00090113 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS' PERMIT NO.
1 sWNbIR S NAMif: APPI-TCATION SUB DATE
PHONE: 10885 SWEET OATS ST SANrrARYNO.0009A1403NO,
jVd1 M"11700
Faze ARCNI'fECI'/red t"''l. SON MARY A TRUSTEE HLDG ELECr'fN PLUMB MITCH
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LICENSEDhat CONIRACnGR'S DECLARATION. Job Description
IO� Ili by a tl I I licensed u I f Cl Code,i r an unecense
s- Cw 'mScf 78011 fI) J fthBus d1 f.. . day license
¢y�; ' int Ill ' J1 t
rezre¢ Ice . CI. 4, Li M�rL
3 Date ce 1 'e E( AHCHI I FCr'S DLCLARA I zV
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O'� I coulcrond Iny plana shall h,wcd I.,puhhc m.onh
.H, Laea,edrmr...ioart SEM WOOD TO TILE 3
a,c e ae OWNER-BUIL UER DIiC41RAT1ON
t�i I herehy al inn ma I um ewn,pt fano the Contractor',L cen.c Law far IM1e .^
F-Z>• fallowing reason.(Seaton 7031.5.Boston,,and Profensionr Clyde:Any city ar muni,
F ow Huh oalretaint I I lter,improve.dernal ish, repair- any structure r
y> priorm t 1st yo fu Npl,l. II ch pemsiu 'g J.t neat
a. thae he is licensedTaranto t the Too,mines oftM1 Contractors, cloon Law(Chapter 9 Sy. FL Floor Area Valuation
(commencing w'th Secuon]01)(11 of])is,iim 3 of the lied teas and I ale,.xions Codes
or that he i.exempt therefrom and the basis,for the alleged exemption.Any violation
of Section 7031.5 by any applicant ter a permit,nbjxc,,the applicant to a dviI"cal'y
of oat Inure than five hundred dollars($500). APN Number Occupancy Type
01,as ownet of the property,or my employees with wage,as their sole corm enwtion.
,111 do the work,and the,lincture ,nal Intended nr off entl lit hale(Site.7w4• $14000
Hoduess and Profession,Cade The Contractor',License law docs not apply to an Required Inspections
wnor of property WI hand,or improve,Htereon,nod who doe such walk himself
or through his own employee,.p rvand tha such impmvanenta ro not intended ar
olfemd tar at,,If.howwal.the build nr ln,pmvemunt I,sold wietin"an yea of • .1 v
complcdon,the owncrbuildcr will have the burden of proving unit he did am build or 32651033. 00
nlpn,a rot pup,...c of cdc.l,
❑1,a,owatol i iexela,ivvlycoamaiogwith licensed mnoacmr,to 305 — FRAME
construct then tett(Sm.9f Wr
,Business and Professinax eale:)'ne Contractor's
celve Luw into,not apply to tinowator propen,who bum,e,im,not thereon, 307 — INSLILATION
and who contracts for such projects with a enmmemts)Itemised pursuant u,the
Coamnar,unel„e Law. 601 — ROOF TEAR OFF
01 vm aemp,m,dcr Sec. .B&P C Bui this r,a.nn
602 — ROOF PLYWOOD NAIL
owace Dam
WONKr RS COMPI!NSATION D17CLARATION •603 — ROOF BATTENS
• IherebyaffirmanderpenahyofpnrjumtereonhemHawingdectamann.x: 604 — ROOF IN—PROGRESS
0 I have and will maiaam a Certificate of Consent I.>elf-inwre far Worker's
Compensation, as provided Iia by Section 3701) of the Labor Code, for the
performarec o(the work for which this pem,iu is issued.
0 I have and will maintain Worker's Compensation Insurance,as required by Section
5700 of Om Iaha GNe,Ior lie'I'd came of the work fo, bi,h this permit is
hued.My Worker',Compenwtion Insurance canter and Policy number arc:
CamanPaley Na:
C17RI IIICA'I'ION(sF ENEMPTION FROM WORKERS'
COMPENSAI ION INSURANCE
('This section need not he completed if the pconit is for are hundred dollars -
1$100)or le”)
I corny,mal in the performance of the work for which this permit is issued,I -
shall not employ any pcnnn in any Inanner an sIo hy,'.me whicct m Inc Worked
Col,ll,envntinn l.ay fC.tlifotnia.Date_ �V
Applicant_!<[L,_
NDTICIi TO nP L A i':I.a in this .e tifi..n of in<mption,ria mould
nen,me.ubject m Inn worker's Compcnsmion pmvlsiuro al the tactor Cndc.you must
Q Q forthwith comply with.such provisions or this Permit shall be deemed revoked
Z
CONSTRUCTION LENDING AGENCY
l herrebykfit,affirm Thal there iso issued ce. haulingugnncy far the perfimnencc
the wad ice which this pcnnit is issued(Sec.3(19],Civ.C.1
b Q Lender,Ndmc
,5 z benders Address
(.7 Q 1 cenify that I have read this application and state that the above information is
kL F. correct.I agree a,comply w;th all city and°nuray ordinun v,and dao law,hinting
Q U rebuilding construction.and hereby outhorim representatives of this city to enter urym
Cif] he above mrnunnnd property fol'In.pecdnn pamo,c,.
} pmt (We)agree to save.Indemnify and keep harmless the City ofCapcnin,against -
4 luculitics.judgn,enn,cosi.;,.at expcmc,x whin,Italy in any way accrue against said
U Z cityin CANT ND Rthe NDSA AND
permit Y
'" APPLICANT REGULATIONS.
Signature
WILL COMPLY WRl1 A1.1.NON-POINT Issued by: ` � DHIC CJ
SOURCE RCGULATIONS. —e
Signature of AppliessalConumctor Dam Re-roofs .
BAZARDOUS MA'I'rRIALS DISCLOSURE
Winthe aVplinaatarormrebondinganun
pa,t,,ama ,andleba:�rdue.,n,"dial Type of Roof '
a,donned by the Cupenina M1Blnicipal CnJe,ChaPmr 9.1 z.anA ube Heahh and Safety
Calc. ec25532(a)T
Ym p No
All roofs Shall be inspected prior to any fooling material being installed.
Will(lie applicant at future building occupant use equipment or dcviccs which If a roof is installed without first obtaining an inspection, 1 agree io remove
Distremitict? us air camaminantn a,delincJ by the Huy Arca Air Duality M"nngetnem
1th.. aI materials for inspection. Applicant understands and will comply with
Ove, 0Na I non- lint sour gulations.
I have real the hmanual eamriuls 1.,mo axns under Chapin,6,95.1 111c
Cnlifomia Health&Safcy Cede.Sc,ion,255f1A25531 and35534.1 understand that
if Ine hal zs nol,x,r y It amok lhln it is lily respan..Ini,y tonicity the
twcupam f the u cents which must he met prior it)issuance of a Certificate of Cyd —
OCeYn°" Signature of Applicant Date
Ownnra mhoriaJa . Ali roof coverings to be Class 'B•• or better
OFFICE