01090072 (2)CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
IIUILDINO ADDNIi55.
-
I'ERh11'I'NO,
OWNIiN'S NAME:
APPLICAI]ON SUR DATE
PHONE.
SANITARY NO. CONTROL NO.
iv9
ARCHITECT/ENGINEER:
i. INFO]
RUILDIHGIlL
BLDG ELECT' I'IIM- H 1[CII
LICENSED CON FRAC'JOR'S DECLARATION
Job Description
Thal I ant lacnanl erprnvi'" "'d Chaffer 9(commencing
I hereby affirm und
wish Section7000)of Division 3 of the Businessand Professions Ctak,and my license
to full li,rce unJ tll�d.
License Clans Lie.N
n
Date S OTCLm
ANCh ll be u e UECLAic I ION
mcom
1 understand my Plans shall M nscA az public rtn,Na
,
/ O
ON
OatREon
VVV
exc1.DER n the Conlr clo Licence Law for the
1 herchy al' that loon um,pn I'nmt the Contras
i Co Any city orcounty
reason.(Section ]U3str Hmftcrsand
improve. or
which requires construct, +her, improve
which re or repair any tateme
h lNorvh,
n tie l....o
Pitttoa.,i.... t
nsederl,nreymro, meapionso lir Corperms a,EIea Law(xclisert
that heps'o,wdpSectio to the pm.,dana.l
Sq. FL Floor Area
Valua$t+O
ocnmmmnrsuctn.ela.War, Code)
(a is with of Division 3 of the and Coital
/50O
legedans
ion. Any vi
or Sect he In exempt mtrcfrom and the Nasi, for the alleged exemption. Any violation
t therefrom
or that he om a
of Section 7831.5 M any.pplicam I'nr u pcnnit suhj«u Sec applicant too civil penalty
P3NNumber
Occupancy Type
firlot more than findlot ]red danars(550x).
7
/
me will wages as d,drsnlc mmtiona"on.
J
❑ Las evnernf properly.onny cmployces
will do the murk and the amctum is not intended or offered for .sale (Sec. 7(144.
Required Inspections
Brame., and reare,bor, Coderrne Co.,,., n Lmcow Law deco am apply in an
r of pr'pery Who folks or Impro4es thereon, and who Aces such work himself
orfiredthrough his own ho
bundtd that such improvements an not intended or
sold within nae or
nalproving
hmbodde
eveees. ,
ormretl Ibr vie. IL year
rise l leive t fir burden
Ilh nceb d fp B@tis J'J not build or
c,nplt II "M1 of n
e.
improveI p try: f I )
'
as owner f theproryn5 exclusively contractingwith ficereted contractors 11,
C t urs
n Leis p jeer (S ]told N. a d 1 f C,., improve,
leer: I I tel ISt . ufp pent 'h hlJ' p tendon
�
and who umtmet for such projects with a wnmdorts) licensed pursuant to the
91
Contractor's Liccnxe law.
116 P C for this reason
/
rD tun, venya ntNer Sec .
weer �� 9(��r'
as W'ONALR'S CO, PENSATION DE 'IAN L(.
(A
henhy a1En l under Penalty of perjury one of the following declarations:
1II
❑ 1 have unit will maintain it C>rilicntc of Consent to self inwro for Worker's
I Comdivination, as pro. idol for by Section 370) of the Labor Craft, for the
performance of the sod, for which this permit La issued.
❑ 1 have and will maintain Woder's Con,pen.mtenn Inwmnce, in, required by Section
370Cl fir the lahnr Cnde, fnr the ped,mnutnc of the work rat which this permit is
,sued. My Workers Cn licnsarion In,umnce carrier and Policy number um:
Carrico Policy Na:
'
CERTIFICATION OF EXEM1910N FROM WORKERS'
COMPIiNSAI ION INSURANCE
(Ther .section need not be complered if the p[nnit is for one hundred dollars
(SIIXA fir he"')
I acoify that in the perlbnawntt of the work liar which this permit In issued. I
shall not employ any per-in in any manner m as to become subject to the Woollens'
Cnmpeonadon laws of California. plate
Applicant
NO[ ICE TO API'LICANT. If, after making this Celt fleets of Exemption, you should
become subject to the Worker's Co ldicemdan pnrvl"i m' fir list Lahnr Cn le. you must
fnnhwhh comply with such provisions or this permit shall he deemed revoked.
.
CONS 'FRUCIION LIN OINO AUI!NCY
I hereby uRrm than there is a cnmwction lending agency for the performance
of the work for which the, pc.air is issued (Sec. 3197. Civ, C.)
Lender's Name
'
Lender's Address
1 certify that I hate read this application and state that the above information is
omen. I agree to comply with all city and county ordpmnee%and %tare laws relating
1 rebuilding mnnuuwiou.nod hereby authonearapmcentativeanf this citym emerumen
I the ohnvc.mcmioned prnpcny for inspection purposes.
(We) a,. in save, indemnify and keel bamtlexn Sec Ciry of Cupertino agnnd
l liabilhis, judgments, adv and espenws whmh only In any wary acerae ageemt said
City in consequence of the granting of this permit.
' NDIRPOINT'
Date
SOURCEREULATI�ADt)r',C(lMl'LY\"I'HAL1,N0
SOUNCE NIU
—
1signaturenrnnpraaat/
ISSIICdby:
D'
Re-roofs
HA1A15 DISCLOS URC
Win l,e applienal fir mtare Intddmg nevulwat %tart m let Ile I,amrdmt„naurnal
'type of Roof
ata ddincd by the Cupclion Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 255321.17
ores V,
All roofs shall be inspected prior to any Fooling material being installed.
Will the .pplecantar home building oamanluse eveimnate,de.iro which
If a roof is installed without first obtaining an inspection, I agree to remove
unit haeanlnu%asr en at dran,as delined bythe If., Arta Air Quality Management
])iatrict,!`
all new materials for inspection. Applicant understands and will comply with
6
Yea p(N1
`
all non-point source regulations.
have mad. the h.umaterials requirements under Chapter (1.95 of the
fJous
California l lculth R Safety Code, Sections 25505, 2553 and 25534. 1 understand mat
if the huilding does not currently have. repair, that it is my responsibility to notify rbc
'we” mit aof the myuircmenu which Brost he nod por ono isxuuncc of u Certihcam of
°'vaf'o y _
-'� (a'L�� �—
Signature of Applicant Date
All roof coverings to be Class "B” or better
nwnm m t r„en agent
OFFICE