00080211 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT No,
OWNER'S NAM.. -
W49110 -1 HN 1 HU AVE- APPLICA11aN 51&00$021. 1
[ONE: SANT rARY No 08/301s1P0IM
not ARCHI'I'EC'1'l1iNGINEER: BUILDING PERMIT INFO
O O_ III,IIG ELECT PLUMB MF.CH
5V
l-1 I_I I_I I"=1
co LICFNSLD CONTRACTON'S DIiCLAIIA'rIUN .lob Description
z- w I hmchy:dRol hunt an licensed ander o vivimu of chigac,9(,1 nam"im,
FFy xth Scnion](Nhlll of Dtvisinn3 nffhc Business and l'ndcssions Codc.andntyli,mov
is in tall torr,and effect.
z Lieenm Class Lie,it
x o i D: Contractor. HOUSE DEMOLITION
m LL'� 'ARCH]recrS DECLARA]'�]4�
he used as reeo� N.
zLLr,u av
a p'p [.¢nosed l'ndc>viourd
>i m LL OWNER-B' 'R DECLARATION
1 hereby affirm that 1 am es In so the Cmnructor's LieenseLaw for the
f—%< following reomn.(Section]031.5.B end Pmkssions Code:Anv city nr aunty
x p which requires a permit to construct,alter,improve,demolish.or repair any structure
aim prior to its iwtiance.aho requimsthe applicant for such penniuo file o signed statement
that he is licensed pursuant to me provisions of the Contractors License l-aw(Chapter 9 Sq. FL Floor Area Valuation
(emolument ng wan Section HXX11 of Division 3 or he Purine,,and I'mfe%sions Code)
or(hat he in exempt thcrcfmm and the basis for the it Cged cNeloption.Any viulution
of Section]1111.5 by any applicant I..a pendia subjects the applicant to it civil pemtlty _
(it ommain ntanfive handled dollars(SNXI. APN Number Occupagesk•m
❑I,as owner al f he Pnq,ntyo sty emplayce with wagux as than sole evnupcu
will It.,the work,and the araame is nal inmoded or opened lot vale(Sol 7(94.
11 c"and pn,rc"ion,Ca Ic*1 he Contmemrs 1"ionise I.aw doe.n apply a;a 3750904 6.R20ired Inspections
of aua,s ny Who hRdds or impm ec thereon,and who don Inch work himself
through Nx ova nnpluyces,Procne.mat such Intpmvmnens arm not.mended or
carne&for sues R:Imwecer•the building or improvement r sole wahid one year of
ca,nnpmdmn.me mune,-bwmer w;uha,�e me burden or proving tlnm he die no,build ter NO ASSIGNED INSPECTIONS
Z
np/r'}1�•arz purptxsc of soled. .
Plh as nw r of the pmpi am exclusively contracting with licensed contractors to
soma me project(Sec.7016.Business and Professions CA,:)The Contractor's
License Laxdoes not apply to an owner of propcny who builds or improve%thereon.
and who contract%for such prelims with a conmecto%) licensed pursuant It,the
01 maam'v Liccme Law. /
❑1umam',Lianon,&c. - .Bk1'Cfar this mason
owner nate ✓.A.
W'ORKER'S COMPENSATION DLCLARAI'ION \/
I hereby:stain under penalty of perjury one of the following decdraimne
J I have and will n moats a CmriBcoa of Consent ar scllinxmu lar Wo,laW,
Cntnpemotion, u% provided le, by Sent 39811 of the Lubar Code fm the
perlomwmcochework lisrsmelt thi%perantixi iced,
❑I have mrd will nmintain Worker's Cotnpemu,ion Insunmce,as restaffed by Section
37W nl Ilse l.tmar Coda for the amformorwe of the wad Ibr which tbi%permit is
:,seed,My Worker'v Compensation In%crance emner and Policy numhcr are: ,
Currier. Policy Nn.:
CERTIIBCA1ION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be complcted if the permit i%fair one hundred dollars
(5(00)no less.)
1 eem y It.,in the performance of the wok for which this permit is issued,1
shall not employ any person in any manner%o as to hecmne subject to the Workers
Co arwavation Luws of California.Date
Applicant
NOI'let:10 APPLICAN:If,afar making this Certificate of Esmap oro.you should
Ibvm at subject mpen
the Work,,',Cocafon provision,mf the Lubar Code.You oma
/Q 0 1 ou idt uontply with nuc11 provi%inns nr this a nel,hull he deencd revoked.
g? ^ CONS]RHC`iION LENDING AGENCY
11uroby _
a ' 1ul'Bnn than them it a umamnian lending uguncy fur tau pvrtormanee
W ul'Jm wok In which 11111 pastil is Awed(Soc.3097.Civ.C.)
S (] LcndeC,Naas
z L I.cndcrs AJdre,,
C.7 0 I verify find I have read this application and state than the above Information is
LL e. correct I ugrec,o comply with all city and county oNinanres and sate laws relating
U to M1uilding comtmction.and hereby authorize representatives of this city to cuter upon
the aNnvmentiored property for inspection part
F1 (We)agree to sore.indemnify and keep humdess the City of Cupmdro against
m liabilities,judg,rmms,cons and espemes which may in any way acerae aFaimt cad ^}
O Z, City in consequence of the granting of this permit. ) 6 6P
APXUCANTUNDERST NDS AND WILL COMPLY WITH LLNON.PoINT Issued by: Date
50 UTATI N
nano, Date Re-roofs .
IIAZA '.)16 MATER[A DISCLOSURE
Willntc:tpplica,anrfudcWading«cu store or handle hamdou.soatenal Type of Roof
ao ddhned by the Capcnmo rvwnirtpal Cate.Coup c,1).12.and the(Health and Safety
Cade,evi'n 25532(a)? o No
El Y1% All roofs shall be inspected prion to any roofing material being installed.
Will the applicat or t'aavu bonding occupant use aptipncnt ut devlas w'h'ich If a roof is installed without first obtaining an inspection, I agree to remove
sitnuuadru.sir cnnnuaino d,as defined by me Re,Ama Air Caulk,Manugcarnt
nodce - all new materials for inspection. Applicant understands and will comply with
ElYes CNo all non-point Source regulations.
I Loc read the hvardau.v....anal,rcquirctnems under Chapter 695 of the
California Hoalth M Safety Gde.Sections 25505.25533 and 25534.1 undersand tom
f fie building doe,not emnemty have a tenant.that it is my msgm,dd iI.m notify,he
ccupant of the mquimmems which must b,me, Certifeate of
Signature of Applicant Date
Owde or aammd.m eat Daae All roof coverings to be Class "B" or better
OFFICE