00050107 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HUILDING AI
2 70 MARTINWOOD WY PHRMITNO.
O`h'NCR'S N'MII AO APPLICATION SUB D
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PHONL SANITARY NO, 1.
9 I J
ARCHITECYIENGINEERo BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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ZO S��z LICBNSEDCON'FRAMOR'S DECLARATION Job Description
I C 1 henry affil Ila elion leaned under pnwi.ions al Charter)(conmmming p
p v:kw wins Sin(ion 7lNXq of Divlsinn3ot(hc Buxinc,x:mA rmtro,ma Cadcadni,karse
zx ; t,m full force and ff �
c 6 Liccnm C].. Lie Lic.If
m
e.w U Date Convenor
3 u.In ARCHI"FFCr'S DECI.AR—All 0N
t'=eI land mmJ tryplans.h heuxd.,public.md,
�M�; - RE—ROOF
El6 p I' 'rot• r
ON'NIiH-11UILDIiR Dr;C1,AItAr1ON
cby affirm that I ait exempt from We Contractor's License Law far the O
F.a a following reason.,Section 703 1 S.Holmes,and Pollessions Cade:Any city or county
F O which myI a peril to construct,alter,improve,demolish,or repair any momentum
ne pnortoitxissua.ce,ah.:eenacts the ap�licam fart such pennino BlcusigneJ mammem
(hal he is licensed pursuant to the pmvismns of the Contractors Liceaw[.me(Chapter 9 Sq. Ft. Floor Area Valuation
(rommming with se f....7obm of oiviaim,3 prom Bu,incaa and 1)ho,ions Code) $8900
or that be Is cxentpt thctetront and the basis for the alleged cxcmptioa Any violation
or Section 7031.5 by any applicant far u snit subjects the applicant it).civil penalty
of not mom than fivchundred dollars,(SNH). AP3Ndtt�.lie�r�8. 00 Occupancy Type
on W
01,as owner of the prapeny,or my employees with wages as their sale compensation.
will do the work.and the swaure is not intended or offered for sale(Sec.70,14.
Bu'mu,,and probes ror,Code:'I he Cualnc,r,Idcerw,Law lutea ren apply In a. Required Inspections
r alproperly Who build.ur In:pravu.thcfcon,and who dam such work naa,cll'
or through his own employee.provided that such improvements am not intended or
offered for sale.IL however,the building or haprnvcmcnt is laid within line year of
completion,the a.,-ncolmimer.ill nage the burden of pmving that he did not Wild or 305 — FRAME
improve for purmwn of vleJ.
01,as owner of the propert,ren exclusively contracting w'tm licensed contractor,In 307 — INSULATION
Lino nel the project(Sec.nw4.Hn, s and Profc,an,Cala:l'Ilie contractor. 601 — ROOF TEAR OFF
ca e Law doe :ot.pplr ,,an I ,of pnq,any who halm ur iittprovI,Nemon.
and ho con(.I,far m,h Oujaelsawith a catanaaaa,)horowd I,.,.,a,to the 602 — ROOF PLYWOOD NAIL.
Commerar',lJorme Lase.
0 l am eempl comer Sec. .B R PC far this Amsor, 603 — ROOF BATTENS
Dun"- 1 IN
unar1IN r7—oP6—� 604 — ROOF TN—PROGRESS
C PENSA'I'ION DECLARATION
I hamb alimt under lmnulty ul esrjur" one 0 t he rollowing Jedaations:
0 I have and will maintain a Ccrlilicate of Corwin to self-imam for Worker's
Compensation. m provided for by Section 371X1 of the Labour Coda. far the
,information of the work for which this .it is issued.
01 have and will aminmin W..mar'.Compenation Insurance,as required by Smtion '
3760 01'the Labor Crac,for the Imrformance of(he work far which(hi,permit is
sued.My W..la',CI i,,av inion Inwtance carrier nod Policy tmtnber ares
Carrier. Policy No.:
CERTIFICATION OP EXEM"EON FROM WORKERS'
COMPENSATION INSURANCE '
(Phis section need ant h.m.... led if the permit is for one hundred dollars
(5100,m Ic".)
1 vanity Ihm in the pcoi roarm,of the work ror which,his permit is koad.1
shall am employ any ,,at in any manner sq as m bernme subject as the Waders'
C."han" Linn Laws n lifomia.Dat
Applicant
Ill'ICF.' A it
linking Ihi.Canificam of Exunption.you should
baaante whje, m theay'rker'.C:m:pen.otsan pmvixinn,u[(ha Lubin Coda,you mtam
C O I'onhwlth comply wi0 uch provisions lir d:i,permit shall be dccmnl mvnkW.
r
4 CONSTRl1C1'ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of the work for which this parnm is issued(Sea.3097,Ci,C.)
Q 1<nd,C,Name
7 z Lcrehm',Address
U 0 I certify that I have read this applicellnn and stem that(he above Intiu..a, i is o mud.I agree m:comply with all city and county ordinances and state laws relating
0 r,I rebuilding construction.and hereby.u(hmiA,represenunive,afflak city toaster upon
the.hive"mentioned unfairly for inspection purpows.
F�•, y fWe)agme to save,indemnify and kap harmless the City of Cupertino against
► [A Iiabil ities,judgments,costs and expanxs which may in any way acerae against said
V z City in consequence of the granting of this permil.
A PPLICANT U N UERSTA N US AN D WILL COMPLY WITH ALL NON.POINT Issued by: Date
SOURCE Rlig IVI ONS y'
sigpal a manDDate Re-roofs
ZA OUS MATE RIALS DISCLOSURE
Will the m .ai buildingat,am ahandle aNma.'a..]
Type of Roof
oedeBmdby lbaCaptnn Munici,,l Code,Chapter 9.12, ad the Health ad Safe,,
ta. un zss32m)?o
yes rel�
All roofs Shall be inspected prior to any rooting material being installed. ,
Will the I,Ihcam afirombuildmgamrupamuwcquipinantmdevices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hamrdou,air conmmiments as defined by dw Bay Area Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
Ove. N. all non-point source regulations.
I have mad he hamrdnus mamn.B rcquiremmnts under Ch oar,6.95 of the
Collforniu Health&S,loy Calc.Sealant25505.25533 and 25534.I maler.tma Nut
nebuilding Joc,nal currcn(ly Imvc a mnwt,th:n i(i,my re,rymsihility w notify Ihc —_--'en'%/ '�
IfcapanI of the ratio arem,which snow be ntet prior m issuance of x Cv,iheme of „�11AA( S
Daernera, Sign• ure of p-p cant Date
2 C.a
Data All roof coverings to be Class "B" or better
OFFICE