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�`C�NT&ZAGT3OR INFURIVI
PERMIT NO.
BUILDING ADDRESS:
LEGACY ROOFING & WATERPROOFING
04110053
APAN
IN
PERMIT ISSUE DATE
�1111
,HON
SANITARY OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm Net 1 am licensed under pmvisiou of Chapter 9 (commencing
With Section 7IXIB) of Division 3 of fm Business and Professions Code.and my license is
m Ibu from and effect. {ar. Zl..5c
License Class �`' Lw.g
REROOF W/ SHINGLES
Dam n1 Co...., ': a,F iv v ••y
ARCHITECTS DECLARATI
INSTALL 1 LAYER 30 # FELT AND 30 YR. DIM. SHING
I undersand my pja Iofll W used u public records
((
...
Licensed Professional ^CT
OWNER -BUILDER DECLARATION
11mmhy affirm On 1 wo exempt from the C .... cmfs License Law for the
milnwins mason. (Section ?1131.5, Business and Profevinm Code: Any city .1 county
which rospimm a pcnnit m covtrum. alma improve, dcmol6h, or repair any apvctme
prior to its issuance, also repaims the applicant for such permit to rile a signed statement
Limens, Law (Chapter9
Sq. Ft. Floor Area
Valuation
that he is licensed parmantin the provisions of NC Cmunclurs
(commencing with Section ?")of Division Sof the B usiness and Professions Code) or
$2700
that he is esempt therefrom and de basis for dm alleged eeemption. Any violauen of
APN Number
Occupancy Type
Schon?031.5 by any applicant for a permit subjects the apliaant to a civil penalty of
not mom than five hundred dollars
❑ I,uowner ofthe pmpeny,o my employees with wegesu their salt compensation,
Required Inspections
will do the work, and the swaure is not intended or offered for sale (Sec. 70,l4. Business
and Pramijons Code: The Comncmr's Limenae taw docs not apply m an owner of
properly who buildsor improves One on,and who doessuch work himself or through his
ravn caupsycol. provided that such improvemcnu are not inmA ed oroBered fersale. IL
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving Nat he did not Wild or improve for Pon = or
sal, J.
0 h u owner of the pwp.ny, am esclusively contracting with licensed convenors m
rouuan the pmjecl (Sam. 7044. Basin¢ and Pormssu e, Code:) TM1e Contracer's Li -
cove law docs not apply to an owner of proper( who Wilds or impurities and.
in
who Contacts forsuchply
Contra,
witheeontmnorty licensed pursuant to she Contractor's
License Law.
❑ 1 am exempt under Sec. . B & P C for this meson
7 %J
Date
WORKER'S COMPENSATION DECLARATION
1 hcmby affirm under penalty of perjury one of the following declarations:
VV
❑ I ham and will maintain a Cenifcat, of Consent m self-inaum for Worker's Comp.m
sauon, as provided for by Secuan 3700 of the labor Code, for the performance of IW
work for which Nis permit is issued.
0 1 have and will maintain Workers Compensation Insurance, as requimd by Section
37W of the Libor Code, for Ne performance of the work for which mis pari it is issued.
My Worker's Compensation Insurance earlier and Policy number arc:
Carver: Sfed< P:",( Policy No.: 211 22"'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
MIS section need not W completed Bthe permit is foron, hundred dollars ($]W)
or less.)
1 ceOfv Na in the pnformance of Ne work for which this permit a issued. 1 shall r o
employ any person in any mannerso as m become subject to the Workers Compevafion
Laws of California. Dal
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption. you should
become attnem m the Wmker S Cpmpevnion provisions of the labor Code, you mum
faMwilh comply with such provisions or Nis Pamir Shall W deemed ranked.
CONSTRUCTION LENDING AGENCY
hereby that there issued(ee.3 lending agency lnr the performance of
which
the work for whicM1 this permit is issued (Sec J097, Cih, C.)
Nam.
;ender'¢ Addreu
I Certify that l have read phis application and now Nat the above information is
_
correct. I agree m comply with all city and county ordinances and Sam laws mlaling to
Vbuilding Construction, and hereby authorize representatives Of this City to enter upon Ne
above-m,ntioeed property for inspection purposes.
W (We) agree to save, indemnify and k,.p harmless the City of Cupertino against
incoiueajuce Oftheconning expenses; which may in any way acrotic against Mid City
of this perm it.
z Aconsequence UNDERSTANDS
� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
e�Fr �[, /tfyf (/' //
Issued by: Date
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SOURCE REOI1k,AT1
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Re -roofs
Type Roof
Signature of Applicifu tractor Dam
HAZARDOUS MATERIALS DISCLOSURE
of
Will the applicant ur (muse building ectesla. note or handle hazardous mamrial
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safmy
We, Section 25532(x)?
❑ Yes a1 N,.
All roofs shall be inspected prior to an roofing material being Installed.
P P Y g g
-
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will die applicant or future building acu ant use equipment or devices which
np s paAr
Dist ws vii conmminan¢ az dcfned by the Bay Arca Air Quality Management
all new materials for inspection.
Dislrict1 �
District?
❑Yes `UI Nu
I have read the haiardasmamrials requirements under Chapwr6.95 ofthe Csiror-
nia Health&Softly Codc,Sccuou25 5,25533ud25534.lunders dNuifthe Wilding
/r's
docs not currently have a tenant. Nat it is my responsibility to notify the acupanl Or OC
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mquimmemawy�nmux_wmet�toissuance ofaccrdremeofOica nay.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner Or eutho iced agent Date
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CUPEkTINO
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® CITY OF CUPERTIN#
REROOF
PERMIT APPLICATION FORM
APN #)S D
b
BUILDING
BENERGY
Date:
BUILDING
BSEISMICRE
Seismic Fee Res
BUILDING
9
Building Address:
BUILDING
BPLANCHK
Plan Check Fee
10092 w�
Cn
cx 81 t
BUILDING
Owner's Name:
Phone #:
C P¢A;�VCoww.
ko sw :; Slt P
Contractor:
Phone #:
License #:
.� c7 Rcy%n
4C&-467 -uS'o
00 "Y&
Contact:
Phone #:
Cupertino Business License #:
Lc cl—
t408-Zro-Cie) 37
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑
Built -Up roof
5!L Asphalt Shingles
Nt
Asphalt Shingles
❑ Wood Shakes
-
' ' "''" ❑
Wood Shakes
- ❑ . Wood Shingles
❑
Wood Shingles
❑ Other (Specify)
❑
Other (Specify)
Number of existing coverings
❑
Provide I.C.B.O. Report #
❑ To be Removed
❑
Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
T�Shllk 3v
Residential ❑
Commercial.,...
Fire Zone_: Yes ❑
No ❑
Confirmed with Planning Det. if
\
there are any restrictions: LJ
Co6t of Project:
Type of Construction:
Occupancy group:
Z. �ob J
hla,�
ADDlicablie-.. Fee ID Fee Descrintinn Fee nrnrnn
BPERMFEE
Bldg Permit Fees
BUILDING
BENERGY
Energy
BUILDING
BSEISMICRE
Seismic Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING
C�
CITY OF CUPERTINO
?-'« ice,- ° r "``' '"'v
INFOi2MATION
a
BulLOwc OfVIs1oIN PERMIT
CONTRACTOR •,
BUILDING ADDRESS:
PERMIT NO.
LEGACY ROOFING & WATERPROO
ING 04110053
A
PERMITIssue GATE
Mill
En
SANITARY OL NO.
ARCHOECTrENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
Op
LICENSED CONTRACTOR'S DECLARATION
O DesCrl tion
P
I hereby affirm that 1 am licensedunder provisions of Chapter 9 (commencing
-
vdi
with Section]OM)of Division Sof the Business and Profession Coch.and my license is
in full force and cffces 3�
, �i0'e.b v
5511 gg@�� I
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License Claus g
�Conuanor f�_
REROOF W
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Dam ff ter.
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ARCHITETSDECLARATIO
INSTALL 1 YER 0 ET AND 30 YR. DIM. SHING
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I Ondcruand my P shall bu used u Public records
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Lkcnsed Pnefcuionsl -
RATION
OWNER -Tropp Rom
s S
the
I hereby .(firm 1 am ucmpt from the COnuacroYs License Lew for the
0 o
$
following reason. unlit t ]o sr. Business and Pmfce rnal Cale: Any city or county
on
which requires a permit to impmse, demolish, or sig any suuuure
<
e a
prionnitsiensedpalsuntur the theappkinnt forsucthe Contpermiu0iecrim aw(Chned mmcm
t. the aaltur.pplicant
dm nimvctaw(ChapmrY
Sq. Ft. Floor Area
Valuation
�
pmvisism"oftConusiness
Section Business Pretensions Cade)
$
(that comma cingwiJpurstion7 and of
(commencing with Of un3Orm
$2700
..
& hvks
Al egad
Net ha u exempt therefrom and the busts far the alleged exemption. Any violation of
is..
APN Number
- - Occupancy T
P Y YPe
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
not more Nan Bic hundred dollars (SSM). I -
'
❑ I,as.,of the property, Or my employceswith wages. unit sole compo eaddim,
1C;C)n:7n10 OC)
Required Inspections
will do the work. and the suuctme u nos intended oroffertA forsake (Sac. 701es
4, Busins
t apply an awr of
and Pron fessioCoade: The CorLt. Cortisone, Li. Law does reN m
property who builds m improv. thucon, end who does such work himsel f or through his
own employcr4 provided thrsueh imyrowmen6 amnot intended orofferel forsake.IL—'6-
however. Ne building or improvemem is sold within one you of rompletion, Ne owner -
builder will haw the burden of proving BOB ha did not build or improv for purpose of
soled.
❑ 1. as owner of Be, property, am exclusively contracting with licensed cone on to
construct the project (Sec. 704,4, Business and Profession Cade:) M Conmxmri U.
.
cease law does not apply In in owner of property who builds or improv. Merton, end
who contracts for such projects with a eontramar(s) licensed pursuant to On Camrectofa
- - -
License La -
aw.❑l.
0 .Acemptundv Sec. ,B&PCfmthismMom
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dcdantions:
I haw and will maintain aCeNBwm of Consent to self -insure for Workst'sCompen-
xation, . priwide d far by Section 37M of dm labor Code, for Lha performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
of Nc Codc. fm the Perla the work permit u issued.
cancer A number ANis
s Co
My Workch Compensation Inurance carrier and Polity number arc:
My
_
Cartier. Sfu+C Perm,( PolkryNo.: 2Se22''11!`f
CERTIFICATE OF FXEMFTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is forom hundred dnllars (SIM)
nr less.)
I certify that in the performance of thee work for which this Permit 0 issued, 1 shall not
employ any person in any manner an. to become subject to the Workeri Compensation
_.
Lawa of California. Dale
Applicam
NOTICE TO APPLICANT. If. after making NU Ccni Ecam of Escmption, you should
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become subject to the Worker's Compc.ation provisions of Ne Labor Codc, you must
foMwiN
comply with such provision or this Permit hall be deemed rooked.
i V,
CONSTRUCTION LENDING AGENCY
'
1 hereby affirm that than is a construction lending agency I'er the performance of
1 0
she work for which this permit is issued (Sec. 3097, Cih, C.)
Lemices Name
Lender's Addreu
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I cenify that I have mad this application and sum Nat Nc shove information is
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jV
cores I agree to comply with all city and county ordimmts and sum laws relating to
building construction. and hereby
euNarim repmsenutim of this city to crime upon Ne
W
.hovetiesjdncd property for inspection putpwhich s.
CL.
(We) agree m save, indemnify and keep harmless the City of Cuper irm agent
liabilities,judgmentse costs And expmueswhich may in any way sane againstsaid City
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A consequence of the of this
r.
UNDERSTANDS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
D WILL
Issued by: Date
SOURCE RE 7f_pf.'s._
Re -roofs
/t
�� 11/1
Signature of Applic anDDem
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Willy applicant or form building occupant nom m handle mamritl
t
the Cupertino Municipal Code. Chapter 9.12, and the HcaiN and safety
Health
. de.
Sed io
Code. Section 25532(.)?
❑Yes No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which
—If a roof is installed without first obtaining an inspection, I agree to remove
n ha.ardnus air contaminants. defined by the Bay Arca Air Quality Management
all new materials for inspection.
isuimt
❑YesNu
thaw mad lha h.aNemsmaterials rcquimments under Chapter 6.95 Of dm Califor-
nu Heal" Safety Code, Seaton 25305.25533 and 25534.1 uMcrasaM NatifNe buildingTs
/�
dams not currently ly have a tenant that it is my nespm onsihility nouly the Occupant of the
/
regmrementsw but hoy atMorrei.vanaafaccmimi,sof �j"ay.
Signature of Applicant Date
Nle
All roof coverings to be Class "B" or better
owns araathorfzed .gore Dam