00100166OFFICE
CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
[BALDING ADDRESS:
PERM) r NO.
1 04-M2 rnMFRRFT CT�w
reef
00100
OWNER'S NAME:
APPLICATION SUB DA] I?
r-ter'No ROY
10/25/2000
WE: ")
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SANITARY NO. CONI RRL NO
ZAR
CHITECLIENGINEERo
BUILDING PIikMI'f INFO
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BLDG ELECT PLUMBIMECH
LICENSED CONTRACfDR'S DECLARATION
Job DCSCFIptIOn
I hereby afiina thm 1 ant licensed ands, prnvi,inm of Chapter 9 (commencing
uCi•
with Sit, InI17000)thDlvblan Jofthe Hu,ior,, and Profess....., Cale, uad my Bronw
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'nfullf a hit Mao.
hi«mecliew Li<..
SHAKE TO COMP
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orae commnm
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ARCHITHCI'S D,CLARAr1ON
1 undcntand my plans nlwll M1c used rev' public road,
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X PiRE
O LICCrtMJ Professional
LL
UILUIiR DECLARATION
Oat
1 hreasy ,Mirth that ret scntpt Ionn the ComrusCo Lmcnnc Law for me
Ian
¢
]p7LABu,ine,smrPrvl Professions Any city or county
hollowingreason,permit
M
wt, fry pe in,,construct,h demolish, Ystructure
ca
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r
I Laup th til .'anti ape InL"c ,b J.atenmm
l
III, he bans a p t Low (Cl
m.tr I'
Sy. Ft. Floor Area Valuation
6dq
ion3 t Business Cor)
with Division 7 a1 the Burmc , and
th
.what
tSection therefrom in.. Any ci
and Any viP
heeI, a therefrom and the kers fm he alleged emmpnit
or that he is
to realty
911E s by any applicant 5a a permit.,unjects the applicant So a civil penalty
of 31.5 h
A PN Number Occupancy Type
of ream tm,r. man live hamlred dolwr, (s510).
no,
I. as awncrotf the property. or mY emplayces with wages as their sole compemation.
–.
– •'
Required Inspections
do the work, and the ,mature is not Intended or altered for sale (Sec. ](94.
Law does
lusma%s and proheaouns Cotlm The Contractor's License I,,, apply o an
,w of pmpcay Who build, or improve, thcrenn, and who does such work hietwlf
or through his awa'employees, provided that such improvements are not intended or
305 — FRAME
offered lar sale. II; however, the building or Improvement it,old within one year of
,mpladat. rot awacr-naimer w,It bavatha hardenar pooingdiat hadal bat m ildor
307 — INSULATION
improve for pia,av a of sale.).
601 — ROOF TEAR OFF
0l as owner athe Inopeny. anal e.ewt,ively contracting with licensed <onmumm m
,m.mn me pmjccl (see. 7014. Bu,im„ had 11 I- taro Code.) ]It, Comramors
602 -• ROOF' PLYWOOD NAIL
License Law deas not apply to an owner of property who nttilds or Imptnvea memm.
and who <ontrall, far such project, with a <o thwam,) licensed paevo nt m he
603 •— ROOF BATTENS
Contrucmr't License l"'.. -
❑Iam aor ale, BxPC11)Fa11,Ion
604 — ROOF IN--PROGP,ESS
owner Date. ��^^�X `)`)��
'OMI'IiNSA1'IOwCCLARATI�
KBk'S
t
I herehy Minn under penalty of Perjury one of ma lollo ong decimations:
1 have ;rod will maintain a Certificate of Convent to ,elf-Imre for Worker',
,
o;npro,corn, at rmvidnl 1'or by Section 7700 of the Labor Cade, far the
-
Ierramumee of the work lot which this permit is I... ad.
❑ 1 have and will mainwin W nkcr', Compens;nion (mamba, a, reyuircJ by SectionOut
0lShe LaMar Code. fur the wHao aa,a of the work lir which this permit is
.meds My Worker's Compensation Insurance currier and Policy number arc
C'nrria,: Polley No.:
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CI?R I'IFICATION OF 17xl;min [ON FROM WORKERS'
COMPENSATION INSURANCE
,
0[it%section need not he enntplelaJ if the permit it far one hummed dollars
WHXp of less)
I ccnify that in the performance of the work La which this permit is issued I
shall not otaploy any person in any rammer ,o ;is to become subject at the Wadcrry
Cbmpn amino Law, of Cal, litmus Dote
-
Applicant
NOTICE TO APPLICANT: It, after making this Cenifica¢ or Exemption, you should
L
becom.,ohn,,,, le Worker, Compensationprnvion,ot She Lubar Cade. Yo. moa
.,
I'nnhwhh comply with inch askin i, ret this permit had be Jaunted revoked,
n
CONSTRUCnON LENDING AGENCY
1 hereby aflirnl mat there k u conwucti m landing.,an,, fin the performance
of the work for which this Penna i, Hurd (See. 3097, Civ. CJ
Q
lender's Name
7
Iwi&rN Address
I cantly nut 1 have read Ilii, arplica0an uW state mat the above mono union is
orrea. I agree m contpI, with all city and rc.rW ordinance, and slate law, rcluting
L)mbua
trngcon,aion. and hereby authorize reprewematives of city memo upon
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;4
the nho—nent toned pm,,I, for ar,,coinn mapown.
.
CL.
(We) agree .I ;oe, indemnify and keep harmless me City m Cupselinu hgna,I
y
"L
Iiabililics, judgmem,, costs and e,pennen which may in any way nerve ugvind ,aid
the permit
La'A1PgI A"N..
LCOMPLY WITH ALL ONIfJT
AVI'LICA
ISSnCd by:DateI
(Siammreo���eRe-roofs
A ,RIALS.)", (STIR,
Will the upplicanl or.mum Mnpoing o, q it amu nr handle hlvmdous mineral
Type of ROOF
as defined by the Curtains) Municipal Code, Chapter 9,12, and the Health and Safety
CIA, Section 2553200?
O Yea RNo A
All roofs shall be inspected prior to any rooting material being installed.
Will the applicant or future Molding oecupanl use equipment or device, which
If a roof is installed without first obtaining an inspection, I agree to remove
mit h 'cedom air comamiount a defined ny the Bay Are. Air Quality Management
all new materials for inspection. Applicant understands and will comply with
❑Ye, )(No
all non-point source regulations.
I have read the h.eardoux materials requires eau under Chapter 495 of the
Califnrni,, Health A SuOy Coda. Section, 25915, 25573 ;nal 25574, I Imdemand that
if the hulldiag doe, not currently have n Immnl, IIII, it N my ne,pmnibilhy m notify the
occupant if quircmem: It It masa be, amt prior m issuance of a Cer ilicme of
ocenplaw 1p (-��
Signature of Applicant Date
All roof coverings to be Class "B" or better
owner or aro a- Dam
OFFICE