07100061 CITY OF CUPERTINO
BUILDING DIVISION pERMIT ���:���T�� ���������*
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aui � n i r �� a �� ES �ASCOIGNE TBD —'IO BE DETERMINED P 07100061 .
R'S NAME: �� �� DA �
JOHN REINERT 10/16/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHTI'ECf'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMH MECH
� � � �
i p � LICENSED CON7RACI'OR'S DECLARATION JOb DeSCClpt10❑
: V� ( hcrcby aCGrm that I am licenscd undcr pravisions oC Chaptcr 9(commencing
; z� wiih Sccdon 70(N)) olDivi�ion 3 of ihc Busincss and Profcssiuns Codc and my licensc is RE PLAC E BEANI GLUE LAM DUE T� DAMAGE
?� y in fu0 foree and cfkc� ������ , ROMANO ' S C ONS TRUCT I ON PD B S L 1 �/ 8/ � 7 $1 � 7. � �
� v� Z Licensc CI Lic. M
�F,� Datc Contracar. /5' d'�1/'9 6
� A CHITEC['S DECLARATION
7 a a 1 undcrswnd my plans shall Ae uscd as public rccards
)yU
' u. y Liccnsed Pn�fcssional
� y � OWNER-BUILDER DECLARATION
1 hcrcby alTirm that 1 am czcmpt from ihc Cantracmr's Liccnsc Law Cor thc
� p O Collawing rcason. (Sccuon 7b31.5, Busincss and Profcccions Caic: Any ciry or county
�,°, � which rcquires a pcimit w canswc4 altcr, impmvc, dcmolish, or repair any swcture
`? Z} prior w its issuancc, also rcquires Wc applicant for such permit to file a signcd stalemcnt Valuation
- < ihat he is liccnscJ pursuant to thc provisions of thc Conuacmr's Liccnsc Law (Chaptcr 9 Sq. Ft. Floor Area � 2 5 � �
r t �(commcncing wi�h Scction 7000) of Division 3 0( �hc Busincgs and Profcssions Codc) ur
��3 � �hac he is exempt Ne�cfran md Ihe buis Cor the allegcd exemptioa Any violation at
Section 703I.5 by arry applicant Cor a peimit subjects the applicant to a civil pcnalty of 3 7 5 2 8 010 APN Number Occupancy Type
not more than five hundred dollars (SS00).
❑ I, as owner of ttie property, ar my cmployees with wages u �heir solc compensation,
wiil do Ihc work, and �he stn:cturt is not intended ar ofterzd fcr salc {Sec. 7044, Business Re u ired Ins CCC10I1S
and Professions Cade: The Conuactor's License Law docs not apply W an owner of 9 P
propeny who builds or improves thercoa, and who daes such work himsel[ ar thcough his
own employces, providcd that such improvemen�s are no[ in�ended or otfered Cor sala If.
however, the building or improvement is wld within one yesr oC compledon, the owner-
builder will have the burden oC proving that he did no� build or improve tor purpose of
salc J.
❑ I. as awner o[ the property. am e�cclusively contracting with liansed rnnuactors lo
construct the projett (Sec. 7044. Business and Pcofessions Code:) 7Le Convacwr's Li-
cense Caw dacs not apply to an owner of propeny who builds or improves Ihe�eon, and .
who conuacu tor such projects with a convactoKs) licensed pursuant w the Canvacror's
License Law.
�l I am ezempt undu Sec . B& P C for �his reason
a Date _.. _
WORKER'S COMPENSATION DECLARATiON
1 hereby affitm under penalty of perjury one a[ �he fallowing declsrations:
❑ 1 hs.�e and wilt mainain a Cenificate of Conscnt to sclf-insum for Workcr's Compen-
sation, as providcd for by Sec[ion 3700 of the Labor Code, for thc performance af thc
work for which �his pertnit is issued.
❑ I havc and will maintain Worker's Compensation Insurana, as tequircd by Scction
3700 of the Labor Code. Cor the performance of the work for which this permit is issued.
My Wor s om ensa ' n[nsurancc carticr and Policy numbe�ac� ��, �
Came Palicy No.: l 7��
CERTIFI A EXEMPITON FROM WORKERS'
COM ENSATION INSURANCE
(This secUon nccd noc bc completcd if the pertnit is for onc hundred dollars (E100)
ar IcssJ '
I cenify th.t in thc performancc of thc work for which Uiis permit is issucd, t shall not
e�ploy any person in any manncr so as W bccomc mbjcct ta ihe Workcrs' Compcnsauon
Laws o( Califomia. Datc
Applicant
N01'ICE TO APPLICAM: If, aftcr making t6is CcniGcate of Faccmptian, you should
become subjcct w the Workcr's Compcnsaqon provisions of ihc Labor Codc, you must
, O farthwilh comply with such provisions or this pccmil shall6c dccmcd �cvokcd.
z "'" CONS7RUCTION LEND[NG AGENCY '
F r ►�-. 1 hcrcby aRrtn that thcre is a conswcti�n Icnding agcncy for thc perfortnance of
�C, � ihc wurk fur which this pertnit is issued (Scc. 3097, Civ. C.)
W� Q L.endcr's Namc '
� z Lcnder's Address
V 0 1 cenifY Ihal I have read Ihis applica�ion and staie thu �he above informatiun is
�►�" correct. 1 agree to comply wi�h all city and county oniina�es and state laws relating w
� U building conswction, and hcrcby authori�e rcprescnutivcs of this cily to cntcr upon �hc
� W abovc-mcntioncd properly (or inspccuon purposes.
a (Wc) agree to save, indcmni(y and kecp hartnless ihe Ciiy of Cupcctino against
�� Iiabilities, judgmcn�s, costs and expcnscs which may in any way acccuc against said City
U z in consequencc o[ U�c gnndng of Ihis permit. DaLC :�— � C'
�"" ICANT UNDERSTAND D WILL COMPLY WITH ALL NON-POIPiI' Issued by: �
SO EGULA'I7
( ' �� � Re-roofs ���
Signamrc o Applican on r '�
HAZ O�JS MATERIALS DISCLOSURE Type of F.00f
Wi11 thc applicant or futurc building accupantstore or handlc hanrdous matcrial
iefincd by the Cupertino Municipal Codc. Chaptcr 9.12. and the Hcalth and Safety
�. Scction 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Y� .�
Will thc applicant or futurc building occupant use equipmcnt or Jcvices which If a roof is installed without first obtaining an inspection, I agree to remove -
cmit ha�ardous air contaminan�s as dcfincd by the Bay Arca Air Quality Managcmen� all new rr.aterials for inspecr,ion.
asu����
� Ycs ,.Q No
1 havc rcaci the haiardcws ma�crials rcyuircmcnts undcrChap�cr 6.95 of thc Califor-
nia Hcalih & Satcty Codc, Sections 25505, 25533 and 25534. I undcrstand that iC ilx building
docs not curten�Iy have a tcnan4 wat it is my ces ettibility to noufy the arupant nf �hc
rcy ' mcnts which mu met prior tc� anu a Ccnificatc of cupaocy. � Date
__ �, Signature of Applicant
A ll roof coverings to be Class "B" or better
wncr or authori .cd cnt �