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00093306 (2) CITY OF CUPERTINO PERMITNO. BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: BUILDING ADDRESS: a 1 Ill SANITARYNO. APPLICATION SUBMITTAL DATE ER; " E" 1078 OWBROOK Y MAX BROWN CONST c 40 "HONG:' I 702 S DANIEL WY 09/14/2000 AR ECI'/ENGINEER BULDING PERMIT INFO x 300 (408)260-1260 �d F• i LICENSED CONIBACfOR'S DECLARATION Job Description O N— I hereby anthem mal 1 ann licensed under provision of Chapter 9(mmmeming P O4—� P=Ce with Section]000)ofDiviaion3ofNe Business and professions Code.and myyliccnu is Of $� in full force ands . �T �Q� Of w< [,on m Lil.. 1 IV ,_ PCs,-..� Dam C°nummr /77"'kkl..���� D SHINGLE I�'0 OMPOS T I01 ARCHFrECrS DECLARATION&erns a� �� (� (,2.,WOOD J $ , 1 undenund my plena shall,used.public records K4(.T'�' (d5 1 a— Dl V"'0_'y1_&/O✓�� �Y rc SS.CC o a licemd RorneimW OWNER-BUILDER DECLARATION C z a 1 hereby rgipn,hat 1 em exempt from Ne Cad.. License Lew,fon the 7=n following reaann.(Section 1031.5,Business it R pess ofeisionr Code:Any city n county to3 a which requires•permit m croswn,deer,improve.demolish,al rcpev any u— Sq. Ft. Floor Area Valuation prior to its i......also requires the applicant(much permit to Ill..signed autem ad that he is licensed punuant to the provision of the Commanders License Law(Cbmsm 9 (cix.nn,with Smile.71)Nh of Division 3 of the Bwimn and Plefessiom Code)or sane ApN Number Oceu 'ryI haand,he is'newt therefrom Ne balleged 0.for the alleewmpfirn.Any violation of P y 'J Pe Section 10313 by any applicant fn a permit subjects t,applicant m•Civil pmalry of 3 b •Z2 n:,) Ie., -- pm some,than rive hundred dollua(S500). Laamam'.furepmped,..yempinymawithwages.theiraolednmpenr,anon. Required Inspections ' will m the work.andme ruunure if not macrale iornaew for We(Sm.100a.finsimas 36922037. 00 and Professions Code:The Contractor',Lima.law don ret apply to an.a - prepeny who builds or improv.thereon.load who deer,such work himrelf or Mough his own employees,provided that such improvement,are not intended or oB.cO for We.If,however.the building.,improvemen,isroll wimm np year of dn"ttinlion.the .305 — FRAME ower-Willer will lave I,holders or proven,that heed not wile or widows for For. pnewwe.). 307 — INSULATION ❑1,as owner of t,pr°pert,am esd.Ovely conhmting with loaned comments a 601 — ROOF TEAR OFF camirm.the prejeel(Sec.]DK,Bmsaid d Profeuhms Code)Thm The Conmmb Lt CO.law dm,amt apply ofanowm,ofpropnywWWRdaorimp°..ronenn.and! 602 — ROOF PLYWOOD NAIL who contracts for such projects with aconvactm(,)Idmud pmnt rsuant to CUraxm s Licen"Law. 603-- ROOF BATTENS ❑l and exempt under Sm. ,B&P C for this reason 604 — ROOF IN—PROGRESS Ower Dee / , WORKER'S COMPENSATION DECLARATION we I hereby affirm under penally mf perjury arc of the follmving dmlmdow. Ihive and will for by eCmi/Gale of Comethm aloe.fortfor Worked Compere /)(/ worn..provided fon mi Section 3]00 of the Later Code,for the pedmmurcc of the 7 work have which rola permit is issued. X7(1 have end will maintain c Iskn'a Compensation Irk for hi h required by Section / of the lvswc my Wmare6saW�r pCewayk+.far ylme perfoamryanmce of rix work for which this—pTer�mXit pis issued Carrie G^+f'IfY tIL(s)/Y O- Policy Nlorylu (S /t1tt—W CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thi,smtinn need ren,wmpletnd ifma pemtit is forom hundred dollen(5100) or lass.) I minty this,in the pdo.,of the work for which this permit is issued.I shall not employ any person in my manacle° ry as to becoaaubjmuu me rt w° en'Compn- latinnlaws°fCelifo u,Dec [•t•IU (�(J Applicant IOl1l}riV/��NYRe NOME TO AP CAM':IL after making this Cenifiwte of Exempun,you should ,come mbjmt to the Workers Compensation previsions,of the labor Code,you most forthwith comply with such provisions of his persalt shall,decided revoked. CONSTRUCnON LENDING AGENCY O Q I hereby d5on that mart is a constmctiom lending agency for me performance Z 2 me work for which his permit is invited(Sex.309],Civ.C.) ladle/,Name f Lendeex Address []] , I emify mu o 1 have rll this applicatins,"m on and at the above information is d 17Co.,.I.gree to comply with all city and Gouty ordinance,and state laws relating to 7 Z building concoction,and hereby...bon.rtpaef,Gives of this city 1.mer upon me V 0 lobove.memiomd paopeny for inspection puryofc,. Lp. F. (we),IOm On save.indemnity and kap harmleas t,City of Cnpmino elision O U liabilities,judgments.costs and espouser which my in my way ammo against said City >a Wan con,equence of the grating of this permit. [� d APPLICAN'l UNDI: NDS AND WILL.COMPLY WITH ALL NUN.IroIhT h SOUL ' REf.ULAT S. t.7 coon Sigw re of ApplieamtContactor De" HAZARDOUS MATERIALS DISCLOSURE Weil the epplicand or mere Wilding Occupant fete or handle hawndaus material Re-roofs w defined by the Cupertino Mumdif^I Code.Clupmr 9.12.,"the Heilm and Safety T e of Roof Code,Section 255311%)] / yP ❑Yes �j Will me Byplicwt or future Wildingmdgp.nt use equipment or de.ie.which All roofs shall be inspected prior to any roofing material being emit hewrdous air eonourivnls.,defined by the Bey Area Ail Quality Mmagement installed. If a roof is Installed without first obtaining an inspection malt] ❑Yes INC'"�// I agree to remove all new materials for inspection. Applicant I have dead me harardawe materials reyuirtmenb under Clupmrfi95 of the Cali- underst ads and will comply with all non point source regulations. IUmu Health��S..25�5,2"3 53y mp25534.IedarsfandmatIfthe ingf'ity rtsponsidlirymn.ifY me m'upwt0 suame afe mifin"nf OcIgnalure of Ap ican[ Date Owner or authorized agent Date All roof coverings to be Class"B"or better OFFICE