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CITY OF CUPERTINO '*v+• , - " `"`""""
BUILDwcDIVIstON: ,., PERMIT . �COWRACTORINFORMATION --- ...
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BUILDING ADDRESS: PERMIT NO.
LEGACY ROOFING & WATERPROO ING 04110051
M PERMIT' ISSUE DATE
E.
SANITARY OL NO.
ARCHITECT/ENGINEER: (408) 46iJi-0150_. _ BUILDING PERMIT INFO_ --
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm Net I am licensed under provisions of Chapter 9 (commencing
with Section 90060 of Division 3 of the Business and Professions Code. and my license is
in full forte and effect. $0 6
from clow G- Cori -- REROOF W/ SHINGLES
D'w tv ARCHITECI'SIUECLARATItl INSTALL 1 LAYER 30 # FELT AND 30 YR. DIM. -SHING
IundcntsnJmaapatla public record
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Licenttd flafcssionel
3 OWNER -BUILDER OEthe Com ION _
i 1 hereby .(firm that 1am 1.. Burin from the Cts.. C's License Law for the
O ,allowingmuga. Permit
nDLS,Businessand w,duoli Code: Any city nrcaumy
�i which requires a permit re umss the aMinn.pplicant
improve, h Permit t or repair any sttactam
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print tos imcman e. purse requires theWapions of for Connatmis tokenso rile a Law ed (Chapter
< (that the commeacingwid pursuant m the of Division( the Co urines an cnsclaw (Chapmr9 3q. Ft. Floor Area Valuation
$
(commencing Is exgwith orefon90W)of basis for
afthe
eged essandin.My Vi Code) of $18(jQQ
Nat k u exempt Owrtfmn and Uma bus Lor Ne aileged e••—peon. My violation of
Section 7031.5 by any appliaas for • permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than Live hundred dollars (5500). P Y YP
❑ I.uawner orlha propmy, or my emplayces with w•gmuHeir sok compenvuon.
will do the wed,and the atronum is not intended 0, armed far s•k(See 1044, Basircsa Required arms Professions carie: The Convenor, License law dors not apply lf an owner is q
own ertywho
s. Wildsorid that
sch imprandwhodoesamhwork himttlfm Nmugh his
own employees. Nr such impm old within
natinwded m leered for.Owner-
however. Nebuilding hu den of proving
inissold withinot Wild ar completion. gi awmr-
baadec will haK the harden ar provins that nil did not ladle m improv far parpn<ar JAN 192005
sale.).
❑ 1, as owner of Ne property. •m exclusively contracting with Ilcnued coduscwn m
cause L s N6 does
(Sec. n an weer of and property
who
Cade:) The Contractors nd p� �'v
Li -
cause law dos not apply je ts owner of pmpens who builds or impto es Nemo^, and ®J L fy
who contracts for such project with a conuactar(s) Licensed pursuer w the Contnctors
License Law.
0 lameminsumder Sec. ,B&PCforthismuon
Owner Data
WORKERS COMPENSATIONDECLARATION
I hereby of urn under penally of perjury ane of taw following declarations:
bare and will maintain a Cmifateof Consent w self -imam for Warkeri Congo. -
cation, Lear provided for by Section 3700 of the Inbar Code, for the performance of d¢
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for which this permit is issued.
❑ I ban and will maintain Workers Compensation Impurities, u required by Section
3900 of the Labor Cade,far dmperformmce of the work frwhich this permit is iuved. -
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y Worker's Compensatifro-'n--Insurance conic, and Policy number art:
Cartier._S{s*�l T�anA Policy No.: ?�.i 12i So •i ,
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE
(This section need Out la: completed if Ne permit is fora^. amdmddintars 5100)
or Icd.)
1 Cmury Nat in the performeocc of the work for which this pdmit is issued. I shall not
employ any person in my manner s^ as in become subject the WmIXTS''Cotfulti mi
Laws of California. Dam
Applia^t
NOTICE TO APPLICANT: If. •fmr making Nu Certificate of Exemption, you should
Wcome subject M the Worker's Compensation provisions of the labor Code, you mus
Oforthwith comply with such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat Here is a construction lending agency for the performance of
Ne work for which this permit is issued (Sec. 309], Civ. C.)
Lender's Name
Z Ltndsrs Addnevs
Q 1 certify OIL 1 have read this application add some, that the &Win Information is -
correct 1 agree to comply with all city and county ominuvxs and slow laws relating w
U Wilding construction, and hemhy audoria opruchamn.i of Nu city to enter upon the
W above-menudgm pmp.ny forinspection which may
6, (We)Agree to use,indemnify and keep harmless the City or Cupertino against
Tq
in
equnce of ts•crosand expenses thispermit, may in any way accmc against uiOCity
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ar Use or this per mit.
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ADat
APPLICANT UNDERSTANDS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: '
SOU R ULATIONS.
Re -roofs
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Appli wr
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or Idem building occupant store orhandlc hazardous material
as defined by she Cupertino Municipal Code. Chapter 9. L2, and she HcaRh and Safety
Code. Section 15531(a)9
❑Ym 94.
All roofs shall be inspected prior to any roofing material being installed.
- _ - - -
Will thea font or mwre building Occupant utt a ui
PP Bequipment or devices which
If a roof is installed without first obtainingan inspection, I agree to remove
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hazardous air contaminants as defncd by the Bay Arca Air Quality Management
all new materials for inspection.
Iso
❑Ym GNU
I have mad the hummous materials requirements underChapem6.95 of the Califon
niaHalmh&Sammy Code, Sections 255(15.25533 and25534. 1uaderslond thdifNe Wilding
dao t eurtcndy have a umme Not it u my rmpomihility so mdry dm aaupant nr the
Y- '- ` fI /
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myuimmm:nu ichmuaWmespriorwissuanaoraCcnif¢awarOccup/�.
Signature of Applicant Date
fs/.ii f r
All roof coverings to be Class "B" or better
Dan., oras mi,ed agent Dam