01100166 CY V OF CUPERTINO
s,4 DING DIVISION PERMIT CONTRACTOR INFORMATION:
4
BUILIihNG ADDRESS:. r PERMIT NO.
20835. ALVES DR COSMOS ROOFING 01100166
WNER'S NAME: APPLICATION SLIP DATE
ELLEN WHITESELL 1901 OLD MIDDLEFIELD WY 10/31/2001
SHONE: (415) 493-6373 SAN- ITARY NO. CONTROL NO.
- „
C ARCHITEC(ENGINEER: ILDING PERMIT INFO
.z,UU - BLDG ELECT PLUMB MECH
- G7 1"-I C7
S
so ""' LICENSED CONTRACTOR'S DECLARATION Job DesC71 On
f z-,o I nertnr aRmh mat 1 am uccnsee anger provisions erenap�e79lcemmencins - ROOF P
,gitlao Sexual 7")of Division 3 ofthe Business and Professions Code.and my license
:,i is in fall force an n y �./
w L,case CI O "7 "
13a.u.G Dat ZARCHITCCT'S Dcon
ECLARgTI N /
u'o,5 t. ' Y�'Itnndllincnd my Fill hall be sea as public o as
h eiO ILmer ed prof annule -- - r •'�/ - f+fv:. r ..
t�cfi m OWNER BUIL DER DECLARATION
+ 1 bereb)alBnn that 1 am exempt form the Contractor's License Law for the
z meowing ressen.lSenion]0316.Business and Professions Cede:Any Thy or team, - $15300
4 S 0 which requires a proof m criminal alcor,imprmx,demolish,or repair any acral
i6 .prior u < Iw q th pplicensf hpc 'u fl Fed ssamment. . _ _ - - _ _
not rte elttmw pats tr thtp 'ons o(the Co rmct tsL ex� (cnapher9 -A3A Valuation
(tato gw,' t 2INn) fn ie t fit Bsatn-ydP fs'hons Coda COIN]
or don he hs seal thwl'and the bans per
the allagetl exiling
d.Any vial in&
-of'canon".k.5 by anya ma am far a permit subjens the applicam m a evil penalty'
cornet'me ma B M1unaxaanars("'). 305APNNV94ME > t ;- Occupancy Type
CIra:owner efts property.or my employees with wages as their sole compensation, 307 - INSULATION
will do the work;and the social is not intended or offered I.,sale(See 7oaa;
Business and Profession&Coda The Contractor's License Law does not apply m an 601 - ROOF TEARkl0f}>FInspections'r) -11I
owner of property Who til or improves mexoo and who etta such work himself 602 - ROOF PLYWOOD NAIL
or through his own employees.provided Nat such improvements are not intended or
offered fo le If-fiow r,the builbit o . . _._ ......".. .._ - _�-____-.W_
g p emeningsho 'mid gild or 603 - ROOF `BATTENS - � : ;,N-
completion,p rtesfsall. Jlhave th hN ofprovingmtw6dnot httlor 604 - ROOF IN=PROGRESS _ J
' improve for purpose of sale.).
^'r. ;as owner of sbe pmpcny,em exclusively convening with licensed contraanrs to '
j _ conswn the does
project(Sec.]04•i.Business and Professions Code)The CommitTrion
l: ry
wid-whcense lawtoesnotrapplysuch
mmjrLS.WIhan owner of pmpcnY who Wilds
seimproves Merton, I
.god wver's ions forsuch porjccia.wiN.e.rontranorls)licensed.pursuant ho.the_ 'h
.: :.+ C em exam hundar Sec" }•.-. vi" t" H
nannm's License Lew.
;fir ❑I p• _ &PCfnr this mason
Osvor :Z
WORKER'S COMPENSATION DECLARATION
I hemhy a(Brm`under penalty ofperjury,one following declarations. _ t
.itch e
;09,hvJuaM'wilI.maintain a Ccnificahe of Consent m self-insure for Worker's
-0,
'Compemstion.arpmviaed'for.'by Section 3'!00 of the labor Code;-for therL. -•-- -
+'pErfrsmnncc bfNe'svurkYoewhich this permi(is iuuM.
pTI h ivc'Snd will'mainuin Worker's Compensation insurance,es required by Section
/3]00 of the labor Cade,for the performance of the work for which this permit is
.stud MyW k sCampo io Insmar4 carr tlPalmy. we
Cera+ YRS �-^•/l"PofcY No. • 00
C CERTIFICATION OF EXEMPnONFROMWORKEIR t U,;' v -Av 14" ki.
COMPEhSATiON,INSURANCE_,
ihim 10%aI need not be completed if the permit is per one hundred dollars --_--
IkiW)nrless.)
r , 1com l th t in the performance f, m which d ct to t o issaed'I
shall not ply nope y cart r so sea t become bled to the Workers
0_ Compensation ry . Laws California.Dvte
Applicant
' -.,; 1 -
NOTICE TO APPLICANT If. B making Cecil ptdy a
should
Zco ) hi heal k sCo � ro .rocisim, f theLabor Cose.you alforthwith comply with such pm ons or thec t ah II be tlaioned revoked
- --' - '- '-
� of the vertkfor� 'CONSTRUCTION LENDING AGENCY
r
a:� Y rah mat the hs nswn lend g agency fo th performer e' s •h.,,
R7 �^ ch th prm'i . '.isuad fS .309'/Civ.C) ""'- '' •'
p,:f� "L<ndas Nanm 'a
r7 z Lend i'Add •rv.. -. ...._ .._ ._......._ _._.......
a'r I cert(,mat 1 M1ave reed Ms applmation and smte Nat the about nformman is
t[r nen.I agme m comply with ell city vnd equnry grdinences and sine laws relating
>�_[J mhiltling conshmaion.and toren,duthanze reprtuntaaves of thiscity m<mmupon - - ---- '- '-
'W the eve cmcmionetl progeny:a mspenion puepous.
Tee io save.indemnif end kee hanNess the Ciry of Cupertino against
+1 abihun)dg nth:cost d cape wh h aY any w Y e ginot and -
U ,7a aCry n onuq ace pfm g fmrs p<' t �
aAPFi1CANT UItDER,TTP 1 AN \WLLO MPL9 W'mfALI NO P NT h': r. _ ;.:,�G.3/---
SouRceaEcuLArlon� �Q Issued by:
'bate
.Si tonal of Appbcanl Carlpf Re-roofs
1.BAZARDQUSMATERIALS DISCLOSURE ,`,'!!"
\ tYlide,apercanttif rare wading accapam h 1Wi le hazard mnenal .Type Of Roof _
m def cd by the CupertinoMunicipal Code Chapter 9.12 and the Health and Safety — '
CdBe Sen on 23532( ' ',--,Ty
❑Ys :l G7Ae�n r t �;l? l.`,� ', tx ". f`_ =4 +f.�i'.
fix :.14 ,fIi , .:.1 l
_ A1Lroofsshall be inspected prior to any roofing materia] being,installed.-,
W Il be ppl to futureWilds,xc gam useegop em a ice.ionch If a roof is installed without first obtaining an'ins action;'(agree.torremove
emit hazardous oma is bell by theBay Area Ah Q al ty Managemcm g p
District? _ all new materials for inspection._Applicant understands and will comply.with_
L.
.
CY �� - - all'non-point source regulations.,.,,, ,�,;
1 ho,-e d she d mamriils - _ t i t•. -
q he is and Ch p¢ 6 95 of me
California Watch&Safety Code.Socams 25505,l25533 and 15534:d-understand that
fthe buldngda o,e dylo .leach than ycespons bity 16 notify -- -"- -- - - - __
recal t f m ' ms . h muse be mei p to isaua a of nif¢ale of
ill
Z Occupancy', .Signature of Appficant - Date
-Ownc ser authored t - -..
-, she.. All roof coverings to be Class 'l or betier
...OFFICE . .. _., .... . .