04100072 CITY OF CUPERTINO h: � 2rp�eevxau+
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:''-
BUILDING ADDRESS: LOS... OJ ROOFING 4 PE0.MIT x.4100072
0849 BARRANCA DR
OWNER'S NAME: PERMITISSUEDATE
MARJORIE HATTERY 1771 SMITH AVE. 10/12/2004
HONE: SANITARY NO, CONTROL NO.
(408) 298-9399
ARCHITECTfENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MF.CH
Lop LICENSED CONTRACTOR'S DECLARATION O O O O
m❑ 1 botchy affirm That I am lift sed under provisions onsCono. 9(commencing ( Job Descri o� ® p ,p, g
UW W with Scctiotchy a r Division m licensed
the Business and previsions
GWc Chapter 9(co license is tIiCZZ�a Ilgll$\'edB/(�� Hp�
inrpurorceandef m. �. REROOF FRONT OF HOUSE ONL
ED
012L Liccnx Class Lic.N .
pro Dam u- •m TSDECr��
uJ As shall
ARCHITECTS DELLA AT N
M1 understand my plans shall M used as Public records OCT nP 2004
Dau
u.t�, Licensed Professional
yre,g
OWNER-BUILDER DECLARATION
Conte ON app Ig 11 pp,
.�00 I hereby affirm that 1 am exempt s an sec Contractors is License Law for the y®1 I�I�Y{pt L tlpGeJJ�')
Is e O following runs(Section]o sir Business mpr ve.Professions h,or:Any city m county
Is
m which requires a remit m construct,alter.improve,demolish,or repair any structure 6
Fir Prim it)its issuance,3150 requites the applicant for such Permit o File a signed emremon
-_o has he islicensed pursuant indopm.isfon5nthe ContononsLieenxLaw(Chapter 9 Sq. Ft. Floor Area Valuation
yt- (commencing with Section 7010)ol Division 3 ofthe Businessand Proressionsctye)m
i Nat he is exempt dmmfrom and he basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects he applicant to a civil penalty of Occupancy
not more thin Five hundred collars(SSW). GGU aDC p y Type
1,as owner orae Imarco,or my employees with wages u deir,mle compensation.
will do the work,and the strumure is not intended or offered for sale(Sec.7W,Business
Lord Professions Codc:The Conmctoh License Law does not apply Ire an mwnm of Required Inspections
property who builds or improrrs Nene m,and who does such work himself or though his
own employees.provided that such improvements are not intended or offered for sale.It,
however.the building or improvement is sold within one year ofcompletion.the owner-
builder will bars the burden of poising that he did not build or improve for puryme,or
sale.).
O 1,asr of to proam exclusively contracting with w
licensed contactors
construct the property am
Pori(See.70sa,Business and Professions Code:)The Cunrranor's Li-
cense law does not apply to an owner of property who builds or improves thereon,and
who connotes;for such poijecu with a contracmrts)licensed pursuant to Ne Contractors
License Law,
❑I am exempt under Sec. B h P C for this reason
17N
wner Date
WOR K ER S COM PENSATION DECLARATION
1 hereby alarm under penally,of perjury one of the following Saturations:
1 have and will maintain a Certificate of Consent tin self-insure for Worker's Compen-
tion,as provided for by Section 37W of the Labor Code,for the performance or the
rk for which his permit is issued.
have and will maintain Worker's Compensation Insuranceu required by Section
of Ne labor Cale,for me performance of rhe work for which tis permit is issued.
y Worke(r'ss Coosmppeennssatiioo'n�Insurance carrier and Policy num beer aam:rver.✓//1 f as /04 Policy No.:_}�L_
CERTIFICATE OF EXEM MON FROM WORKERS
COMPENSATION INSURANCE
(This section=ad not M completed if the permit is for one hundred dollars(SI W)
it,baa.)
1 coni!"tat in the perrmosocc or the work for which this pcomit is issued.I shot l nut
employ any perm in any manner an at In become subject o the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IC after making this Cenifcate of Exemption,you should
become subject to the Worker's Cum pensminn provisions of the Labor Codc,you must
.JO funhwi in comply with such provisions or this perm i t shall he deemed mvnkcd.
'ZZ CONSTRUCTION LENDING AGENCY
F I hereby affirm that there is a construction lending agency for the performance nr
CL' be work for which his permit is issued(Sec.3(N].Civ.C.)
aLender's Name
z Lender's Address
U Q 1 certify Nat 1 have read this application and sum that the above information is
W F correct,1 agree to comply with all city and county oNinnoccs and state laws relating to
V building eonstrumimn,and hereby anionic repmromativis of this city to enter drive be
shove-mentioned poipcny for inspection purposes
F y (We)agree to save,indemnity and keep harmless the City or Cupcninu against
fn liabilities,judgmenu.costs and eapmues which may in any way acerae against said City
V z in consequence of the gmming of this Permit.APPLIC /
^ SODRCART UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date I /
/011-v y
9sdgawrc ApnllmanW..dmmemr D3te Re-roofs
a/ �1fAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Or applicant or fuwrc building oecupam smrc nr handle hers tons material
as defined by the Cupertino Municipal Codc.Chapter 9.12,and the Health and Safety
a1mGyle,Section 25532(a)?
❑YesNm All roofs shall be inspected prior to any roofing material being installed.
W111 the i prfieam or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
)trier?
❑Yes �&u
I have mad the hamrdnusmacrials requirements under Chapter 6.95 of Ne Califor-
nia fico,, Is dIyhave.Smduu 31 it i 2my r and 25534.1 and ou ly t ehad
vvcupc building /of
encs meureney M1am a mnanl Nm it is my responsibility m notify the Later. of tc 111
Cqd m�+is�Ir' mel prior ret l5a dance mfa CclllrC3m Of Q'empdney.
71�,7/cu.0� SigAatureofAppG ant Date
owner aumoria d agent D,e All roof coverings to be Class "B"or better