00100063 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PRRMI P NO.
063
96,'OWNER'S Ntit' "� } - APPIACAI ION SUIT DAT 1:
61010912000
PHONE: SWli RONALD E SANI'T'ARY NO. CONTROL NO.
0-7.02
O0 ARCI IITECIENGINEER: - BUILDING PERMITINFO
❑LD ELEC' PLUMB MECH
sUl
S N j LICENSED CONTRACTOR'S DECLARATION Job DeSCfI Ion
QZ w I hereby alta..0 mut lion lwe ed jade.prwisaum of Chapter 91e+mmeneing
with Section 7(XM))of Uivisinn t of do Hominess and Prolcssions GNC,and my liccule -
mC Is is full one; Ielfet.
s.m< Li.cwCbsS Lie.# SHAKE TO COMP
o u Dila Co;nmeor -
AI ON
a O I undcrmnd my r1ARh shall be used m LAR eetrds
y O O hicanccJ Ihafchsiuwl
o OWNEII c'eann'l DECLARATION
1 hereby affimt That I am enempl Item the Commaor's License Any c Lew lira ILC ✓
F'a< following rei(SeCtiun 7031.5.Hosinesvand Profasioas Code Anycityor county
i x o which requires a permit lir construct,alter,improve,dcmol sh,or repair any suucaum
µ615,n priorm ill isnun,e.alsorutt
luim,the applicant such pennio file aligned staternenl
mal he la licensed naLaanlIII provis;Fns,ofthe Contractor eucet.eLaw lChamer9 Sq. Ft. Floor Area Valuation
0ntnmeneing with Section 7")of Division 3 of the Business and Profession,Cale)
art That he is exempt best at and the NN,for IIIc alleged cscntpliun.Any violation
tf Sectio1703 1.5 by any applicant for o permit subjects the applicant to a civil Anally
IIIi nraeLonfivehmmredmamra(s5n1n, APN Number Occupancy ype
❑I,as owner of the pmrcrty.or ry annuoyees with wages its their sole compersmion, _
rill do me work,and ate srvame is am amended nr offered for side(See.7014. -� G .-
.arid,..and rrofiI Code:'ne Contractor's License Law docs not apply to an Required Inspections
wase,of proP[ny Who build,lir Impnwer There and who docs such work hic—Ir
un through his own cmrdoyecr,provided that such improvements an not included or
Brred er.rlde,u',ho r,that buildni,or arl hold"unit one ya of 305 — FRAME
lampletion the rtsner-builder will Invests,hurdenof proving Thal he did nn Mold or 307 — INSULATION
atpmve far rurporc I.F-1..).
❑1,tv owner of the property.not visheively concartng with licensed contractors to 601 — ROOF TEAR OFF
amlrvcl the project(Sec.]IDs.Business ant Profeuimu Cod,)The Cn iutcmr's 602 — ROOF PLYWOOD NAI L
License Law does not apply lit an oxer of p,,,,"y who Wilds nr improves thereon.
sad who enamelsmla
Tor such project,with a conorcl uce+thcd p ,,
uumn m the603 — ROOF BATTENS
Commetars License Law. .
❑l am esenpt ander Sae. ,11&P C lar his reason 604 — ROOF IN—PROGRESS
Owncr Date
WORK17R'S COMPENSATION UIICLARATION
1 hereby affirm under Anally ul perjury one III the I'ollowing declarations:
❑ 1 have Iuul will malntnin u Certiliculc of Consent to sd6inwre for Worker's
Compenattion, as provided for by Sminn 17011 of the Labor Code. for the
lerfor u,nee ret the work Ea which itis permit is issued.
❑1 havo end%ill malewin Worker's Cmnpenwtion in5umace,as required by Section
37W of the Lahr Calc.for the aff.m unce of the work for which this pennll is
sued,My Wndcr'h Conalculation los rmre aMer:md Policy oumbcr am:
Carrier. Policy No.:
CERI'IFWNFION 01:PXL'MP'rION FROM WORKERS'
COMPENSATION INSURANCE
I Dias action recd not M ccaddoed if the remail is for one hundred dollars
(S ltab or lens.) ,
1 eerily that in the arfnmunce of the work for which This recant is issued,1
shall nal cartel,any person In any memo xn Its to heroine subjm ,,the Worker'
Compcluseion Lars of Califitmia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Esemrtion,you should
hecoue nuhjcm to the Wader v Gnnpenr'ation provihior, ,I'he Lnba Gale,you mull
0 O Iothwith comply with such provisions or this permit shell be AcemcA resulted. '
G
r^ CONSTRUCT ION LENDING AGENCY
a ' Ihecot hiclvu, cruelsaconed(Sec. 097.Cie.ency for the perfonnnnce s
Lead work for whicL This pencil is 6hucJ(Sec.y)q7.Cie.C.7
5 Q Lender's Nante
= z LcnJcr's AAJrca. ,
U O I Emily det I base read,lik upplic'atiun and dam that the above imLmmlion is
4x. (.. calcitic.1 agree it)Conody With all city and county N' ce d state hoss rebut,
O fes) Ion II g i n dh hY B p ft s Its. t t enter Ion
the abuse actuated property fit,in pr t p p
F 11
(We)age to save,inderatify antikeep harmless the City in'Cu,arrina against
lin
liabilities.pd,forid,c t J expenses whichry in any way eine against said
U
City in convequenceat the granting of this piston. _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT Issued by: DatC/Q'7GOv
SOURCE REGULATIONS.
Signature of Appreant/Contmctor vale Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or later,Wilding occupant store or handle latmNoas maml'ial Type of Roof
as defined by the Calcninu Municipal Code,Chapter 9.12 and the Ilcallh and Safety
Cade.Section 2553201'
❑Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will The applicant or 0mm Wilding occupant use equipment or des ivo%lneh If a roof is installed without first obtaining an inspection, 1 agree to remove
1,11 Imeanlou,air con0mi minth as deli red by the Bay Arca Air Qual ily Managentem
District, all new materials for inspection. Applicant understandsand will comply with
❑Yes 0 N all non-point source regulations.
1 have read the hazardous materials requicmenn under Chapter 6,95 of the
Coluarniu Health It Sel'dy Code,Seetinns 25505.25539 and 1S534.1 undcrsmnd that
if the building toms and currently have a tenant,that it is my responsibility ht notify the
"Cupar it The requlmnlcuis whleL nowt he mol ,if...Ili i,wuunn rel'a crod'at-nl
Occupancy' Signature of Applicant Date
Owner or authori,ed agent Umc All roof coverings to be Class "B'r or better
' OFFICE