01020122CITY OF CUPERTINO .'
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CONTRACTOR' INFORMATION
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BUILDING DIVISION PERMIT
BUILDING ADDRESS: ,
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ROOFING
PERMIT NO. -
OWNER'S NAME:
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APPLICATION SUB DATE -
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
' 'Job
1 herehy affirm hm I 1 am licensed umler pvwkiom of Charter (contmacivg
Description -
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with Section 7 W0) of Division 3 of the B.'ines, "nd Pndessoms Code, and my lice...
} in full force and effeo. -
Lic.9
Date em„ uc."
TEAR' OFF EXISTING SHAKE- ROOF &
t Doc or
j' ARCfBTECr'sDECUARAnON
REPLACE WITH SAME. -
Iordersiand my plans sh5u he, used a, puhre records
i Licensed PtofessimIl
OWNER.RUILDER DECLARATION
I hereby offiml that I am exempt from the Contractors License Law for he
' fnllawingrasom(Section 7031.5.RdNm,,. and Professions Cole: Any city o county,
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t which requires a pentdl to construct, alter, improve, demolish, or repair any struerure
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priorto its issuance, also requires the applicant for such Permian file a signed smtennod
Sq. Ft. Flo r e'
Valuation
due he is licensed pumuanua dtc the Crinolines License Llw(Chapter 9
(commencing with Section II00) of Divi%ma 3 of the Business and Pr imWons Cale)
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or that he is exempt therefrom and the hams for the alleged exemption. Any violation
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of Section 7031.5 by any.,Iicam bar a permi, subjects the applican, In a civil peaaity
,If a., am than flve hundred dabarto (S500).
APNNumber
Occupanc
° L as owner of the props (it my employees with wages as their sale contpenmtion,
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will do the work, and the str core is not intended or offered for sale (Sec. 7144,
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p D%R�Q.. *&d Inspections'
business and Prnfessinm Code: The Contractors License Use does not apply in an
rafpropeny Who huild, or improresdarem.and x ho does such work imi,ell
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or through his own empWyees. provided that such impmventems am and intended or
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offered for sale. If, however, the building or impmvemen, is wild willtin one ycur'of
completion. the owner - builder will have the burden of proving that he did an, hold or
305 — FRAME
imprme for pa0ose of,me.).
°1. as rof,he properly, am emle,vely comnming with fleen,ed crmrucmrsm
307 — INSULATION
Lin.. [me, me pmjW (See .70,14, Business and Prof.. 11, Cade:) The Cmtlawlar',
601 — ROOF, ".TEAR OFF '
cense law dues not apply to an owner of property who build, or improve., thereon.
.ace who another, far such,prajens with a comommnl licensed purman, to he
602 — ROOF 'PLYWOOD
Canrracme, License law.
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NAIL
° I air exempt under Sec." ,B &PC fee this reason
603 — ROOF BATTENS
Owner Date
'ORKER'SCOMPENSATIONDECLARATION
604 — ROOF IN— PROGRESS
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1 hereby affirm under penally of perjury me of the mllnwing declaration,:
'' ° 1 have and will maintain a CcniGcmc of Coliscnl to selt-iiv,am for Worker',
Com,norimq as pmvideJ fix by Section 37(K) of the Luhor.Ctde„ lit, the
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performmce of the work for which this pc�rdh is issued.
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° 1 hoe and will malnmin Worker's Compcn,atimt Insurance' as mgnimd by Section
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-37,10 of the Lohur Code, for the purl onpancc of the work rim whichrl is permit Is
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i,w eJ. My Worker', C mpeenn... on Insurance Currie(^and Pnlii, marber rc:
Carrier No �>
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CERTIFICAFION OP BXBMPTION fiiOM WORKERS'
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COMPENSATION INSIJRANC17
(This neoJon nced-no, be cninplcted Ube pconit is for one handled dollars
($100l nr
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I v,nLy @al "n lh,ocrfona co ol tM1 k I 1 tl it ': nit
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shall 1 ply any 1w y an non,, as to hen t i e s Meet to tic W eke'
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Comp : I' LlwsafC I'I Dole
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APPIic:nv
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NOTICE TO APPI,ICAN'C If, aliar "raking this Cedilieate el' Exemption, you shoald
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become ilbjeenu the Worker, Contpcnsmlon fookinnsuf t h mu.a
he L"ar Cade, you
forthwith asmPly wilh such ptovisinn<or Ihis I'<'nnil i:hall he Jccmnl revoked.
- CONSTRUCTION I,IiNDINGAGENCY ,•`
I herehy t c y fin IM1C perl'nrinuncc
i s a ndi nCis, g
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tthhias CenJ
pIh,n n h
,fdre work fin ebrch h issued N,, 301
Leader's Name
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LenJer'sAJJres,
I cenify that l have rend thk n,d watim, and sane bit the ahovc inrormation is
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correct. 1 agree In comply with all city unit enemy ordimma as and into law, mlating
m building construction, and hereby authorize repmsentatim% of this city Ili enter upm
the Shove - mentioned property for inspection
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' Dim) agree to save, indemnifyand keep humdeva the Oly of Cupertino against
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liabilities, judgmcen, costs and expenses which may in any why ' erua "gains, said
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City in co ews,co ere of the grommg of Ihis permit.
AP CANT UND• STANDS DW .L COMPLY ALLNON -POINT
•w �k
-Issued by: C �-
s r -rut no f
_ Date; ` )
Signature afn icmmC.at for, ', Dole
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
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Will the applicant or future building occupant stom or handle mosada "s material
Type of Roo
as Jeri nerd by the Cupertino Afun equil Code. Chapter 9.12, and the Health and Safety
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Code. Section 255326T?
El Yes �fN
All roofs shall be inspected prior to any roofing material being installed.
wnlhe op iemn no future budding occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit hamrdaus ter conumim"ms as defiled tryout Bay Area Air Quality Management
Di...iel?
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all new materials for inspection.' Applicant understands and will comply with
all non -point source regulations.
I have read the hamrdou, coaretim., requirement.. under Chapter fi 95 of the
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Cniifo I Health & Safelm Code, Sections 3L.1 that
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u have t) to mend
ifthe building Jnea not cuncn,ly havna¢n Lmmil is my rcuponsibility to notify the
t ant.th t it is y rc.s,
l 2 �`L3 i b
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pant the requirements whieM1 meal he 1 1 prior to iswuncc of a Cmilicale of
C.�
the Yf
r117net /a-/�, ///
Signature �f Applican Date
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All roof coverings to be Class "B" or better
owhermadmint t coot Dme •
OFFICE -