00110076 CITY OF CUPERTINO -
BUILDINc ntvtstON . • - , PERMIT ' ; =CONTRACTOR INFORMATION
BUII.DINGAID S' + � ABOtIE ALL ROOF INr PERMITNOfa6 I.';I.Ibt�Cr�r..
�'R61, BUBB RD
owNFRSN5IERRA LAND COMF!RNY„ .7k117J NORTHRUPST APPLICATIONs�ByMTP/` 0
'.PHONE , SANITARY NO. CONTROL NO
(408)292-4.1.88
M e4Z „ARCHITECTIENGINLER: j BUILDING PERMIT INFO
woo 'BLDG -ELECT" PLUMB MECH
F5 .a
rn 6
LICENSED a ineawdCTOk'S DFALARATION a�.h. ..
o z,�c - 1 n< by r)of m 1 'used tu pr n mr,Code9 a mane I g ° .` v. Job Description ^"
pW who Section]nn) rD' Sof lie Br: n dPrem.a eode:daxr _ '.BUTI_:TUFTO ;SAME' . •e" .
a r u f 'yc an fr�,e�t
tly44rt .n 12�L'3
z Ind o — Contractor
E a ARCHITECT,DECLARATION
J I lua rPl nuMl Irl L / ''
was
—pZS
ff thin pl form
the C muter
L I the
OWNER BUILDER R
1 thin,
Lrlg Section 7031.5.Business I Professions Code:Any city countyLicensed P ,, 1
Which
y -
!'
` pe it In .I t,alter,ammove, 1 Ish p'' y:,uclnx -
L3� pr: t I 'Inapplicantr hpermit 1 nsignedttemen
that he twercedp . I in the p of Contractors e 1 Chalice9 -Sq:Ft. FloorArea
r or eitgw'mSeubmmomdrnbma3urtheHg, a atdionsA �
anhat he is exbmpt IM1urcrrom and the auris far the alleged emm�ptinn.Any viobnion' -
.ofS f 7031.5 by any apPl'ram for ape I oval,me appicamuotvied pe alt,, T
of but msarveh Ieldelam(s5Bn) APN��aa77��T��uln��,{{yy,, r - Occupancy Type
Cl 1,bs owner if the ' ' - v4Jf4V.I t�G. 0
prowny,or employee.,with wages as(entitle compeasnion, _
wd]do he k and he I I :aid intended B dl salv Neu.70,14, - -
,BE d Prousimas Code:I lie c ntrcl :Incense Law does hot apply tont ' gg quired Inspections
wt r Ip p,rtrwn n la p m kr :3
tn.elr 05 .— FRAIh I
• or through h:awn v.,luycc:.foWmvd 0 t such' 1 o n nt are n l mounted or - -offered f .uv.If,however mebalditg r hummove,orsaa is sold within(are yet,,of =_',0.7 —` INSULATION -
- oI pie 1In old will have the burden nrpmv rg d i lo da not bold or
intpn ,f rpmpmeormle). 601 ' ROOF TEAR OFF
r
El 1. fd pvpenyanexmusvly. t r s withrcer.edetm net I 602 ROOF PLYWOOD NAIL
enu the p feel(See.7044,Business and Professions Code)The Contractor's
-
]mL,cen, ,a Law does notapplymanowneral emenywho bnikbe,ir arveslnereon, 603 - ROOF- BATTENS,
and who contracts lot such prome3s,with a munfo4a)habsed pursuant to roe X04 — ROOF !N—PROGRESS
va
Cancmr',lLaw.
❑I wn exempt under Sec' B&P C tar Isis beacon •.Y .- '
Owner Datc.
WORKEWSCOMPENSA'I'ION DECLARATION
I hereby affirm under pcnahy of lwrjury ane of the billowing de'lamtion c -
- Cl I h e'and will maintain a Certificateof Consent to II' sum for Workers
Compensation, as: promed for by Section 37W fthe Labor Code, for the - • -
performance of the wt k for which oda permit is x,ued - f - - '
❑1 have I II Intan Worker s Coupe f Insurance, 4 Iby Section
3700 of the
Labor Cede for the
gy ,,✓ p«Iv oPwork,for which th.per nt is
issued.MyW Worker's p ion Insurance carrier and Pl'y -
nherlfare: �. , , •
�yR �'lY1V Poly Ne:�'"'�u�lra. - ..
. . CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE' '
(Ih ,c(on need tot Mt cnmplclW dlhepernl ebo onohund�ed dnllnry yr _ 4
. •ISI WI I.sJ, .. `8',. - .. .
1 ecrdby that in the,performance tifthe work for which Phis permit is ixsued,I
.hull not employ any person in any number so as to become subject to We Workers'. -
CmnpensalionLawsofCaltheria.Dam - -
NOTICLTOAPPLICANT.'It,all makingin,CermF I f Evernitime,you should - , h
beem,nd suh,,birto lheW 6 .0 p p flu Lub Cdey muni _
Q Q
forthwith C tply With h p this permit II be de bed k L '
V CONSTRUCTION
Wa DQ L1 nareny afrml CONt thSTreRUaCTIcOaNdLENDING
ENDING AGENCY
y fin me performance
ter the work for which this Kemit is Is.ued(Sec.3097,Civ.CJ
endcSome
,
-
z Lcnd .Add ce..
V 0 I nertiy that I Iwvn read'this Ippliwalion ural state that the above information in ` - -
W E.Icorrect.I rime m comply with all city Ind county ordln uarto and xlate laws relining w
Q t..) to building chmWctinn,an'l hereby audience representative,nr this city la enter upon
y W me abuse.mmmoned pntPerry fur irnpecllon prepares..
-F (y - (W) gc n.cu' d fY dk Ph I,,,h City (Cup II agomt '
i..i
cit) Ilub 1'rle. j dgmemf. Is i J espouses Which nay in cry Way tome against sad
a V Z Cily 'y nceoflh b i gtftokpo el. , .- ,
'••' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE aecuLAnoes. 'Issued,by: - Date,' '
Signature of ApplicnmrCumractor `- Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building eccapantstore orhandle naaatdousmaterial Type of Roof
as dcfined by Ihr Cupertino Municipal Code Chapter 9.12,and the Health rand Safety C -
Code:Section 25532(a)`t
O Yes 11 No , All roofs shall be inspected prior to any roofing material being ifistalled. -
Will(lie applicant or future be Iding occaper,usee,lr p I or devices whish If a'roof is installed without first obtaining an inspection, I agree to remove,
emit h e contaminants -defined by theBay Area A Quality M mgmneal
Dist IoY - oN all new materials for inspection. Applicant understands.and will comply with
all�r on-point source regulations. y
1 lmic L)flo'bab,antan,matened,reschareareas md 'Chado;6'95 f the ,
CaliforniaHealth&Solely C J Scene.,2550525533 and25534 1 d,r,hundIh,
f I he bthemydoe, t currentlyn .shearl.thIt is an, ,a,In con,lythe q � -
scup t 1'In, quire a wh ch ora et n pr nr Io iss ce of a Cert rem f ' �t�� hJ��^-C3•l1..10 V I I D D '
Occupancy. Signature ofAPplicant - - }^' Date '
Ow mer c anmoni,ed agent - _Date. All roof coverings to be Class "B' or better
* OFFICE