04090024i
PARCH=�GINE�:
UPERTINO
DIVISION PE CONTRAGTHIR jNFURMA N
ESS: PERMIT NO.O 4 0 9 0 0 2 4
CAROL OZAKZ
PERMIT LSSUE DATE
SANITARY O OL NO.
BUILDING PERMIT INFO
INEF : BLDG ELECT PLUMB MECH
0 0 0 0
ai LICENSED CONTRACTOR'SDECLARATION Job Description
to1 hereby )of Nm 1 nm lithe S under provisions of s Code. 9(commencing
iwith Smuon lOfgp Of Division Sof the Ruvness and Professions Code.and mylieense is
m in fall force andeffms REVISION -TO SKYLIGHTS
az License Class Lac'gORIG PERMIT 404070200
Date ARCHR 1-5 DEr!LARATION
I undcrsund my plans dull W used as public rmords NO NEW PERMIT ISSUED
yU
G
Licensed Pmfcssional
5 OWNER-BUILDER or 1w C'muION
0 0 e hereby.(piece o n 1 am exempt from he Conlon,Co License law for the
c O which mr reuon.(Schon 713 1.3,B -ence, and Profession,Codh:Any city or county
mo which rtyuims a permit m ui svuc4 Alun improve forsu hPermittish-care a signoy ed
swcmm
iypnwmiuiuuance,also requirutMappliumfor:uchTurmilsoaleanigncJstatement S Ft. Floor Area
NWmcValuation
< nislicedpursuanttobcprovisionsofUmOmmacmLaw q•
�$ femoro ting win section 7")or Division 3 of the Businessland Profeatlom Code)01
.. Nat m It merept Ncnfmm and thh Innis for dm.Ikgrd mempuon.Any violation of
Section 1031.5 by any applicator for.permit subjects de,applicator Ip a civil penalty Of APN Number Occupancy Type
not more than 0w hundred dollars(5500). -
1,as owner of Ne property,w my employers wIN wegu u Ncir ark compewdon, 0 O
will tlOthework andthe he Contractor's
ont is noti Licensor a0 does
1061,Business Required Inspections
and Pro wh obu Code:The m nthereon.License Law dors not apply lf an owner or
is
property whom.pct.rind dol s chicon,and who so,
hendedwork omue orNroum his
owneer. he building
i or ifiletvernuch Imps sold itinnal ear efdmnRCRd forum.
Wildm..etc oom un Or impm proving
sold within oro year of cempleuan,the awrun
builder will have fix burden of proving Nat W did oat Wild or improve for purpwc of .
saw.).
t
L as,me pof the Sm.7 .m exdus;and conlrectmor with:)The Coensmm.U.
enmttuct Nc es not Apply
an an owner
of and property
who Wild,
Codc:)Tho C thermh Lid
iuc taw docs not apply c m owner of property who Wilds n antmvss hereon,arid,
who nlnco forsmh projccu wiNaconwcmKal licenced punuam to Nc Contnnor's
;-460R
' aw.
empt under e. .B k P C fm Nu�uon
/_ Date 9�z/off
KERS COAF aSATION DECLARATION
1 hereby aRrm under perW rY of perjury arc of the following dmla�
I hevs and will munmin a Certihcamaf C...1.1O self-iuum rm WorkcYaComNn-
don,as provided for by Section 3100 of the labor Code,for the pceormanm of the
W
ork for which this permit is issued.
rI have and will maintain Worker's Compensationec
Insurance,as mguired by Stion
W of rte Labor Code,for Ne performance of Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Coder: Policy NO.:
CERTIFICATE OF EKEMFrION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nothe completed if the permit is(mom hundred dollars(SIM)
m loan.)
I certify Our in Ne performance of Nc work for which this permit is issued,I shall not
'employ any person in any manner m as N Women subject to the Workers COmpenndon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:if.after making nix Cenirmam of Exemption,you should
become s.bjat to the Worker's Compmu0uon pmvisiam of the Labor Cotler you most
O fornwmu Nu
ide..Ply with such pvibnm permit shall m
l be deemed onetime.
CONSTRUCTION LENDING AGENCY
I hereby a(rtrm that turn is a construction lending gency far etc perfmmance of
Y. 7 de work for which this permit is issued(Ser.3091,Ci,C.)
L] Lender's Name
L Under's Address
j0 I cenify that 1 have read this application and sou that the above information is
L corrccl.I atgme to comply with all city and county oNirunces and sum laws relating to
V building construction.to s
ave.
Inde niyome rep
prearmleseze this
cityucnurupnntW
^ a an
.Wvh-mentioned property for inspection puryo.¢s.
(We)agree b cove,and expone and imp hay roan the CITY of a,aimno agaw City
fq liebilitiu.judgmenu.cosu and exponents;which may in any way ucmc against and City
jz in comcgmnte of the granting of Nis pcmhil. Date
^ APPLICANT UNDE NDS AND LL PLY WITH ALL NON-PO{NT Issued by:
SOURCEREGU ![/-�( alt
T �/ �1 "r Re-roofs
Si wmafA
HAZARDOUS
DO D°u a of Roof
HAZARDOUS building Occupant
Type
Will the eCupertm(Mort Wilding occupantsoreor handle Health and Safety u de0ned by du Cupertino Mumuyu Codc.Clupur 9.13.and cc Hu1N and Safety
Code.Section 25532(1)? / All roofs shall be inspected prior to any roofing material being installed.
❑Yc No
Will the applicant or future building Occupant use cquipmenr or devices which
If a roof is installed without firs[obtaining an inspection,I agree[o remove
emit harardnus air contaminants as dc0ncd by the Bay Arca Air Quality MO®gcmem all new materials for inspection.
District?
Dyes
i have mW thh lunrdnus mamriala mquimmcnu under Chapmr 6.95 of Nc Glifor-
nixHralN&Safety Code.SeWmu 25505.25537 vw12553d.l undcrsund Nazif w6 Wein g .
does not curmndy ha lrn.nk Nat it u Y respomihilitY m noufy rte meapant of Nc
mquirtmcnm whic b Or p r nonce or.cmre.m ar Oc Signature ofApplicant Date
(7) Dare All roof coverings to be Class "B"or better
Own raulAodrmd agent