05070024 CITY OF CUPE
BUILDING DIVISION PERMIT CONTRACTOR_INFORMATION:m.
BUILDING ADDRESS: PERMIT NO
CURT FLETSCHER ROOFING INC 05070024
91 59() ATITITNT(:TnAT f T ._....—
OWNER'S NAME: PERMIT ISSUE DATE
COSTA TSOBANAKTR 'iS4 MONTT("T.T,T,n nVP -r0 f y' l5
NE' SANITARY 0 CONTROL NO
(4081267-2679 __ _ __. __
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
001
w I hereby affirm that 1 am ftheSt under provisions of Chaplet 9(commencing o esenphon
iW with Section and DrvlsionJ of dm Busmcssand Pmfcssmn<Codc,and my Desoto is
imm�mrteanderrem 7 6 REROOF W/COMP. SHINGLES
p z Liccnsc Clan _ J 9 Conic
Dow p_) -e,3 ARCHITECTS DECLARATION
TS
LARATION
nU 1 understand my plans shall W uaJ a public records - �krnrn
0.t; Licensed Professional V/
03 OWNER-BUILDER DECLARATION t7
I I hereby affirm Not 1 am exempt form tW Contractors Liccnu IAw fur the Jam,
as O following mason (Secuun 7031.5.Business and professions Cale:Any City or county
K$ which requires a frourn to construct,altar.Improve,demolish,or repair any xtructum C ^7 G n
y26 prior it)its R mm
ivarec.ahur motorcar the applicant for such p[ l to Ble a signed statement - -
s that he is licensed pursuamloNCpmnsumofOeContractorilx<nclAw(Chapter 9 Sq. FL Floor Area Valuation
'F0 (commencing with Section 70W)of Division J of the Business and Professions Code)or
i Out he u exempt tW mform and the basis for the alleged exemption.Any violation of
Section 7031.5 by anyapphcant fora Permit objects the vpplaaant to a civil penally of 35AdPI2td4gr00 Occupancy Type
not morn Nan five hundred d.IWA;
Q 1,as owner of the property,or my employees with wages as their sole compensation, -
will do the work And the structure is not intended or offered fur.e.(See.7W,Business
and Pmfesnans Code:The Contractors Liamet Law dos not pply as in owner of Required Inspections
property who builds orimprovss Ihemun,and who doessuch work himself orthrough his
Own cmployces,provided Nat such improwmcnu arc not amended oro @red forsale.if,
however,the Wildng or improvement is to within one leaf of complcuon,the Owoer-
builder will hale the burden of proving Nn he did not Wild or improve for purpou of
sale.).
❑1,as Owner of the property,am exclusively contracting with licensed convacbn to
armorer the project(Sec.7()44,Business and Profeurorts Code:)The Contractors Lt-
ante Law door not apply 0 in Owner of property who Wilds of improves drmon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
Liearm law
❑I Om exempt under See .B&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of pequry one of the following declarelmns:
1 haw and will mammn a Camfcmm of Consent in self-insum for Workers Compcm
anon,a provided for by Section 37W of the labor Code.for the pcRormaac of One
work for which this perms is issued
❑1 have and will maintain Workers Compensation Insumna.az acquired by Section
3700 of the labor Cost,for the performance Of the work for which this Permit is issued.
My workee,C mPe far and Policy number
Camcc
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This=auto need not W completed if l W permit Is fOrone hundred doll=(SIM)
or laic)
1 moor fy Not in the performance of the work for which this permit is issued,l shall net
employ an)Person in any manner sit as in become subject to One Workus'Compar ation
Law s of Cahfomu n-
Applicar,
NOTICE TO APPLICANT.If.after making this Campeau,of Exemption.you should
become subject to the WohefS Compensumn provisions of the Labor Code,you must
.J z foMwab comply with such provounts or NO Permit shall be domed revoked
Z'O CONSTRUCTION LENDING AGENCY
P Na I hereby affirm that them is a comwction lendmg.gency for tW Peffurmarm,of
C dm work for which Nu Permit issued sac.30 .Cmv.C.)
W
Q lsndrs Nam-
Sz Landcr'a Ad&x•
V O 1=try that 1 have read this application and soon,that tW aWve infamauon is -
Hcorrect.I agree to comply with all city and county ONmnanm and state,laws reining to
0 C.) building construction,and hereby authonfe mpmsenutives of this city in aaor upon the
} abow-nommoned property for inspection propmea
,r 6. (We)agree to arc,indemnify and keep harmless die City of Cupertino against
to Ii.hdNes,judgments,costs and expenses which may in any way same against suit City
V z an mosequcace of the granting of this permn.
^ APPLICANT UNDERSTANDS AND W L COMPLY WITH ALL NON-POINT Issued by: Date 7 S=J-
SOURCE REGULATIONS.///-� _
/ n 1>—P-6 7— Re-roofs Q i3J.6-
( Signamrc of ApplinHAZARDOUS Date
HAZARDOUS Ma Occupant DISCLOSURE Type Of ROOF
Will the a Cucanwr future building l Co e.Chaps rt9.1 or handle Health Safety
l
az defined by Nc Cupemno Municipal Code.Chapter 9.12,and the Health end Safety
Cando'Scetion25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
i' Will the applicant or uwrc building Occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
it hvafdous of motammanu a dcfncd by the Bay Area Air Quality Management all new materials for inspection.
isui<t?
❑Yes 17`0No
those mad thehvartlwxmaterialsreyuirtmcnu under Chapmer695 of the ralifor- ,
nra Health& 1 �!,
Safety Codc,Saes.m25N15.25533and255341wdcrsondthradtthe Wddmg 7L)T
drys not currently hoc a¢na Nat it rs my responmhdny m noety the cupaas of the
myvirtmcnt..y�iPyµbe priorroiavanecoraccrofeateorampmey. SignatureofApplicant Date
/, g— _ All roof coverings to be Class "B" or better
Owner tar authonsi(a em Date,