00100091 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
nun.DlNG nnul; .tis`103 GTOCKLMEIR CT ' GARY BEACH ''1iRA1°NO 00101T09]
OWNER'S NAME: - APPLICATION SIIII•Il�ra `/`,-S LI Ct
GARY BEACH 1 ¢@ 11 YYJJ
NONE: SANITARY NO. CONI go[.NO.
Mui ARCHITECUMNGINEER. - BUILDING PERMIT INFO
O OI- 1.11 ELECT PLUME NIECH
yi
LICENSED co.rrl<ncroR'surcl.nennory Job Descri ton
ZO L;0 1 licrehy:dlirm,hat I am liven>eJ under provisions of Choprer Y IaemmenNng
�_t J wanmsertion](ggrytnDixi,inn3onneuaxine,.andPrnl"xw,txenne.:,namyheen,e WINDOW REPLACEMENT
2 Y � Ixfit full forec tend etfect.
e S lavense Class Lica
AA O a u Date Cmneuctur
W 6"t- AIRll rl!CI"S DECLAIRATION
F O to 1 undersand my Plans shall be used us public c.w, -
T
w p p LimnseJ Yndcz Tonal
o of OOWNER-BUILDER DECLARATION
I ncrehy off nn IM1m I am ramp,fon the C...nowm,',Llcanxe haw Faille
following rca,un.(Seniors]031.5,Bwlneo mnf Pnden,ion,Code;Any city or county
z �
which ,nv mitt t aItn lrd I',h Py.t umc
in Poo , t also requires theapplicantf suchpt permit nsigned.rtmem
Llan he is licensed frateto he prov,,aneofm C I ,Lici 1 (ehider9 Sq. Ft. Floor Area ValUaV9000
(commencing wnh Section 71011)of Division 3 nl'the Buy nese and llravxs ons Code)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Seva a703L5 by any upplicuntfor a Permit snbjens theapplicma to a ui Ill penalty be
ofhot marethanfile hundred dollars(55aB. APN �V ll 044. QIQI Occupancy Type
0 L u,owner of the Property,or illy employees with wages a,their sole aanpen,odon.
will da the work,and the structure k not intended or offirm l for sale(Sec.7014, yrp]p�Htl qp rC�
Ian an
wderofunJl'nf Whonbuilldh orIintrhe ove%theruml.lccn,c Lie.,od who does sucoes h work lhimself 5J�.f] F11VI"ILred�$s—✓tUlll$.,
ohhis Y provided
�j 1 LNb
or through his own however
building
tom men improvement
neua wi stn oneuled or
ollcmd(or,ale.I[erave,the building ter imp n I`,aet r sold Wil@in true year of ,
mmpwe for the purpose
ofhaildia
sae.),will havc the bootee of Proving that be diA not build or -
impmxe for paryose or,teled. -
0 h as owner of(M1e po p,"y,am exclusively contacting with Iicciwe aomuaeory or
corolla,the project(Sec.7044,Bu,incs,and Profess.....Cede:)The Contaaw'h
License law doe,nm.PPly to i n owner el p,, y wI bulldx or impn,or,(hcmam,
nnJ who Wrens fnr such P i ccs with mmnorts)licensed Punuanl n+[lie /
Alam ee rSec._ B Cliu thin lemon � /
Oanincrecuri.
.me- a llifli
a 1 D 12611
WORKf CD"1PENSATION DEC( RAT )N
I herehy uRrm undo Pcnahy of perjury tine of the following Jeelmmimm: 0
1 have and sill n mintain a CeNfcan+of Consent m self-;omen Iia Worker's
us provided for by Section 3700 of the tabor Calc, for the
pednnnance of the work lin which this permit i,issued. ,
01 havc tend will muinmin Workea,C.... en,al Imumnce,as rcyulnH by Suction
3700 of the IaMa Cale,for the perforance affix walk far which this penal i,
:,seed My Wnder'n Cnngrenxminn Insurnnee cooler unA Policy number Ire.
Cnrricr: Policy Na.:
CERT ivbcxnON 017 EXEMIsTION FROM WORKERS'
COMPENSATION INSURANCE
ITM,wenon need not be completed if the Permit i,for one handled dollars
1$100)terIn".)
I certify m.a in the Penonnun a of the work for which this Penni,is issued.1
shall not employ any person in any almoner so un to become subject In,he WnrlwsF
Compenuution taws of California.(lac
Applicant -
NOoCE TO APPLICANT:IL murr nuking,his Ccnifieme of Exee'dow.you should
become r.uhjcc,m Inc Worker's Campennution powi,i... of the Labor Code,you mux,
Q O fonhwi,h rnreply with such pmviniemorthis permil,hall M1e dectnedo,voked. -
F ^ CONST RUCTION LENDING AGENCY
1 hereby union that then is a construction lending agency for the perfonnence
of the work for which his peon i,Isnucd(See.3097,Civ.C.)
fy Lcdcr's Nmnc
5 Z Lnadrrx ndarms
V C) I certify but I have read 1111,appfemion and state that the above information ix
fro E. cornea I agree u+comply with.all city and county ordinances and state laws relating
Q O mtbuilding corchaction.and hereby:mthnrirevepresemmlve,orthi,city w ruder cpm
re alwn-memaoned pmpnny Tar imxpeclien purposes.
F y (We)agree in save,indemnify and keep harmless the City of Cuplumno against
V] Ilubil i'en.' Igments,ansae add cF'a co""' may In'any wary oaerue aguin.a aniJ
V Z City ns yuence ill the gmmmg is permit. /f
^ Al LCA UNDERS'TANDSA l LCOMPLY ITHALLNON- DINT Issued by: QDate / 42 W
U .EI .GALA I S. IQ ' —
SiBnerrofnppoexm/ amtmcmr late Rerroofs
H RUOUS MA'IERLM.S DISCLOSURE
Will the applicant or t'aturn building excapenl%low or handle ha.adasmduial Type of Roof
as defined by the CUPenino Municipal Code,Cheprr,9.12.and the Health and Safely
Code,See.n 255320)? 0 No
All rool's shall be inspected prior to any tooling material being installed.
'I naoAid r.u,cif IIaaul it IOurc Notw rnng selopant ono eym;'vent or lie'Irl whnn If a root'is installed without first obtaining an inspection, I agree to remove
Di,
ed by the Buy Area Air Ouanry•Management
D,,,r;en all new materials for inspection. Applicant understands and w111 comply Win
all non-point Source regulations.
I have«ad the hamrdnu.v mzrcnah naps emcna under Charter 695 of fl e
California Health&Safety Code,SectiunQ5505,25533 and 25534.1 understand that
if the bu'ding Alma nal eurmndi aenlenanl,In 111 i,my rcxpumiMli,ymnuBty the
ace u m meyuiremernh wM1m a be and Prim n nuance of te ettinctiof
Cepa L3 L) Signature of Applicant Date
—mer+rteatnorirm agent ( Datr All roof coverings to be Class"B" or better -
OFFICE