00080052 CITY OF CUPER7IN0PERMITNO.
BUILDING DIVISION PERMIT CONTRACTORINFORMATION: O U U OS Z
flUI1.DINGAUURF55"630 OAKCREST CT SANITARY NO. M
0 _KVBM=AL Dr
0•,NeRSNAME: RONIT B AVIV GOREN N'c
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IONC: ❑
ARCHITECroENGINEER BALDING PERMIT INFO
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F Um E
v LIC SEDCONfl C(AtSDECLARATION
z o„'- 1 hereby affirm,the I am Chapter
licensed under provisions of 9(commencing Job Description
oy—o
m with Sation'r000)ofDiviaion3of Ne Buaineseand Rofmiom Code.and myliamcis
F—c � NO CONDITIONS
z < in till force W Wect.
O i license Clan lie.N
5 N Uatc C E
C O J ARCHIl1i.S DECLARATION DECLCLARATION
vn y 1 undeutand my plain shall be used a public records
E
W
1,5:2. Licensed professional
� OWNER-BUILDER DECLARATION
t=< I hereby dflect the 1 em exempt from she Corston end License Law fm the
O following of.s emit a 703 xtrame Business and ve.derom Cede:Any city or cnunry
a m
which rtqufrm a permit re comtroct applicant
mmpross,demtliitt a rash any ttrement Sq. FL Floor Area Valu on
prim to is issuance,also nt to me the app rant fonuoA permit m file•signed statement
Nat he is licensed pursuant m the provisions of the Contractors License Lew(Chaps 9
(c...,utgwOh Season 70M)of Divisiot3ofrhe Business ond Profession Code)as APN Number Occupancy Type
Oat W is exempt therefrom and On basis for the alleged exemption.Any violation of
Section 7031.5 by any aW licmt for a permit subject.Oa epplicant m a civil pealry of 7424AWA-3 LAM
pt mart Nan five hudrcd dollar($500).
I,as owner of Oa prmpery.or my employees with wages as their sole cmnpemmion, Required Inspections
will do Use work,and O cameal tau is or,intended or oferd for We(Ser.7066,Buvnea
and proteaiom Code:The Contractor.License law does an,apply m an awrcr of 305 — FRAME
property who builds or improves thereon,and who does such work himself or through
his own employees,provided Ns such improvements are not intended or offered for 307 — INSULATION
We.If,however,the Wilding or impmvcmcnt is said within fae ye.of mord oun,Or
w,err-Wuxrwill hartBnWtdmofyovor,Oat heMreatWild orina,m.efar par. 601 — ROOF TEAR OFF
0.uowoer of ffic property.m exclusively contracting with licenand comencoom to 602 — ROOF PLYWOOD NAIL
mmmoul On project(See.71Na.Business and pmreamom Code:)The Cmtractor.U. 603 — ROOF BATTENS
came Law docs ern apply m an owner of paapery who Wilds or impowa thereov,and
who contracts for such pojoea with a conmcou(D licensed Wreasto m red Contractors 604 — ROOF IN—PROGRESS
Limns raw. -
�lamexemptanWSec. ,B&PCImr isreatn
Owner D.
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following deelmtiom:
I Wve and will maintain Section
37M of Corwin Code.
sum for Wmkcr'e Co of the
r waste,r pick Bo for mi Section 3700 of she Labor GOde.for the perfm,arape of the
0 1 for which Nis permits is issued.
37 1 M1aa and will maintain a peoftr compensation Insurance.h in.per by Section
3700 of Oa LOWY Code,ifor mUrc pertormance of the work for which Nis permit is sawed.
My WOrkafa Compem+atim Insurance eerier and Policy number are:
Carron: Policy No,O
CERTIFICATE OF COMPENSATION INSURANCE FROM WORKERS'
COMPENSATIONINSURANCE
(This section rad nm be compleaad if rhe peons,is texture:hurtleed doll ars(SIM)
or less.)
I certify Nat in On performance ofthe work for which this permit is issued,)shall
not employ any person in any manner so as to become mbjecno the Woherf Compare .
anion Laws of California.Date
Applicant
NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you slwuld
become s.bjat on the WmScex Compemadm poviMoms of On Labs code.you must
fmthwilh comply wits such provisions or this permit shall W de,med revoked.
CONSTRUCTION LENDING AGENCY
Q Ihereby ofltm Out there iaecmrwcuon lendingageney for tWp:eforwv:ea
z ry Oc work for which this permit is issued(Sec.3097,Civ,C.)
4 lenders Name
fY > Landcfs Address
fz] 1 cerify Oat 1 have read this appliwaimnd aawe that the above infomadm is
C. Acorrect.1 agree to comply with all city ad county ordnance.and stall laws relating m
z Wilding cmatrucum.and M1cmby andomee representatives of this city to enter upon Ne
V O abovememioned popery for inspection purposes.
I, E. (We)agree to awe,indemnify and kap harmless da City of Cupertino against
Q C.) Iiebiltu",judgments.costs and expenses wbichmay in any way accme against word City
in consequence of the granting of this permit.
'rn L APPLICANT UNDERSTANDS AND WILT.COMPLY WTI I ALL NON-MINT
SOURCE REGUTATRtNS.
� z
Signature of ApphranOCuntrectp Dane
HA]ARDOUS MATERIALS DISCLOSURE
Will a he applicant orfntme Wilding occupma sone or bsndle hazardous ma 69 Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Hat and safety Type of Roof
Coda Section 25532(.)7 yp
❑Yes ON.
\
Will theapplicant arfuture Wilding Occupant use equipment ordevices which All roofs shall be inspected prior to any roofing material being
emit haysrdous ah conuminma as defind by the Bay Ana Air Quality Management installed. If a roof is Installed without first obtaining an inspection
,istripn I agree to remove.all new materials for inspection. Applicant
❑Yes 0 N
I hewc rad the local.,maadaisreq.iremenex-nein,Chapter 6.95 ofthe Cali- understands and will comply with all non point source regulations.
forma Hulth&Safety Code.Sauam 25505,25533 and V5M.1 undcraM That if she
Wilding does not currently have a aeranl that it is my responsibmliry m nmify the Ouupant
of ted nouvemenra which must be mer poor to issuance of a Cmificaa of Oceupancy.
Signature of Applicant Date
(honer or authorized agent Dale
All roof coverings to be Class"B"or better
OFFICE