00080173CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
HU ILDING ADDRESS:
ime
I'IiRhll'1' NO.
O11WNER'S NAWll —
`' , ROOFING
APPLICATION IOM"
ARCHITECTAENGINEER:
M08)279-6t7t
BUILDING P12Rhfl'1INFO
BLDG I.111L' I'I.UMII MI:CH
LICENSED CONI RAC'['OR'S DECLARAf]ON
Job Description
Iam.fthe dander nsof Cha p¢,9(commencing
Ilion
andfor
o
with Section ]Ixxd of Divi.inn 1 of the Bu,inesa orad I'rufcuninns Cuda orad my lianm
70affirn Us
full force :rod elfec —reqq qqQQ
C,In„ Lic. k ��0
Licanc
)mc $ Cu,nmont_�rJ��
,„.
* NO CONDITIONS -
ARCIIIIIiCI"S DECI.ARAIION
1 undersand as, plias snau ne used a, penfie maYra
Licenced Professional
OW A'I'ION
U.I
I hereby uffim, ,hm I am e,cmpt from the Co ttrecmfs Liccnx• Lux' lir, the
031.5,UIIA1i1t
and Pmfcesio
]W LA Poe C oc'. Nry city structure
lermit
is,Iluwinu ices a t r,Masi after. li h. or repair anystructure
x'nich
le,",arerte....con,tme6alter,ilto111demnnah,
prier n, p ter such pe u,igen( aunemum
the thevision
Sy. Ft. Floor Area
'
tion
s Live
nt to o the Contractor's Li
%l ceased pural suant (Chint,
thin hareaLl,
pu,,fli
7tbeprnvisionion ad Prat,,
and Cenci
iI eid Calc)'
leg wish ]m
or thatteeY
Any vi
for the corruption. Any violation
t therefrom and the or the le
or ohm he is exempt they LITI ural the
or
ore ct,the no
of 1.5 by Y...ppmm„ fir a penrdt .nnjenn me npnfiwm m Y siva penahy
APN Number
y c
nomSection e h
of no, more man fisc nYradmd dollars (S500).
❑ 1. as owner of the propenyl o, toy nnployec, won wage, an their sale compensmiva.
kl4uired Inspections
will no the work and arc cunm,ue is not intended n, oferea for ,ale (Sep. 7W4.-71,632.
Busur,s and Profession, Cale: The Cn inannr'n License Law down nes apply a, in
r of property Who band, or improves thereon, and who does such work inni
or through his own employees, provided that such improver. arc nol intended or
hnldmimprovement Iold
305 — FRAME
offered for sale. If, however, the g or „ within one year or
"ample lon, the owne'lea ds, will huce .he burden of pricing thea he did not I ill nr
-• INSULATION
irruptive forpmpcs.of,:de.I.
307
❑L asawner of pro,any.ams,cludscly, contracting with licensed coutmmoa to
- 601 — ROOF TEAR OFF
Lon,orao the project (See 7044. Bri,we,s mul Prolas.io I, Cod,) Tl e Ca.wetor',
— ROOF PLYWOOD NAIL
icense Law docs ma apply ,,arcane, afloopeny who Wild, or Improve, nucleon.
61tt
and who eonbansfor such Injects with a eonbnen,rlq Iiannecd par,mou ou .hc
— ROOF BATTENS
Comeacon',LictmeL..
603
❑1an, eaenuomaderSee. BxPClo, has re'aon
604- — ROOF IN—PROGRESS
WORKER'S COAIPF.NS,[I'IO.N DECLARATION
'
I hereby affirm under penalty of perjury one of the following declarations
'
❑ 1 have rand will andare n a Cenificme od' Consent mself-insure Be Worker's
C.... mcneatin s provided fur by Sectio, PW of the Lobar Cala f r the
perfontmoee of the work for which this Iannil is issued.
have and will maintain Workers Compensation Insurance, as required by Section
Y�I
Jl x) "''he Labor Cndc, for the perfummnm of the work for which this permit is
-
issued. My Worker's Compensation Imunntce currier and Policy nnmher um.
,
Carrier,92I,neCC Neri"11 Palmy No., (awhodl7lig_C(�
CERTIFICATION Olt M%'MPrION I'RONI W ORKERS'
.
'
COMPENSATION INSURANCE
('I his seen o I need not be is I land i1'.hc permit I, fe, ono lood'cd dollar.
fig I00) or tce.)
I cenify that in the performance of the walk for which this permit is issued, I
,hall ran Yn,ploy any Ian'on , I— a neem m me waneR
`p�
'
Cantlanmt'on La fCalifomiu m
Appllcnot �f,1rr
Atli
NOTICIi TOAPP Youemashould
tris,,i,i cmeof E,,h...
CatikeL must
lac Code,
ncemuc,uh'im he W..k provisiohall
visions
r his he decimal
rcnnx;m canply »am .ace Provisions or this permit serol Ina deemed revoke..
1, such r
CONsTRUCI']ON LENDING AGENCY
I hemhyMinn hal here is a e..nari Inuring ri for the rcharname
of .he work for which this permit is issued (Sec. 3097. Ci, C.)
Lender's Nume
r
Lender's Address
1 cenify Ilett 1 have ,ad this application and.twe than the above intb.n.kill on .s
rte., I agree It, emn, ly wits all city and county ort irmnen and ,m¢ laws mlwin6
m building co i,mi, inn, and hi all rieereprescano,cx or this sly to mine,' Ipra
,
the chose-ancrained progeny for inspemion purr„ses.
(Wc) ngrcc to cave, indemnify and keep It I... he City al Eli f'ol n uguinet
'
liabilities, jullmart s, east, and enpenmc which may in any way accrue against said
City in cnmcyucncu of the granting al da, Penni..
AND WILL COMPLY WITH ALL NON-POINT
L-y
Y
APPLICANT UNDERSTANDS
Issued by: Dale 2-yt—
y'
SOURCE REGULATIONS,
Re-roofs
Signnnic,I' AppliwaI1Cunuuum [)me
HA ,\RDOUS MATERIALS DISCLOSURE
Will,he'uppOrnmor Ilam hrmding.cenp...n.clorcor haolle bmarelonn,natedal
Type of Roof '
m defined by the Cupcnino Municipal Cade. Ch firer 9.12, and the Health and Safety
Code, Sema„ 25532(Olt
❑Yes ON.
All roofs shall be inspected prior to any rooting material being installed. .
Will the applicant orfuture building weapamc,ee9Yipnaator devices Moth
If a roof is installed without first obtaining an inspection, 1 agree to remove
mi, h.valloo, air containment, an defined ray .he Bay Area Air Quality Management
Di'lawo
. all new materials for inspection. Applicant understands and will comply with
❑Yes 0N
all non-point source regulations.'
In... read flue h...Nnus mmerial, orgiremem. under Chapter 6.95 .1 he
crtlioncia
1f the building d«a nol n.r,cndy hall, a tcnum, that it is my mgxm.ibiliry to notify the
gla I+oo
raeYpant it the re9nhcnii which .a„ he n.e, ndnr m ku,lmeona Cenifiwm of
�114ta,� o
O-el.. n r/
Signature of Applicant Date
All roof coverings to be Class "B" or better
UnaamorYYmod,edagent D:.m
urrfce