00090131 (2) CITYILLDi c DIVISIONNO CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMITNO.
OWNHR'SNAMI:. + ,I,
♦ APPLICATION SUB DATE
HONE', , IR1 - 0/20 0 .
• SANITARY NO.STRIAl - RD 1121 1CON TROL NO.-
W qX ARCHITECT/ENGINEGR: , BUILDING PERM['1'INFO
BLDG ELECT PLUMB MECH
y¢a I_l fJ f� CI
Z S = LICENSED CONTRACTOR'S'DECLARATION - - ] b Description O Z—C I hereby m uffuthat 1 bin n
licece under pmvisiuns of Chapter 9(eundroming pf
q m J wish Smuen conn mi,imm�n cane nn.ina.ana Proro„ntn.c ee,and my uan,t -
m^�
I,in fit]Rare any,ni�pp
WIu Licrn,oC (_.J� Lic.M O(o[O O
a LL y Daleo-b— conn e,,,r SHAKE TO COMP SHINGLE
,5 ¢ ARCHITECT'S DECLARATION
d :onJ yplan—holl be eda pubfirmcord,
yse
a00 I,eco dP 1: _ -
k o iOWNER-BUILDER.In, AVON
W!2 I tarsal m t1 t l ,in f th C , t , Law f,r thefoll ��
which
g fe .(S c, 7831.5 B : vnJ P f a d o A y troy
nary
Fo h l yu p n ,' t lt - 'np d T.h p ' y., cart
3m Pro r t ,lona to rectnesmara tt Caltd mtiu Men -
InorieervingIs sedpunuaoue00)ofiiion.n 3 of th Busines Land ProdlawollsCor9.
) S Ft. Floor Area
or that he its exempt InIonor, nd the hsiohe the alleged ProrAnyv,code) 9• aluation
or thin he is 31_1 b tbay to,pi und,hc'Pone fns the subjects
th exticant l.Any vPenalty
of Suction]031.5 by any vpplicam far v'I,unni,wM1leek the applicant to n civil poetry `CI
anmrm,ne,haa rye handreadolmrs(s58m., APN Number .' OccupancY yPe
❑i, nn p pet structure v pI r " ... ,
will I ,h k thetintended tYrell sec, to an
Business and Professions c n n Contractor's 1 1 does pkhimel `r` f& cored Inspections
w r ofh his(ty em to Ids or provided
fo rM1 coat nna hit eats such wink himself,I P
lir through his awn however the
provided,or,such vementememrurc not inended fir M
offered Inrsale..' ct burden winos t erimpmvemtb,.i„land he did are y,or of _ 305 — FRAME .
onin lefo,moeweenbmlaer will nage me carton arnraalag titin he cid nor nnim or 307 — I'NSULAT ION
Intpmve far purpose of sale.l
❑has nwomrofthe,... ty.arae.eled,elycentrnmiagwith licensed offl,acta..no• 601 — ROOF TEAR OFF
- -coram are pnji,er(Sec.70,4,ensines,and prnfesstoa.Core)The Contraam2e rF..O^e' — ROOF PLYWOOD NAIL
❑canoe Law roes not-11111 Lane owner of Impeny whe builds fir impanon,thercan, •anti who commas far such pmjecs with a cnntractodo)licensed parwnm m the
Cenlmetnfs Liceam Law. 603 — ROOF BATTENS.
❑I vin exampl anacr Sen. ,B&v C for tin,roa,nn - . 504 — ROOF IN--PROGRESS
Owner Dam
WORKER'S COMPENSATION DECLARATION -
I hereby affirm under,penalty of perjury onto(the following drelfratina,:
❑ I have and will bailout;v Cenificate of Cooled to, velr-inmm far Worker -
Compensation, Ii provided fur by Section 3700 or the Labor Code, for the
performance of the work for which this permlt is issued. -
I have and will maintain Worker's Compemmtnn Incunmce,no required by Section
37 1 of the Labor Code,for the pcourt once of,ha work far which,his permit is
blood.My Wbrk•', ,nation asorance carrier and Policy i nmher arc: p
Cnrricn_��y��Policy Nn: i�Q/ -
CERTIPICAI'ION D EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This semina need nut be ntmphe'd it the panni,is for no hundred dollars
IS100) aocv) _ .-
I certify Inv(in the perfommnce of the work for which,his pc it.,ninon,1
shell not employ any penia in any banner so aw m become subject to the Worked' -
"a"mob laden Laws of Culifnrn ic.Dine -
APPIIaun -
NOTICHTOAPPLICANT:IL ager nmking this Cenilcvm of Exemption, ushered
Z heeene.ahjem 10 rhe Worker',Cnmpensaenn provisions(of the Lab or Code,you mn,t -
O fonhwi,h comply with.ach provisions or this perm's shall he reemeJ revoker.
z
CONSION LENDING AGBNCY; I hemhy orlon that rheaem is is a v nmxm(See lending e.C,) fonhe performance
A. ti LeaewoNunn,which,hi.v permit is issued(Sec.9!197,Civ.C)
A Lmtdcrs Numc
A. z Ixndv's Addres • ,
C '-"let
that l h I this 'applicationJ T, th t the b t
or nationis '
[� -tree, I upme 11,comply with II cily ad coolly l a e:a d:are laws rclaY ,
to mild' g rondoaction,andhruby ardbanIm 1,nesendannot,of this 1yt Iter upon
the aheve-ro n k ca pmptny form,conce purposes.
[y G (WI)rilowl at I've andearnifytold ke p latiblese,theCity fC p n' oa'aml
i..i V] "nhilit judg
V tcost d s swti h yin any w y c uec
City it lial,trencrofth grabor bi
APPLICANT UNDERSTANDS p , PY WITH ALL NON g OinI
SOURCE REGULATIONS — n said p
'
'
q oo issued by: ` `tel - Date
Signvwre of Applicem/CmnromorIF Date Re-roofs -
HAZARDOUS MATERIALS DISCLOSURE -Will are applicant or future banding ecaupant,om or handle naxaolen,nta,edal Type of Roof .
us defined by the Cupertino Mmiclpal Code,Chapter 9.12,nna the Health rind Safety, yP
Caaq Sca(i.,,25532(a)7 .. _
IDY`° " ' •' All roofs shall be inspected prior to any roofing material being installed.
Will'he uppueannorrmorenniminsottapan„n.eegtapmea,o,do which 11'a roof is installed without first obtaining an inspection, I agree to•remove
all maardaec am cmneraccumns defined by line say Area Air Quality Monagement b P g
”'""oYc 9 all new materials for inspection. Applicant understands and will comply with
all non-point source regulations. -
i h d the di i l I :as q t'undo CI apt 695 of,he
if b",' Health&Safra}Code,S f ,25505 25533 td25534 I I neva odthat
If the hgditgl .nut currentlyh amint that", ray resp "hlty, ready the ' 20 OO
eeura t f the n 'reme , h cl .the t pr , issuance F a C l luvre of -
Occup
9 Signature of Appli ant Date
Owens. am deed agent tem All roof coverings to be Class "B”or better
OFFICE