03010187 P/ CITY OF CUPERTINO
BUILDING DIVISION PERMIT 'CONTRACTORRINFORMATION:
x f x , :.: .
BUILDING ADDRESS: WAGNER ROOFING CONTRACTORS T-MC.NO.
6395 ATHERWOOD AV 01010187
OWNER'S NAME: 12242 SARATOGA-SUNNYVAL R )APPLICATION SUB DATE
NICOLE LEA 01/28/2003
41 ONE:: (408) 777-8331 SANITARY NO. CONTROL NO.
ARCIIIILCTyENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACT'OR'S DECLARATION
W u F I hereby affirm that I am licensed provisions of Chapter 9(commencing Job Description
�¢� with 5cnion''(tIM ttDivision]of elm Bust and Pro-7fessions Cude,aod my license is
<�y in fullfnrceedJ ttea/3 6! 2Ff REROOF
z:Og4 Li I y Lic.M -
?va D Li
��� ®
<KO�OI sshatI use AR TION
Y I understand my plans shall M tide]as public records
LicensedProNssiimal EB T 3 2003
OWNER-B empt frUT'.CLABATION
u�00 I maxo .(firm that I sen exempt from the Cisions o e:Any c Law co the .sof�l
unty
,S0 followingnitesa Permit
17(1]1.3, t,aittessandove. emoli Code:Any city sruhim sy LD1
K$ which tcyuirca a permit m construct,alter,improve,demolish,or repair any structure
w;d^ poor to its issuance.also requires the applicant for such Permit to rile a signed statement
420 that W is licensed pursuant m the Provisions of the Cimmemia Licensc law(Chapter9 Sq. Ft. Floor Area $51r"tion
Ae- mormencing with Section 7000)of Division 3 of the Business and Professions Cede)or
.. that M s exempt tit mfmm and the body for the Alleged exemption.Any violation of
Session 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 6XPUI%ifkeiU 0 Occupancy Type
not more than five hundred dollars($500).
❑ I.an owner oflhe property.or my employees with wages ss their wlc compensation,
will do the work,and the structure,is not intended oreffered forme(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply m an owner of 3 0 - INSULA
7 d Inspections
property who builds or improves daemon,and who doessuch work himaelfor through his 607 - ROOF TEAR OFF
Own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve for purpose of 602 - ROOF PLYWOOD NAIL
sale')' 603 - ROOF BATTENS
❑I,o owner of the property,am exclusively contracting wish licensed contractor,to 604 - ROOF IN-PROGRESS
construct the projcn(Sec.7814,Business and Professions Code:)The Conmaesn's Li.
cense Taw does not apply to an owner of propeny who Wilds or improve umrtnn,and
who contracts for such projects with a contractional licensed pursuant o the Conferences
Liecnm Law.
1 am exempt under See. B 4 P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one mf the following declarations:
I have and will maintain aCenilicam of Conant to Self insure for Worker's Compete
cation,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3701 of the LAW,Cade,for the performance of tW work for which this permit is issued.
My Wohcr's urartccc cr and Polis numMram: �.y
arriee . wrr �^ r Policy No.: 2F
CERTIFICATE OFMEMPTION WOFAB KERS'
COMPENSATION INSURANCE
mussection need not M completed If the permit is formic hundred dollars(SIN)
less.)
I certify that in the Performance a]the work lir which this permit is issued.I shall nil
employ any person in any manner so a In become subject o the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ceniticao of Exemption,you should
become subject to tM Worker's CO nKmadion provisions of the labor Cafe,you must
OO forthwith comply with such provisions or permil shallM deemed recused.
z srN.. CONSTRUCTION LENDING AGENCY
[�. I hereby affirm Nal there is a conshueion lending agency Tor the Performance of
ai t�-t the work for which this Permit is imucd(Sec.397,Civ.C.)
W�Q Lcndcr'a No
= z Lender's Address
U Q 1 cmify Nat 1 have read this application end smtc that the above infmmodion is
ty scream.I agree to comply with all city and county ordinances and slam laws relating to
V building emminetiun,and hereby amhodre re,mimmatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
fz�q
Liabilities,judgments,costa and expenses which may in any way accrue against said City
V y
APPin LICANT AND Of the ranting of IND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULA ONS.
Re-roofs
Si icof Applicant"Conuwtof Da
HAZARDOUS RIALS DISCLOSURE Type of Roof
Will dte applicant or future doing Occupant store Or handle hazardous material
as defined by the CuPeminm Municipal Code,Chapter 9.13,and the Health and Safety
rode.See thou 25532(e)7 -
❑Yes E]No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future buildingoccupunt use equipment ordeviccs which If a roof is installed without first obtaining an inspection, I agree to remove
cmif hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑YCS ON.
I have read the hazardous materials requirements under Chaptcrti.95 or am Calif.,. ` �'
nia Health at Safety Ceske,Sections 355(15.255]3 and 25514.1 understand mal ifthe Wilding
does not currently haw a tenant,that if is my rcapdmiihility to notify the occupant of Ne
reyuirtmenm which muss mm priorwi uancc oft Ccnifica fOccupanry S ture of Applicant Da
ow r emodcadasent (D a All roof coverings to be C 'B" or better
DdftDWhlw
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CVM*a CA ysoir-M
Tdgiboom (4oelrr-M
• CUPERTINO 1M (4MMUn
Building Department
Subfexb RwoogngPSTicmtb4a!yofCuPaetlao,
1. Prlor to Parrott ia'snoe,you must agree to amply with 1997 UBC Standards
.nd Munutactures epadeca*m an reroo$ng,
2 :� aovwritten parptrnogvsaallullnotbeapplied without9mt
be
approval shallobtained�i inspector.A&a on and
aoatPhthed. g Spector when the reroo&tg is
& All roots ahAU be inspected prior to any roofing insulation.
4
To
reoetva a fWaign oitfeom the City the following step,are fid,
1) Prain%m d =and/or tear off approvrL
3; rogresa�padtaas approvaL
a) %wk�anuterinewlatiom
6 Ttplywood is tnetelled,a plywood nail inspection is required.
Arty roo ft which is applied without fist
require the removal of all naw Material down
Pyr Chy huPwtiaq an be p to the sheat t the
DdPORTANTs
1. Flat roads UWAluve a adMum of PA"Per toot slope and demonstrate that
these is rm pondie&
2 An LCLO npmtis required to be oro the fob site at the time of hmpedion.
We=dm t nd the above Policy an rmoo9ng and will oamsply w9h this Policy.
H meowMaes Name Med 0jr-C N,c eq
Adder; 639.5 162w000 s}vfAwooling
CouqMyNama:09 x
lot Antcuumd
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(C2def liuilddng oflWQ I�+
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