00060116 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC'T'OR INFORMATION:
HUILIIING ADDRESS: PERMIT NO.
(lN'NER'S NAME: A70 PENDERGAST AVE EASTMAN RLICATI S IIDAI'r
11 IG
{UNP: eARBL1 BARBARA 1418 DBUGLAS ST
SANT"I'AR .N(l.
BUILDING PERMIT INFO
ANC({1'1'IiC'1'l1iNGINEER: BLDG ELIiCIPLWIII MECH
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LICENSED COcenRd male,S orkin,of TIONChapter
Job Description
C —C 1hereby affirm that 1n3licencedunder Pnrvisionwof Chapter9(commencing
fish F-u; with Sectionorce and ofect.Division de Business and Vm&slam Calve.and my lianas
<y� is in lull force and affect.
yy
m a Lieems Class Lic,e
xoa..0 nme CoECILA• REROOFS COMP ROOF
w �+ ARClhalIECI"e UIiCLARAI'ION
1 undumnnd my plunv xholl he oath nv public mcnNc
Limned Pudessinnal
ic`—,thy°
ON'NIaR-n ar,oNlI n DECLARATION
w I hcrchy.fens than I am musipt from the Cssors Code:
od:Any c I,uw fin the
F Z Infuwhich
reason.(Section]I13L9, t,antra and nurser.
demons h,or Any[an nlcuumy
P 2 p which rcyuires a permit¢)nmsnuc6 uM1eq innpmve.Demolish,or repair any slrvclurc
at o prior to its issuance,also quire,the applicant for such permit to file o signed statement
seem chat he islicensed pursuant tnthe pmvi.stn,of the Cornmemr.License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 701 of Division 3 of the Business and Professions Cade)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
or Semon 7031.5 by any applicant fora probit subjects the applicant to a civil penalty
of.,it mom than eve hundred dollar,.Wild). APN Number Occt IRMPC
❑I,"owner of the property.or at,employers suint wages as there wile a+ntpansmio r,
will 1 k tl d structure I intended e d t at,(See 70,14, -
11 ,a1 and lydlsion'Cade. Ihsunmt -:Lu.oLLa 1 "and yIntin squiredlnspections
owner of pralnny Who builds or innprovex dercon,and who does catch work himself
or through his own caploye..provided In,such inmra emena aro nes intended ora
afr red fon sale.If,however.the building or improvement i.-sold within one year of 305 — FRAME
iimpletion.the owner-builder will have the burden of proving that he dm not buildor 0
mpmxe far pntpaa of sale.). 307 — INSULATION
01.as owner of the propcny.am exclusively contracting with licenv.N contractorsin 601 — ROOF TEAR OFF
construct the proper(Sec.TW.Business and Pmfroions Calc:)The Camracl %
icensewwdoesno,trii aa.owns.ofpmpcnYwh.build,orimpm.e.the reon. 602 — ROOF PLYWOOD NAIL
sad whn contract,far such project with a commercials)licensed pursuant m the 603 — ROOF BATTENS
Convacer's License Law.
Cliff naempt under Soa, .B&P C for this reason 604 — ROOF IN—PROGRESS
Owner D;ne
WORKER'S COMPHNSA'1lON DECLARAI'1(IN
1 hereby nlfim,under penalty of porjuO one of the fallowing ded:vutionc
❑ I M1:m and will maintain a Cenil Seed of Consent m Lairsure for Worker's
Compemmion, be provide) hoc by Senior illy of the labs Gds, for he
performance of the wed for which this permit is issued. V
❑1 have and will maintain Worker's Compensation Insurance,as paired by Section
3900 of the Labra Code,for the performance of the work for which this permit is
sued.My Worker'v Compeavtion Insurance carrier and Policy number are:
Carrier: Palley No.: '
CERTIFICATION OI+EXEMPTION FROM WORKERS'
COMI'ENSAI'ION INSURANCEt
CI'his section seal an be completed it the penin is li+r one
hundred dollars
($I(Nq m lass.)
1 coily that in the pedinm:mce of the work Far which this hermit is issued.)
shall not employ any person in any manner so as to become subject to the Workers'
Compensation Laws of California,Data A'
Applicant
NOTICE TO APPLICANT:If,after ranking this Certificate of Exemption,you should �
become amen er the Workers Compmm
emn provisions ofth !
e Labor Code.you must 0f' p
ZO forthwith comply with such provisions or this Permit shall be deemed revoked
^F ^ CONSTRUCT ION LENDING AGENCY '
CC , I hereby affirm that there is a construction lending agency for the pert'ormance
of the work for which this Perish is uuwd(Sec.3099.Civ.C.)
LQ I.r le,,Nmue w� /
Z Lenin's,Address ti
U 1 ccnify that l have read this npplicmion and statement the above imanda um is
LI. E.r consul.I agree to comply with all city;aid county ordinances and state laws minting
0 U to building construction,and hereby auionee aclreuntatives of thiscity menteruprm
} (a7 the above-mentioned Impart for inspection purposes.
t--, a (We)agree to save,indemnify and keep hartuales,the City mfCuPcm;ro against
(n liabilities,judgmenu,costs and narcoses which may in any way amme against said
U Z City in cadayuence attire germing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b ( ( Date
SOURCE REGULATIONS. y'
S[,,amaof A,plicunl/Comrdoter U;nc Re-roots
HAZARDOUS MATERIALS DISCLOSURE
Wit thec"ticarn timer buprnng nergmm ocor handle bloadvax mntod:a Type of'Roofs .
as Joined by the Carleton,,Mmao.,rl Colic,Chupmf 9.12.and the Diad and Natty
Crile,Section 25532(a0".
O Yes 0 N All roofs shall be inspected prior to any rooting material being installed.
Will the applicant or future building occupant use equipment o-device^whim if a roof is installed without first obtaining an inspection, I agree to remove
nit Insinuations air contaminanu as dcliresl by the Bay Arca Air Quality Managernmm
Nluicty all new materials for inspection. Applicant understands and will comply with
Qyes ElNo all non-point Source regulations.
1 have read the hmurdous mmerials mquiremcros under Chapter 6.95 of the
California Health&Safety Calc.Saninns 25505.25533 and 25534.1 understand that
It the huilding doe,not cumntly M1ave n tenant,d;r iI is nay responsibility to nnOty the
cupant of tireme
negnircms which must be n n prier to issuance of a Ccnifm
ee of
I. i'.. m, Signature of Applicant Date
owner at art ho.Lcdagclnl Date All roof coverings to be Class "B" or better
OFFICE