 9 Sq, Ft. Floor Area Valuation
(cimm he,is cwith Section om and the ha;is er:the a If ged ex iaJ Professions Codel
or,hot LCix cxe,npl,hamtrnm and Ilia bash for Ilia alleged cxmnprinn.Any violudmr
of Section 7031.5 by any applicant for a Acme subjects(he applicantm v civil penally -
ofnotmorcthan five hundred demrs(S50f). APN Number Occup' e
❑h as owner of the peope'ay,or my employees with wages ns thclr sole compensa;on. '
will do the work,and the xl actare is nor intended or nlrercJ for rule(Sec.7194.
Husiueas and ProtaWf l s Crxle:TM1e Cunu'ncmr's License Law Jun nut apply ur an Olred Inspections
r of prulreny Who huildr or Improves,bacon,and who div.'s such work hlnmch
or(trough his own employees.provided that such improvements are nut intended or
offered for sale.If.hawamr,the building or impm emem is sold within tete rear of 305 — FRAME
iimpletion.the owner-builder will have the burden of proving that he did not build or
mprove for wr,swe of sale.). 307 — INSULATION
❑ ,miwnmiftnnprepany,amexalmmelyc,rmraamrgwithfanaedcomrecmrsm 6101 — ROOF TEAR OFF
Lm,I.O,he projecl(see.7044.B.,nexx aad Prnrnsn�,,.elrllf:yrnf Colmacler a 602 — ROOF PLYWOOD NAIL
icense Law docs vol apply m an owner of pmpny who builds or improves thereon.
cad who contracts for such payects with a cormcdar(s)licensed pursuant to the 603 — ROOF BATTENS
Constraint's License Law.
❑tum cramp,under Sce. .B&P C(...this masno 604 — ROOF IN—PROGRESS
Owner Data
WORKER'S COMIIHN.SA'IION DHCLARA'l ION
I hereby aff an under Anally of perjury one if the following declamtians:
❑ I have and will a aimain a Cettiliam of Consent m eft-in.,.re fur Wnrkarx
Cnnymnsaua,. as pmvldM for by Semon 3700 ur the Labor Code, for 'he -
peflbr nascent the work Ibr which the pernth is i...ad,
❑1 have and w;11 arainmin Worker's Compensation Insurance,as required by Section
370()of the Labor Crile,for the perfnnnance of the work for which this permit is
issued.M1 ''�\/)'york}a,'s Cnmpenxami�n/'�ylnxurunce cagier unJpl'orlicY number v^7
Cnrricry�QLI!✓1—I'uliry No: j" 00 LQ��
CERTTIPIC 'ZION UPI\ILMIIIION FRONT WORKERS'
COMPENSATION INSURANCE
(This section need not be co ni lend if the pr nn is far one hundred dollars
IS IIK)or less.)
1 certify Ihst In the perfmamnew or the work for whlcli,Iris p,,,I is Issued.1
shall Dol employ any penile in any manner so as pr Mann subject to the Workers'
Compensation has of Culifnmia.Dare
Applicant
NOTICIi TO APPLICANT.If.after making this Ccaificam of Esemptien,you should
became subjectIi Ne W akeh Cnmpca,cliin l,h
pr,o.oanx ac I.ahnr CM,you maw
Q O f... , II comely wpb such p.....nna of Ihix Iremril Shull be deemed Invoked. -
to CONSfR CTFION LENDING AGENCY
1 hereby affnn that there is a consstuctioP lending agency far The,perfrcmaace
W
film work fm which This peril(is issued(Sec.3097.Civ.C.)
S Q Lender's Name
.7. z Lcnder'n Addrfsn
U Q Imraythat l have real this application and.state that the above information is
4. (.. cmrcet.1 agree to comply with all city and county ordinances and Stam laws rearing
Q U w building ennstcrion.and hereby amhariu representatives of this city m+enter upon
tm
he ohnvcmentioned pmpeny for inspection purposes.
t: cem 4 (Wclagrsave;ndannabyrad keep harndexs t he City of Cnpfnino agairol
F.I Vi b ibilita".judg,n all,"I'll and expenses which Itiny in;Dry way recraf,grunt said
U z City'llr cnmcyucncc of The grantinit this permit.
APPLICA NOP.RSTA SAND ILL COMPLY WITH ALL NON�POINT Issued by: Date
SOUR, — 'LATION
sibn:rtarf if APphea,wL'air; - Dmf Re-fool's
IIA%AHDOUS M, rnRl I,S ulscLos FIRT I
WType of Roof
ill the appx nnnfr;al llenn,nr(alum IwlAngSxcupwu stnrc i'handle hrm,dauyp '
as defined by the Cupertino Municipal Code,Chapmr 9.12,and the Health and Safely
Cash, ernes 2553200? 0 No
All roofs Shall be inspected prior to any roofing material being installed.
Will the appfellI or mma hllildmgofcapam use ellu;mncnlorden'Iefs wmeh If a roof is installed without first obtaining an inspection, I agree to remove
It,h:vardn ss Dir conmnlimmts re delinul b,,ba IF,Arnl Air Quality Management
all new materials for inspection Applicant understands and will comply with
4# Yes Cl No all Dol,-point source regulatio s.
1 have rem(the LvCode. materials s 5goirt.133 a under Chapter 6.95 nil the �J
it he II,,[Truth do&S;tley CnJe.ia,,; 25505,155A unJ 25534,Iay I,, di the,
arcahn'JJing dofx nu,nvmn,ly huvcu nn,,lh:n six my rcrpinnihillry,o di'd,
CYP01 rt[Itrll\Ir 'Ir rl bC mil pmlf Ill lxxaaaeu nl a Cr'nllealf V
PCs,
Signature of Applicant Date
ncrr,rnathofiafda of uati All roof coverings to be Class "B"or better
OFFICE