00090185 CITY.OF CUPERTINO�
BUILDING DIVISIONPERMIT; CONTRACTOR INFORMATION:
BUILDING ADDRESS ' t' PERMIT Ad.
WOBBS Y '1
�e OWNER'S NAME.. ♦ APPI.ICAI'ION S A U
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HONE: : _UlR!qERs- ffif
S SANIIARYNO�- "r!T .1 .
• r��'Z ARCtIITECI'/F:NGINI FR DING PERMIT INFO
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- ... IILUG ELECT PLUMB- biLCH"
Nye I'
z y LICENSED CONTRACTORS DECLARATION
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h, flrth'II I'c d J -. " ICI pa 9(eanne g CrIp
Hzwithf late ]000)ycXf`�L 3 f he Bu v andl ficonar,Codj ndnyl 'Wei
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3 d F Dae ` L t - T/0 'SHAKES. ' RESHEET. 30#:,FELT AND 40 Y
ARCHI fEC9'S DLCLARA'1 ON _
CSy�=O to� l understuud ny pi ns shall he u"I as uhh,reenNs -
ar1�00
Licensed Pfe' -'I
- OWNER BUILDER DECLARATION t onto
"=" 1 h r by xNrm,ba,1't , pt fourhetC t a L L F thefollowing (year 7031.5.B ', d Pr p,, Code A y c ry county , -
z � wh M1 V r: p to .t' tit p J "1 epnr any stra t e -
w ca pont , 4 .thef suchpe 'rt fl signed statement
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c. that he is licensedp ': ft the provisions aftheCounturfors I Law(cn'pwa Sq.,. Ft Floor Area Valuation/�
(m g lh Sect 9fN1U) f D' 3 f th B :n J P f : .Code) _ y
rz
burns,is e.c opt throw nn and the,Ki for bbd alleged cych,cau,.Any i.hrr i + '
of Susie 70315 by any applicant far aparrj,Iwihjv,k@e conduction I odvll petrlay
nrnmmr,ethan rveharried aelmrs(ssoof. < - . ABN Number; • .. ' ` Oecupa' ,
.❑I as nxner of thePr morn loeeswith wa ah .` ion.,If
P Y Y P Y8
_ Bus n thek thet t intended,.,doffered f :I apply
]o an - ,
ow d eProfessionsC d 11 ro t i Lochic i T ,ply ro an IDSpeCtIODS -,
ofh his
ei hits or nita s, n,dwho a nicht rkli mself
nrvihrough h's toxo et pl ) .provided Jh t h. P ,. aKindled -
offerea ror sale B,however,to b ildng e t i sold -withinyear of 305'_ —,' FRAME.
a nple kar be ow,a,bt lder'will have the Au den or prnvi ag that he did un bo la o - .
tmp f p p f 1 ) 307 — 'I'NSULATION
❑ me property,.aexclusively one's l g with licensed contractors to 601' ROOF_' TEAR OFF
Lconsumer @ project(S ]IM4 Business d Professions C )The Contractor's
in L e „ tont ply fp peer hahaalk' inpr.e+p,e�m. - 160.12,- ROOF PLYWOOD NAIL, '
vad h , , for ,h'pi 1 c6 ve: ul aod.)fl e 1 p av the
Cont e, r.I L + 603 ROOF BATTENS
Cl I vion eachrop,uade,See. R&PCfar Dili i 604 .— ROOF IN-
PROGRESS'
Owneir Date
WORKERS COMPLNSAI ION DECLARATION' /
I harebyarfuto underperialtYfperjury torroofthe follo,singdeclairlions -'
V7 1 1 I ll t C t f m I'C enl,to If r Wi k ��.
Co p , provided by Set 3700 I th Ladner CaU f d •/�a� �}
per! f thek f which
h N'. peornin is issued.
1 r
1have and will northern Worker'lComponsation Insurance.as required
Section
sa.i f turbo,r R d thep I c f the' ark f which thisporn t.is
u lMy�Wo'�rkcrsf�C p ton lnsury ee cartegr andPol�c�y`nunbcr.re I [J ,
Carrier V; Kms' Ynl c>Na 4a,( 1711, 1 s• -
CERTIFICATIONOFEXEMPTIONFROMWOk WORKERS' e1.
COMPENSATION INSURANCE r n
a is section need nn(be completed T the permit Is for orIe hundred dollars
v. s100)Tice,)' -
I ainfily,lal' the Terranova.of the work For which tris phibitis issued,) ` _ -
shall not thopley tiny p Yh)s to account, ct ro thers
e Work
Con p nsal on Las I California' Data
n' },
Applicant
NOTICE fOAPPLICANI If, ft - k g thisCartificandefReenthican,you should I -
becomesub)ecnotheWorker's C 1 t provisions of thLibor Code,you hats,
.0 Z forthwith ce iuy with such pmv s o,.s or ti s pem,ll shall hadcaused revoked tt .•- - -
- t
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''.F�ti CONSTRUCTION LENDING AGENCY
E-4 I hereby oR,rrntiat,here is a iosWuim lenJng agency for the performance
of the cork far which ahs portion s issued tScc3097.Civ.C1A IzndName .,
- n ”- �' �. �. .. • e .rr .
JL •. + ..
Loni Address
-
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entry that Ibase III this application and ,aid that I infatuation
chi I agree to earthly ahll city` d courry0
d' dstate l relating _
�J tubuilding construction,- dh by du p a i es afthis ditytoenter upon
W the b t oned property f r inspection p rp es.
y Qy (W) greeIoe „de unify aidkeep lnillesethe City of Cuperine sound .y , '
+r
V) liabilitiesj dg' a red,end p as which may in any way accrue at said + �•>
City in cansyuenLc of be grnnnng.1 his Portrait, - - .,. �r r ' -
APPLICANTUNDLRS DWILL CO 4Y WITH ALL I-P NT/// ]sued b 'V\,J G �' /�/Oy cc_
SOURCE REGULAT S DS`A A ` 9�� Y 'Dttle•
Signature of Appllca'nUCommctor - - r. 'Dale Re-roofs
HAZARDOUS I ERIALS DISCLOSURE
Will the applicant orfuture houlifing occupol.,a handle hazardous nal ral Typeof Roof
-
asdefinedbytheCupertino Municipal Code,Chapter 9l_ ,nolhe Head@mdSfe,, x r 1
Code,Sectio,25532(x).- - • -
❑Ye5 + '
D, All roofs shall be inspected prior to any roofing.matenal being Installed.
Wldthe•a illcemoria bandied by th a Bay ArI nl neuality Micesureart
01 6 P 4 Pa
If s ' s
smith ' I-. coni ,. �sdnrmcdhytheBnyA�eaAir Q ItyMenogemem I a roof 1 m.teilled without first obtaining an inspection, I agree to,remove •,
Disa , - / all new materials for inspection. Applicant understands andlwill comply with
°YeY alfficn-point_source regulations.
1 have rand(he Incurious t q e (,order Chapter 695 of the •' - t
Calf in Health&Sf ly Code,SectlOns.21505,25533 and25534I ruderstand that e
lithe building doenot currently l a tori that tis y p hin y, tlQ the $ �„ ,•�� ,/f
e . i
neap a ah m a s whach i h t p m hotoes.of a n rwie f 5 `
°� n` eSighature of A licabt Date
Own author..e Feat - Data ' ' •, _ All roof coverings to be Class B",or better .
OFFICE'
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