04110052CITY OF CUPERTINO
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BUILDING DIVISION PERMIT'
BUILDING ADDRESS:
PERMIT NO.
LEGACY ROOFING & WATERPROO
ING 04110052
19
lUikU M
Miss,
PERMIT ISSUE DATE
SANITARY aI OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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I. hereby afford Nes 1 am licensed under previsions or Chapter 9 (commencing,
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with Seelim,7")of Oivivon Sof NC Businessand Professor. Codc.and my license is
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full force and efface`
License class <—Yt Lk."
REROOF W/ SHINGLES
Dam LLI q Conl.im, Ll LAO,
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ARCHrtECfSDECLARATIOil—
INSTALL 1 LAYER 30 # FELT AND 30 YR. DIM. SHING
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1 under and my plans:!jU used+3 Pu lie ramda
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Licensed Professional f�`�n.-'(
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OWNER -BUILDER DECLARATION
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1 hereby affirm dust 1 am eacmpt from the Conu3cto's License law for Ile
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following mason. (Seeuun 7031.3, Business and Professions Code: Any city or county
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which requires a permit to Cons ,, eller, improve, demolish, or mini, any ruuclure
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pried n its LmU4beC, slot requires LW applicant for such Permit to file a signed statement
License Law (Chapter 9
Sq. FL Floor Area Valuation
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that he is licensed pursontmthe nowsio.nfNeCenluctor's
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(commencing with Section 70XB of Division 3 of Its, Business and Professions Code) or
that W is exempt Ihoefrom and the basis far the alleged eacmption. Any violation of
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-APN Number Occupancy Type
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Section 7031.5 by an)' mrfi.nt for a permit wbjecu the applicant to • avil penalty of
not more darn five hundred della. ($500).
0 1, u owner of red property, m my meploycu with wage u Nev otle eampensttion,
will do ted work and Ne structure is nal intended or offered for sale (Sec. 7014, Business
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and Prefcmions Cede: The Com weren't License Law does not apply m an owner of
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p.penywho buildser improver thercon.andwha doc such workhimselferdrough his
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awnemplay ,pmvd Oarsuchimpmmmwm=nolinl aaroffe fmsak.lf.
however, she building or improvement is sold within one year ofcompleuon. the owner-
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e rden of proving that W did not Wild or improve for purposeJAN of
builder will lave thW
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❑Las owner of the Property, s and contracting with litt.eC t.
x4, . Business Contractor.
come, who na Cade:) The Conmctm.
ant (sec.
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fand property nd
cense Law doe nor apply je an owner of property seed
Law es s improves demon, and
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sed poor
License LacLL for such Projects LIN a COnVYIrr(a) IiCefrSCd pY.Yanl l0 NC GOOUKlOT3
License law.
❑lnot uempl ands See. ,Bg<PCfor this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby upon under Penalty of perjury new of the fallowing decleralio.:
ban and will maintain a Cerificad of Consent o self -insure for Worker's Compen-
sation, as Provided for by Section 37W of the IaWr Code, for the perfonnamc of the
work for which this Permit u issued.
1 have and will maintain Worker's Compensation Insurance. u reyvired by Section
afthe, N mance, pcmmis isissned.
Compede.fed
My WarkeYs Compensation Inw��ramx carries and Polity number are:
My morac and otic number
Carrier. 5isms( T/+W Policy No.: 2915227504
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
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(Thissectionneednot W completed itrhe Permit is forone hundred dnlla.(SIW)
or les.)
I certify tom in the performanee of Be, work for which this Permit is issued. I shall non
employ any person in any manner w as as become subject to the Wotlecrs'' Compen.don
Laws of California. Data
Applicant
NOTICE 7D APPLICANT. If, after making this Ccnifcere of Exemption, you should
become subject to the Worker's Compensation previsions of Be Labor Code, you most
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forthwith Comply with such provisions or Nis permit shall W accred meted.
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CONSTRUCTION LENDING AGENCY
1 hereby affirm than Nem is a construction lending agency for the performan¢ of
QUndoes
Ne worse for which Nu permit is issued (Sec. 309'i, Civ. C.)
Name
Under's Add.
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I Certify that 1 haw mad this application and state Nn Ne aW ve information is
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ween. l agree to comply with all city and county ominances and Stam laws relating to
building
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construction. and hereby authorim repreenutivesof this city to cnter.pon the
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arabic -mentioned Pmpcny for purpowhich ea
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(We) agree b save, indemnify and k¢p hannleu Ne City of Cupertino against
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costs and
dCarouser
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sandt. may in my way accrue against mid City
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s4tor,
ZZincoides,jeccof
A consequence of the granting of this Permit
m of this
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APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:
SOU0.CE ULATIONS.
Re -roofs
Signature of App VGr Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will stem or handle
or future building occupe.
y the Cupertino
as de Sed by tM Cupertino Municipal Code. ChaPrer 9.13, and IW HcmN and Safety
Chapter Health and
Cale, Section 25332(3)?
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All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fold. Wilding occupant use equip r ern or dcviom which
If a roof is installed without first obtaining an inspection, I agree to remove
I hanrdous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
strict?
❑Y. ji'j No
lhave real NchnaNrms .metiers reyviremcnts under Chaplcrd.YS orlW Califnr-
nu Hcaltha Safety Codc,Seetiou25505.25533md25534.lund
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nwdWliflW Wilding
does not currently haw a amen, NN it is my responsibility to notiry ae occupant of use
mquirenum which. Wm at poorwiasr3na ofa Ccmficase or Leedp.ncy/9
Signature o pplicant Date
All roof coverings to be Class "B" or better
Owner mwthcn gem Da.