00120123 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: I'F.RMIT NO.
OWNER'S NAME: APPLICAI ION SUB DATE.
PHONE. 1 v f- - R9YAl- SANITARY NO. - CONNOP.No.
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. B' 'F t _ UNT_ INFO
m0O BLDGILFCIPLUMB
MEC
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UWWU L_-1 I=1 I= Cl xlS ` J _
3321
IC17NSI2I)CoNIRAOR'SDECI.ARAIION
Job Description ,
1 hereby m;irn,mm 1 am licunmd unJm provlilun,of Cha,cr 9(ennunencing
=t; with Sestion7difin Uivisinn 3nf also Bu,ine,s and Roles ions CsWc.and mylicrnsc
In Iiunder as rite
of
License
ca9_ Lie.»�Co9 (o
Lane_I /'�. e'v ContnnRr-P-zoi
�
3 ea n ARCf11lEM S DECLARAHON
� � 1 5 I understand my plana shall M1e u<eJ us public recoNs
w_c o Licensed Pmre>,lonal - REROOF y/
OWNER-BUILDER DECLARATION
O
�` I hereby aRimt that 1 ane eampt fpm me Coal mmor'.a Liao,Law for the O
F% following reason.(Section 8111.5.business and Professions Critic:Any city m«mmy /
F p which requires u pennh to construct,alcor,imPruve,dmnnlieh,or iepairm y smcture -
C prior to ill m &t icnce.a requires the applicant for such permiun file a signed statement
ass m;nheislit cn.edpatL.1111nlhem pmtot'dicemnnnor,uceno,Law tcname,9 Sq. Ft. Floor Area Valuation
(commencing with Seel ion'I(XX))of"Division J of the Iiu.mcss and Professions Cask)
or that he in exempt therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicanl for a permit ncbjc,,a mu uppficunt it a eivil"anal,
ofnotsomeNam rise hundred dollars(S51% APN Number - Occupancy Type
o6a rnrmeprnpeny.n my canphayee wire wage,a,mdraole en...'ti noon.
will Jo the work,and the stmetura is not intcnAeA or offered for sale(Sec.70,W.
falsities,and PnJusaions Cotle:'I IDI Conbacmr',1-kenxo Law docs not apply w;in Required Inspections .
,osric,of property Who Nwilds or improve,thereon.and whI does such work himself
Lir Ommgb hlo own mupinycc,.pr.aided cont,Lich impmvenneto,me not intended or
offered for ale.If,however.the building or improvement is%old within one year of 3261805B. 1.1 1
Impletion,the owner-holder will have the burden of Proving that he did not build or
impose for purpose of sale.). -
LI I, 0I'he pnnpedy,n .seln.i,ely,tn,a,mng wire Germed commetore n, x305 — FRAME
owner
nnamet the ale%m(sea.9111 a.owner ow and Itiolproperty
whio h GsdoU The improves
tat o,an,
and h Law don.nm apply to nn owner tit propos who Houde s Itnn sua t to he .is7 — I IVSUI_AT I ON
and woo commas f.. web prlja7,wart a commetorcsl ucen..,l pursuant to me 1,01 - ROOF TEAR OFF
Contracaars Liccme Law.
❑I nm exempt tilde,Sees .B&P C For his re a son 602 •- ROOF PLYWOOD NAZI.
Owner Lane
WORKER'S COMPENSATION DECLARATION 603 — ROOF BATTENS
I hereby;d'foa ander penalty of perjm,one a.r the Following deemnnhon,: - 604 — ROOF IN-PROGRESS
❑ I hive anti will moirnnlo a Certificate ar C'onwm m wlGineure tip Worker's
Compensation. a, provided Far by Section 37Oo of the Later Cade, fir the
perfomumce of the work for which this permit is iImed,
r4ave and will maimain Worker's Cmnpcnmtinn Insurance,m required by Sell
3]1111 of the Labor Cn le.for the perfmm�mce of the work f r which this ;rl11
issued.MAAy Worker's Compensation In,urmee carrier and Pol i +
icy millor aam:1
Cmria,AAlee -- 'k {Xme_Pulky Nu.:_6-bjp`y=lfy L1
CER FIVICATION Op EXEMPTION FROM WORKERS'
COMPENSAIION INSURANCE
tgnis notion neral not be c'mpicmJ if Om pvnnit is fir ono hundred dnllun
W 00)orless.)
1 a atil',y mut in the performance of the work fur which this permit is issued l
shall not employ any person in any manner a,as In teatime subject m the Workers'
Conmenlation Laws of Cal Itumia.[)are
Applicant
NOTICE TO APPLICANT:It.after making this calibrate of Exemption,you shtmW
re-,t c tFj...w the Worker,Con.pcnsulno aosisiunn II dm Labor Clde,Youmoa
0 Q ftMhwith comply with such provisions or this permit Nall be deancal rooked,
6
CONS'FRUC I ION LENDING AGENCY
a 7 I hammy affirm that them is a construction lending agency for the performance
oI the wads for whld thio pernm i,issued(sec.3097,Civ,C.)
0. Q Lender's Name
7 Z Lender's Add—,
V 1 certify that I have read this application and state that the al information i,
If. [~ corn t I agree to conold,wlth all cily' d counly oolinaaces and state laws relaning .
Q r,
it)building .onei dM1 a m P Pt '. fm rya t pm — 1
mo f d sa p ty Ia t I I
t^. d
(We)agree t enJe l dAphryi theCry rCpen against
Y) I'it t 1Jbt eats,c t 1 Ix h h Y .n)way recent,against,DIA
V L AP (CANT UNDconsequenceERSTANDS
of mo grant DS A of WILL nu. T .
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued *-
Si
\tig'/ �71f CG/ Date �-��'
SOUR 11!RF ULAIIONti. �d/
sg�... ppli'ato mar f he Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future landing aeoupant.ane or hamlle havardous material Type of Roof
us Jetimxl by the Cupcmno MunieipalC c,Chnp¢a 9.12.and the l{c:Jm unA Sutbry
Code.Section 25932W)^
El yea All roofs shall be inspected prior to any roofing material being installed.
walmeap,heard'i,I I hold s'real'aatuseewipmento,Je,is=s Nuh If a roof is installed without first obtaining an inspection, 1 agree to remove
snit ha m lous air sinful int",s a,J! d hY the l,ay Amu Air Qualify Mmoa,c n-d
-DiadeL' ta` all new materials for inspection. Applicant understands and will comply with
oyes Y-11 all non-point source regulations.
1 Italic read the haeurdmn materials requirements under Chapter 695 of tiro
Culifomia llemlth.F Safety Cmlc.Seaton,25505.^--5533 mW 25534.1 undenwnd that
ifthe huil,I l,"'ontcuol,'Ihave ns,he e,iti, ,,y m,pmslnllitymnmify me Y � /� /9 /�jo
emmm ar the ,%nl t curie which pmt ac nae prior m i,,vuuncu Is.I1 Ccrtilibuy er Y {
Occupancy.
Ylgna re of Applicant Date
().net,),2axed agnnr nate All roof coverings to be Class "B" or better
OFFICE