01110127 - .. _..
/ _ UPERTINQ ,
- xummrc' VESN DR t COSMOS TOR INFORMATION
CTTY OF C
PERMIT �CONTRAC
> + ____._......PERMITNO .
9}I QDR�S ROOFING 01110127
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LL ELLEN-M.,TRUSTEE..;',,:.., 1.._. ..1.90.1_,_OLD,.—MIDDLEF.IELD_WY_._ ......
PHONE `'� -. (415) 493-6373 +. SANITARY NO. CONTROL NO.
• -
ARCHITECf/ENGINFR: „ - BUILDING PERMIT INFO
,� BLDG ELECT PLUMB MECH
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:z ad
��, NTRACTOR S DECLARATION .,.Job Description
D Z — licensed under provisions (Co pt 9(commencing '.. ."'REROOF.•... .. " .
q ftheB and Protcss Cd,and rayl nae - - -
s t full T/O COMP. SHINGLES, ADD 30# FELT &
_��a Lrnaecla 000lrD an,3 x 40 YR. ELK COMP SHINGLES
<rc y t t m
d
m Dr Cunion n r
3 e.y ARCHITECT'S DF.CLARAT r'
OAF
1 understand d y pl m'-0hall be used a public recoN.
Eo,O 0 License d Pmfe:i al ,
OWNER BUILDER DECLARATION +
r ec-� I hereby Moor than am'exempt from the Cantrad s License Law for the ,. o,.,� I „ . - ,` <
=.4< followingnausea.(Section 7031.5°Business and Professions Cade Any city or county _ -
uu��$
-d h p y
t t
priort t al requiresthe applicantf suchPa inti flsignedstatement
Chpt9wt h licensed put int the P m th Cn uxcmis o e L (
N I t t+7' .5-.
..t19d
i A
ua[ion
(commencingw1(00)orn3ofine aaCad) T Ft Floor Area1
or t h rlit the f and theb f ub tnied exemption.Any violation
i 1 t on , , . tit_:I
ofSection 1031.56yany upPlie+m(ora pemtssubjects the applicant tocivil penalty
"frootmre than five h unreddrs(5500) 363F1I)9AuI0
I'
-- ... .. ;.,"�, „'.Occupancy..Type._...._ .--
_DI a o n r fdr P pcny Y PI y th a8 as than s 1 pc t ', .-.. _. -
..w n da the ork'ana th m t x t tad rf ep.f . I Is< 7044' FRAME+ - - ...
B roptyiWProfession,Code Th cat t. t: L d t applyn an Regwired Inspectrons
r
owner fp his
l et armies to - ana n rtnedor _ ... -30-7--
or th gqh f pvethe
provided that h, nimprovementso t intended of -, - -
..ofr of -.m whehowever,tfiebumng b p nt emhedidnneyearar ._ ..601':_-- ROOF `TEAR OFF
`m plefor m e16Jld) will havethe hurdenofprovingnhanhedidnot bmldor 602 - ROOF PLYWOOD NAIL
t Prov puryose a
603 ._....ROOF- BATTENS,
__.. .. -
❑Pasy e. f the,popeny,am exclus ly mare im,g to licensed connote,...no •:,'
consumer the pro act(See 70".Business and Pmfiasatoas Code:)The ComurchiCs 6 04 — ROOF IN—PROGRES S � - 1t
Lice se Law does not apply to an owner of property who builds or improves thereon,
and who contracts kens.Lawsach projects with a contrdcmr(s)1i<enseJ,pursuam to the ... .,.._ _ ___._ -. - ., ...._....- .. .___ .-.- _...1.. ... _.._. . .__.__ ....,. ... .. ........
Contractorsng,mida,Sea.
❑lam exempt,unaers �'��� ;B&PCbirths reason
n,
' Owner
... .e -
' COMPENSATION DECLARATION - '• F��r�itmEt�
Ihcmby affinnu dr penalty of pe Jury,one of the following declarations
❑
and
a Consent 1 r Workers
pe , as for l wr Code, for the
- - t ;'I.•DCrC 1 1 2001 O01
Performance of twork hisatms. ed
.
h d'will'tiontionam WLkcjdppahi.then Insurance: s 9 d by S le {� }
W of ilia Labdr Cod f th aped f to k f i In h this pemut s' it
. ',B VILDING l. 1.
.issued MY Work 's C pe t n ns y ' y mW arc. . C` '�
carrier andP h
Cam rI[FIC EXEMPTIONTROM.WORI®RS
+COMPENSATION INSURANCE
(This sba`hn and not be cbmPlded (ilia permi is forrnehmndraileollers
vu'" 1 certify That in the p dOman=of the wild for which this permit issued,I' •' t Y. Ij;i,t i'I�^+ `�Of
shall not employan rs - so a io bcccur b t to Ne Workers
Cmpnealmn awsYof CaRkinia.Endo 1" . ......... .... _.._.__._._. . ............ _ _ .. __,,..,..-�. ._...., __.. .... _-.__ ,. ... _.._ ...
pp nation.
:NOTICE TO APPLICANT If, ❑ ak g this Cenificate of Exemption,you should' I
bet m s biart t the Wo ker C t p provisions of th Lab Code you m st
0
forthwith ply with such provisions a,,his pc n shall be Steamed rc oked.
1 1. _. _..._. _ ..._... .. —:------. , .... _
N tyCONSTRUCTION I ENDING AGENCY
a ? '. -I h eby firm that the a i. con tru t n lending agent}for Ne performance ::I
4L Q Leder Aad
of the kf h
', -
U 0 1 certify that I h se rcatl this application ana installed the above information is
w
[r to t 1 g tr comply with all city and e umy,ordinances and state laws relining
to talawag umaim ad and herehy authorize representatives of this coy m enter upon
thebo thane.sapeny for inspectionp rpt
CC es j agree m save.
ndemnlfy and k p h '1 th Gry of Cupertino against + _
F-In City in .,judgment cents grunting
g Offl h h y..'any ay accrue against send
U`�
City m consequence f theg arcing of Nis Permit. + ' ' '
APPLICANT UNDERSTANDS WILL COMPLY LITH+ALLNON DIN Issued by:'• `• i ;_it t Date4v
SOURCE REGULATIONS r BIW/O/ ,
Sig m eAipr tic t t r ,DateRe roofs .
HAZARDOUSM ER IA Es DISCLOSURE ! !.; Ifj ryt,
Will me Pplicirrd or fithrom n to ng occupharl store or handle ha to dris materiel ....'Type Of Roof,
as aehned by the CupertinoMunicipal- C d Chapter 9.12. d the Health d Safety
Cod 5 tin 25532(¢) ,'p , I r t
tore Nn ,1 a Aq roofs shall be inspected riot to.an ioofin material bait installed
rl k r... P P Y- g.: g
W1l the applicant future building en,am use equtpmnt r devices which' ' Ifa'roof is"ins talled,without first obtaining"an inspeetiom;I''agree'to`tremove
' -
D in t q P I 5geme t - s
defined b m Ba Area Air asm Man . all new materials-for inspection Applicant understands and will comply with
Quality Vifin
m t n°< alcontaminants
me n zmaoaasmat all non point source regulations;-,,
coals rc mrcmems under Cha w 69 of the ........... ..._... _,_ .. .... . ._.._. _I... .. _,.. ,_... . _ ..-,.....
evcu ant of the rc uuemeniawhich a t be met ' Invisibility y hat"
California Health&Safety Coil Sections 25505 25533 d 25534 1 underwear]t
m d a e t t a t that t resot onf the .._-. _.. -. _...... . . .. -. .. ..
'if plus
Occupant q p ss a a CeniBcane of "
ti owMbpraatno nY. I Signature o`pplicant Date _
0«apgp
ocsn tc cranially Is,,e
g - 1 Data All roof coverings to be Class B"or better
— OFFICE