00070069 CITY OF CUPERTINO
BUILDING DIVISD" PERMIT CONTRACTOR INFORMATION:
BUILDINGA IJ ;.5: t NO'
0541ur:R'S N OPWLETT
PACKARD APPLICATA 1 1 3AW21010t&
PHONE: SANITARY NO. CON'tROL NO.
O s]. ARCHITF.0(ENGINEER: BUILDING PERMIT INTO
�u O O BLDG ELECT PLUMB MECH
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y LICENSII QNTR9CfdOION
nerma m,fm l an ficiareand under provisions Of Chapter 9(commencing INTERIOR DE I ]L°f f R{IS°
i-
~ca with full force and effect. on3of,M))wines,anJ l'mrcminn.v crpNc and mYliame
in full farce and effect.
�c�a Liecn.e y �_ ��.yl
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5.w vOFi Uwu— ,�$o Gnanm,or
w nu h.II be'r'5 De main,
t"°3 1,:ndc,%,and my Nae.%non x,,,en 2s panBc neon¢% .
u i p C Licensed Professional
thinOWNER-BUILDER amptIn or the RATION
n ux3 V m 1 hereby affirm thin 1 um exempt ram the Contractor is Llanse 1,o for the
%G '¢hawing n n.f5."I, ,'IB315.Itu,i red o,cn a Cush:Any cilY ur mIY
ce O pric, y e.mit) t t 'II , 1 d I'I I y.t ¢lure
to 6pnan 1, alsorequires,he applicantf such I IIsignedstatement
mato is Ic ,cdi ,sea t' m Pont_ ns nn c t a .1 Le len aide Sy. Ft. Floor Area
(commencing with Section 70(k)of Division 3 of the Business and Profess on%CIAO '
or that he is exempt therefrom and the halt,for the alleged exemption.Any violation
of Section 71315 by any:tPPllcam for a pennit subjects the applicant to a civil penalty
Ofm,,team reran five mmdreddana:.(s500) A I r5�• -Occupancy Type
❑1,w owner of the Pmp,rt,or my employccs with wages as fair role cs,uu,r,a'ion.
rill do the work,and he mactur,is not intended or Offend for.ale(Sec.7(1W, Ng—ASS I GNERqgtAM69 '9FeTi6RJS
Business and PmNs%ion%Code:The Contractor's License Low does not apply u,an
owner of property Who builds or improves,hereon,and who does such work himself
:, hrough his own a ple,va, pm,idad Ilan rcnch improv ant are nm,in ndcd n
offered fit Oa e.If,lin ,.the handing o mprt nusis sold within....e Dar of
wuil
oprove for favow r-builder will hove the burden of proving that he did not build or
improve for puH,p%e u[svlcJ.
❑1,as our of the property,an,exclusively ca ntmaing w ith licensed amaracmrs 1. f
amct the pmjeci(Sec.7(94,Business and Professions Codc:)The Contractor's
L ncaaw Law doe,no,apply ha an ownet Or property woo hands or improves Iheeon,
and who ansa,,,to,snob prejmu whh a uaaoeat(,) licewcd pucnunl to In, ..
cman clot,Liecnse Law.
❑1 an,exempt under Sec. .H k VC to''his rcaam
Owner Dare
WORKER'S COMPENSATION DECLAR6I'ION
I hemhy mtinn and er..maty al Perjury I n,of Iellowing decluradolls:
O 1 have and will maintain a Certificate of Consent In,ell-insure for Worker's
Comlensalion, as provided for by Section 3700 of he Labor Code, for the
performance of he work for which his Ienmit ix issued.
41 i71N1
have and will nndmain Worker,Companxmion Inwrame,its mpainol by Section
ul the Labor Code,lar Inc pc%Ibnnuna Or the work lar which this pertnk is
issue],My Worker's Con,pcnsmion Inamnce carie,and I'nllcy nutnher ore:
camer: e�S$'?'1A —Policy No.:
CLRTII CATION OF EXEMPTION FROM WORKERS' /
COMPENSATION INSURANCE ` Jr
('Phis%action need nal be cotnpl¢Iul it the pcnnil is lar ane hundred dullam
(SHIP)IP)or last.)
I sanity that in the perfamana of the work for which Ibis pencil is issued,I
.hall not employ any Person in any manner so a,to hecon,e subject to the Workers'
Caml,ens,aiun Law%o(Cularmit Date
Am,licml
NCH ICH'm APPLICANT:Il,eller making tis Ccnifinne of Exetnp'ion,you should
hec... o%uhjec,la the Worker,Compen%mian provi,ions of the I,uhor Code.You mutt
O forthwith comply'with web pmvi%ions or(Ink permit shall he deemed revoked.
Z
^F V) CONSTRUCTION LENDING AGENCY
^ 1larcby aflirn„hin there is a comnuction lending agency for the perforniance
d the work lar which this pamll is issued(See.3097,Civ.C)
0. Q Lender's Nana
,z
Leader'%Address
V I cenify that 1 have read this application and state that the above information i,
correct.I agree to comply will all city and county ordinances and state laws relating
Q C_) u,bui,ding con,imvdon,and hereby 2olhnrile teprewnativeu of this city to enter upon
ri] the afavntnenlloned pmporlY l ur inspection parpo,ex
(We)agree menses indemnify attd keep banal..%the Cityuf Cupenlnn again%(
IA luddlllia,judgments,costs and expmcmcs which may in any way accme against%aid
U Z City in consequence of the foaming or this panni'. _
APPLICANT UNDERSTANDS AND WILL COMPLY WIT IIALLNON-POINT Issued by: Dote
SOURCE REGULATIONS.
Signature of Appllcantconaramm - Daw Re-roofs
HA/ARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding Occupant%rare or ha„dlc haeardon,mmeri:u Type of Roof
as defined by the Cupertino Municipal Code Chapter 9.L2.and the Health and Safety
Code,Section 2553212)1
❑ N
All roofs shall be inspected prior to any roofing material being installed,
Will the applfaamO. done f:Bdiagaec,tn2mn%e,•gnimnentordevi«%whim If a roof is installed without first obtaining an inspection, I agree to remove
ctnit Imandow air cnnmmiumal a,dellncd by the Ray Arca Air Quah'l Monagcnent
Di,tHc,? all new materials for inspection. Applicant understands and will comply with
❑re% olso all non-point source regulations.
I have read the hae:odow materials nyuirematas under Chapter 695 of,he
Calif nm o Health a,Sulo,Code,Sections 25505,25533 and 25534.1 un l,oland that
1f the hit iIII ing does nal currently have u naanl,dun it is my m Jaau,lhi l try,o nobly the
occupant of the reynircnmtn%which mast he me prior in issuance of v Cal ifmote of ._
.popsy Signature of Applicant Date
07� 3 a0 All roof coverings to be Class "B” or better
moorino I,. aycal Irate