00080190 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BU ILD INC,ADDR ILSs: PHRMI r N(1.
OWNIIR'SNAMI:. `a VIRBINIA SWAN PE NEW ABE ROOFINGAI'I'LICA'I'IUNS +
1'HONF.: 1512 SANITARY NO. I'—R m11t
O ce z ARC[I ITECI'/CNG]NEER: it 400) r t—3503 BUILDING PERMIT INFO
O BLOC ELECT PLUMB M1IECH
r¢y
LICENSI'.Dt7DNTRAGrOR'SDEGLARATION Job Description
horoM1y a(tinn that 1 um licensed under provisions nl Chapmr 1 feonnuenemg P
Fy_� with Sea ion]I x
r,in lull anen,
Division3ofthe Business vnJ Pndessions Cade,and my rimose y forte and c
c ¢ License _ Lie M J J
. ea. Dale- o+mmam REMOVE TILE ROOF, RESHEETS FELT AND BC
a .r ARCIi I'I'IiCrS DECLARATION q
t- underslar Illyplans.hall heused aspannered INSTALL NEW LITE WEIGHT #46
pI.iccnsed Professimnu
aW�
caOWNIiN-NUILDER DECLARATION
lar 'm I ncrnby IJBr n B+m I um avcmpl o-mill he CI I...ir's License Law I the D
C < following reason.(Section'Jlli LS.13usi and Prefer ,s CAA:Any 61,o only
—z p which realities a Permit w m...I,.dter.oimprom
vc.demolish,or repair any sauctu
ai; prior to its issuance,also requires the applicant lar such pem+inn file a signed statement
ds—
that he I,licensed ausureat to the voristans of the Contractors Licensts Law(Chapter 9 Sq. Ft. Floor Area Valuation
(cemn lancing with Section 9000)of Dmi,ion 3 A the I{usim,o and Pmrnslonv Code)
or that It,is exempt therefrom and Its basis for the alleged cxampuan.Any violation
of Sodion 7031.5 by any applicant Ihr a pencil subjects the upplicmd to a civil penalty
of net mom mad fit.hundred dollars(5500p, A PN Number Occupancy Type
❑Lassunt roftieor myemployct whhis tt
o awm
irsale .upensmior+, $14500
4.
will d,,the work, .,it the ask, [re C at,,tr immalW a oil cod for salt apply
1..,1
Bul.in of and edy Whons ildc me Canlmhods Orono it d ones nm apply m ell+ Reqquired Inspections
nrr ofhis ow Who build,or improve,at such,and who docs such wank himself or 31.646009. 0lI -
through fon. 1,employees.p din that such vow 'm r fintended nr
offered r :'I if — theIl Dol Il l is. n e di n year or
c n11 t Ih r-h II 'lll'vcth 1 fp :nye din, J I InnilJ r'
i.,'+pn f ....... rinsider 305 — FRAME
01 owner the ppenal' exclusively contracting _thlt sedenlalrsto 307 — INSULATION
Lsmr th l i t IS 71113 B d Professions Colic)rheC f ms's
ve 1' e apply to o11nolteny who n 1p or Improve%thereon, 601 — ROOF TEAR OFF
ul whr contracts Ir r such projects with, u t acorns) ecoid a....on m the
cammcmrs umne lrx.. 602 — ROOF PLYWOOD NAIL
0lamtsemptunder Set. HkPCfar his leasan 60. — ROOF BATTENS
Owner
WORKER'S COMPS SAFION DECI.nRnnON 604 —' ROOF IN—PROGRESS
1 hemby affirm under Penally of penury one of the Ii+llowing declarations.
I have and will maintain a Certificate of Consent h+set t-imore fm N'a,er'.
Cmmpcnnntion, ns provided liar by Sell 3700 of the Labor CnJ, for the '
pm) n ,etc nr me work for iwhich this Ieradl is issued -
rhart end will nmimain Workers Compensation Insurance,as required by Section 7 1 of the IaMrt Gd<.for the perfonnunm of the work for which this permit is
roue,.MY W,Jnr�kvr's Cnmp{en's'mion ucnrte cvrriIt and folic,namher are:
Cunler�/!
CERI IFICATION Or HXEMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
(This z,6 aced not he,completed it Iho permit i,for One hand rt.I dollars
1511X11 or less.)
1 venify that in the performance of the work for which this permit is issued.I
shall nm employ any Person in any manner? subj(ct to the Workeri
cmmrtn.:rdnn 1. £ah1i+////�7ma ,6 .
nppllta r4` cn / .
NQI'IC to he W i , king this om.. idd Exemption,you should
hconm subject to he Worker.Compensation provisions of Inc LeMa Cale,you must
Q O fonhwifh comply with such provisions or this lnnnit shall he sMcmed revoked.
F CONS'I'RIJCTION IJ?NOING AGENCY
C > 1 reach,anhrm fit,mere Is a cammmfinn lending agency I'or,the Ismm
J'nnne
W of the work far which this permit is issue,(.tics..3010.Civ.C.)
6. Q Lender's N.mt
7 Z Leader's Address
U Q 1 certify than I talc rend oris aPd1cetio1,I Iowan than the above uflk lion Is
La. F. correct. ugrtc In emnply with all<ty and a.,a.(,ordinances and sine laws'mming -
Q U to building construction.and l+erchy enthorim mpre,scaske,afthis city..+enter upon
rrW the uMwe-mentioned propene for Inspection purposes.
pot (We)agmc Ia save,indr nnify.,ad keep harmless the City of Cupenim,agaimt '
V] filtulitius.j udga.an,,mots and expenses which miry in any way accrual aguino mid
U 7., CII,in eonsequcnec or the gmining of this permit.
APPLICANTU ERSTANDSAND ILL COMPLY WITH AI. NONyOINT Issued by: Date , ^U
SOURCE REGI �y5. �Qa ���
Signnm cnrnpplicnntJC mann D.Jl Re-roofs
IIAZARDOUS MA71i1DAI,S DISCLOSURE
Will the appheont or fmure building occupant smrc nr handle acurammans material Type of Root' -
m JchneJ by the Cupcnido Mm ici al CsJc,Cnup¢r 9.12,unJ rot f{mlfh and Safety
Cale.Section 25532fa)p
0Ye.s . Nn All roofs shall be inspected prior to any rooting material being installed.
W+1l the apphcam or furan building ateapmn meealaipmemt or ill,ill,which If a roof is installed without first obtaining an inspection, 1 agree to remove
it hamrdom air contaminants us defined by the Bay At ear Air Quality Management
DoDrina? all new materials for inspection. Applicant understands and will comply with
OYes N.
emall non-point Source regulations.
I have read the harartlnu,Inawduls 11(1 thcmcna under Chytcr 6,95 of the
Celifomin Health A Safety Code.Sections 25505,25533 and 25531 I understand that
if the banding Joon not currently have a term.that it is my responsibility to notify the
cups I of fiber
lie t,which am M me prior m i%s ane f a Cenifeme of o
°e`'I'I'antr Signature of Applicant Date
n/oto tryst' a� mag Do
�eraramnad,.ca: a� r to All roof coverings to be Class "B" or better
OFFICE