00060010t
CITY OF'CUPERTINO
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CONTRACTOR' INFORMATION:
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BUILDING DIVISION'
BUILDING' 1 R HLPiNh UH
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OWNER'S rTAJBBS� RLITH'
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PHONE:
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SANI'fARYNO. CON "I'ROI. NO.•
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ARCHITECDHNGINPYR: • - ,
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BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION I
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that I' d d l'Ch 9
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r of t y license
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is Infllf 1lderfecd,,
License Cl ... Lie
Dan, Contractor
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ARCHITECT'S DECLARATION I
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,nd,ndand my 'I mil shall : puldle'na,Nv i
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Da ea Professional] . Y
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DECLARATION
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1 M1osh} aB ec that 11. exempt 1 IM1 L i t . Locale Law, far tae
GP f: Cd Any city seamy
following reason, fS Secular Businessland
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wh'h 4 Palo... t .I t Inc' pone. demolish, -p Y t cmrc
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l5dor to its I q 'th applicant f such nt fl signed .t)t rent
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(bath licensed p sI n P of the Contractor's 1 L (Chp¢r9
(eomt min, vv N Section 7000) of D'v's 3 f the Business and Pmfe.....s Cadet
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nrlh In '. pt lhcrefron and the basis for the alleged c pr Any vicl ton
of S_ f 70115hY nY nppl'eant for a fair rf,yrn he afThicaur to civil pemll,
oronamone than Five handled dollar, fb50% ^ -
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Occupancy!Type,
° I.as owner of the Wopery, or lay employee, with wages as their sole eonipensndon,
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will a the k a a o t . I t 1 offered f l (s 7044. J P f . s C fh C t t L d t apply t 1,
305 FRAMEegriied Inspections
v m f property WI builds p th d a such k h' x if
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,hI p> : p provided ch lap er t ,e I t I
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offered for If, e the b ddid, at itatim,emorl k sold ',thin car of
the 'n builder brdenofprovngmth ddnotbrlaor
'601 —' ROOF = OFF:
completion, will
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ilnprn er parpt,arnr I - -
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F - 602 — ROOF,`PLYWOOD NAIL
o L a' sti r one pr e ty ly a roofing ,h l t rd eat t r: n
13 d Parnassian, il d The
' ' 60 3 .ROOF BATTENS .
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imWet the present (5 in a
License fLawJmmn,a apply p p ty bull' tip ferwm
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604 — ROOF IN—PROGRESS n.
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I wan omrtnw L .an prnleew win ommnmaa) 1 eti.ul pnr.aa,t m. mo
Law:.
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❑lam exempt under Sec. ,B &PCfor Nis
111 mor exempt pt arge
Owner Dnec
- ' WORKER'S COMPENSATION DECLARATION
Ihereby affifor are" penalty fP J Y c ra III ,d I t
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❑ d ill t C tf t [C et t If f Work,,',
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-Col p f p d d t by Section f 3700 t Labor C d f the
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pert tiff kl I' M1tl': p t d. ,
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°'1 v and will ablation W Let's C and, did. 1. ummucl', a rectured by Section
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3700 of the Labor Colle, For the performance of [no work for which i1finTintall is
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maned My Worker, Conam,nsummi Insurance ra 'er and Policy murder mm,
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Local:
CERTIFICATION Fit PXEMPf10N FROM WORKERS'
- COMPENSATION INSURANCE
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(,,l 'mf nneed Ibe completed Ca 1 n t' fo hu Wmddoll. is
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I cenpl Net n In of d work for which N Fiction 1
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shell t t empl in ma r, ,,1c,
icy [Anson Y : t tame subject to the Wnrkcre'-
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Com'en d<n Law, ofCalifimmi.. Uam
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Applicant
NM IC LT OAP LICANT f, after narkingthis centineacurEscomphor, you h u
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becomic,subject ill NtW k r ar cca a o. p lfth Lathe, Code. y no t,,
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ror M1wfill n ply with r6h Pr ro i: ne resulted.
, r Ih permit eht II bed iced
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_, CONSTRUCTION LENDING AGENCY
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I c icy' ff I then there t net on lending agency! c @e tm
perfoence
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work fir wh ah ll I rnlis slued (SCe 3097 C, C)
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annual's Name
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Lender: Address
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1certify that l have read OLs application stiff stale that (lie above information, is
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coned l agree m co of ly with all city and county onfirrances and state laws relining
tobuilding faaamcton dl IyvuNO (f the to
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p es of city enter upon-
the abovo ice n aped p l icy, fT invpecti t pamp
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We) agree dtmify and keep h less the City of Cupertino against
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limbilifles, judgmerts, rolls and expenses which may,in try way accrue against sad.
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Cry in aegteneo off gamin,of ilrti Perri
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APPLICANT UNDERSTANDS AND WILL COMPLY WITHA_LLNON -POINT
Issued y: Date
SOURCE REGULATIONS'
Slgnaturc of Applicanllconnmmr >�Dme
RB -COOPS
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HAZARDOUS MATERIALS DISCLOSURE ( -
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' Will the rpplirnt umbra building nccupunr.Inre or manic hiourdousnrcerad
of Roof - , - •. ` -
as delmirl by the Ctparnntan Municipal Cole Coulter 9.12, and the Henth and Safety.
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Code, O year
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2553z
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All roofs shall be inspected prior to any roofing material being installed.:.
Will the applradnl officture n Id s mmapant ow equ p to t which
If a roof is installed without first obtaining' an inspection, I agree to remove
moil hnza'douaar eonlamnann asderned by the Bay Are A Qtalty Ma age ions
District, c
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all new materials for - inspection,' Applicant understands and will comply. with
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on point source regulations
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Ch VI G95 ff Itr read h J t q net: under
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Culs H IN k NinetyCal S f n. 25505 25533 d 25534 1 J ug=
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fee'n d 11 In an yoponsibilinytal trN'
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t cyu e t h tit xt b n t eIm sic f C li me of
Signature of Applicant. :.' , - Date,,.
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, , . .,. All roof coverings to.be.Class "B" or better
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Owr` ufmi,rd agent ,Date