01100086 CITY OF CUPERTINO CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO
0249 AINSWORTH DR OLD COUNTRY ROOFING 01100086
o OWNER'S NAME APPLICATION SUB DATE
- MITCHELL LUANA H 387 UMBARGER RD #B 10/12/2001
PHONE SANITARY NO CONTROL NO.
(408) 362-1111
P0 ZO ARCHITEC(ENGINEER: BUILDING PERMIT INFO
U BLDG LECT PLUMB MECH
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i LICENSEDfOMItACTOA'SDECLARATION
Job Descrip' n
S•!+O hereby affirm than 1 am licensed under pro+s+ons of Chapter 9(commencing
mCuj r ecuon70(10)ofDiv.e ton3oftheBusinessmbPre msaorwCode,andmylicense REROOF.
i.-- w rmCl...ai' (02,2--7 REMOVE SHAKE, INSTALL 7/16"OSE
,ttnse^lass and <� Uc s _,�
O a U n _/ COntrecmr
tLLOF. m 'ARCHITECTSDECLAR FELT & TILE CLAYMAX.
I ondeNand my plans shall be aced as puhhc records
i or Oo Licensed Pmfnssmnal
OW'NER-BUILDER DECLARATION
Mn a I hereby affirm that I am exempt from the Comorlor's License Law for the ix z following reason (Section 7031.5,Business and Professions Code.Any city or county =
8 F p which requires a permit to construct alter,improve,demolish,Or mium,any swcwte -
W sir ne,tons nsuarcgdmrequvutheappitromorsuch perean to flea signed stmement.L_ __ __ serer_.__
w. that he w LcbniN purstiwt id the provisions of me Contractors License law(Chapter 9 S pIt Floor'A6ea,- ¢¢ qq +�. I h Xq,1yDatiOn
(commencing with SallOn,7000)of Division 3 of the Business and Professions Code) 1;j�'.'� F.�L,yk- oi f Z",a-,S I'a L; ,t i tl;i I s.r,A.: $6 7 U V
or that he is emmpt ffilufmai and the basis for me allegro cmmptioa Any vrolai m
of Section 70315 by any apphcant for a Pearson,subs me applicant to a eel penalty pp�.7N !.
Of.1..than five hundred dollars(SSW). 3 2 6 I31 j timt55 Occupancy Type
01,as own.of the property,or my employees with wages.than sole compcosstion, `
will do the work.and the structure is not intended m offered for We(Sec.7611, i
Business and Prafessmns Code:The Commema s License law does not apply to an 305 - FRAME Required Inspections"
Owner of property Who builds or imp ovu th.con,and who does such woh himself 1
or through his own employees provided that such improvements are not intended m 307 INSULATION '
Offsmd for ad. If,however.the Wilding m nmpmvemer,is sod wMm one year of
6 O l
completion,me ownor bxddcr will hive the burden of proving met be and not Wild or - ROOF TEAR OFF 1 '
improve fxpuryosenfsdc) _ 602 - ROOF PLYWOOD NAIL -
_ 01.u owMr of is proptax"am eack"w�ly conbazntg w,m ibeemand eti naeleas to 6 0 3 - ROOF BATTENS t •: , - . .- _ __ .
_
construct the p,w(Sec 7011.Business and Professions Code)The Contraztar's s
- ' License Law does no,apply to an owner of property who Wilda or improves mentor, 604 - ROOF IN-PROGRESS
and who connects for such projats with•coutractm(s)brOmed pursmant to he
Conhacuns Lmm,,Law
0 lain exempt under Sec B&PCfor this reason i •' �'iqq++'
Dose;; , �, , ,, Date ., �'�TK1��®
WORKER'S COMPENSATION DECLARATION
Ihereby aiTm,wider penalty of ttr;may nom.tir,he fagww;ng deaEa„ono. . FEB 0 6 20 02
0 1 have and will maintain a Cemfcae of Consent to self-insure far Worker's
Compensation, as Provided for by Section 3700 of the Labor Cade, for me
performance of the work fm whicb mm panm,rn issued
0l have and will maintain Workers COmparcuum n Insurance,as mgmred by Section BUILDING
-' r me tabor Cade,for me performance k
ance of the wo for which this pemut is
,ss� _
. ` MY Workers Compcniotion Insonnce camcr and Pohry number tar ,-, ___- _ ,,-- -
• ` -_serer-serer{/..-serer .. _.. _. . . _ _
I'+.'F.'. :•j,..11 l'�9d : .-'.y.'t _ .
i ` RTIFl� CATION OF E%EMPIIO O KERS't� i .+ I ah Y4 t.1: •.- . .,.
' is
' (This saubn tad nil M comPlned rf me permit is for Dire hundred dollus s •itll i)';i+)i•:`N�
(5100)or less)
I certify man rn,he Partmmance a the work for which this perm,is nonce,i -' - - -. -.. .•. .. serer :!i):.,: .- .
shall not employ any peson in any manner so as to become subj.t to the Workers
Compensation Laws of California Datt -
NOTICETO APPLICANT.If,diet making this Certificate of Exemption,you should
become subjat to the Workers Compensation provisions of the tabor Code,you must
ti with such pmvnmas or Ms pamn shall be deemed revoked
O
forthwith comply
lti ”CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
nki
Of me work for which this permit is maned(See 7,Co,C)
Q!❑- finder's Name '
O'z Lender's Address
V 0 I«ndy that 1 have read this application and tam that the above infarm umar is
V. t.a c'mren I agree to comply with all city and county ordinances and state laws relating
OU to budding conamelian,and hereby mthonm icpresemum,ofmm city m emerupon,
a me abovementimud pmpcny for ins'atim purposes
(We)agree rat save,mdcmmfy and keep harrab s the City of Cupertino against
Z) liabilities.judgments,costs and expenses which may in any way come against and.
U z Ci,y in omequcnce of she gren,"of mis permit -
1 �PRCA�f N ATIONANDSAND WLLLCOMPLY WITH LN-TDZ Issued by: i JS - Date !l/
VE �\
�g �c HAZ RDOUSMATERIALSDISCLOSURE Data
Wise dia applicants or fir.holding oeiupan,si.a or handle harardw muEial, serer Type of Roof.- _ -
, as dehad by me Cupemm Mumapal Code,Chaper 9.12,and the Hcdm and Safety', [' _
cw Secfon25s3up^...r,,,. serer,,,, ,, ir.,r' i,'S;`"• i )i ' I'.7'-''. '?•iT`{. 6"."•':'.? (tY:',:
area ,. ,, ❑rvti:,' _.-All roofs.shall;be inspected,prior to any roofing material being installed.- ,
4
Will meapphs.ntar from budmrgmemwarltom ar If a roof is installed without first obtaining an inspection'j,agree to remove
earn hanrdous sir emoundnams a defined by me Bay Ala Av Qudrty Management'
Deaden all new materials for inspection. Applicant understands and will comply with
U:w ova ❑Nn all non-point regulations., \,
mivO read me hacardoua mamdals mgwmmema under Chapmn 6 95 of the,
Calif us Health&Safety Coda Sections 25505,25533 and 25531.1 understand that
//
\ f building does not currently have n¢tam,that it is my responsibility a e notify the �d off•Z
ggfupnm o mmimmants is mh must W met pnor m r seance of a Certificate of _ Lid/� s
° /Sinature of A licant Date
g PP
'-• �. / All roof coverings to be Class "B"or better
ncr or tmnonze�i ago Dam ,
i^t . ,. serer .. .. _. . . OFFICE