03010108 CITY OF CUPERTINO "� <•"'•s ""�"' f"
BUILDING DIVISION PERMIT CONTRACTOR INFORMATI,ON
r< Tomas �,,4a*n =fW
BUILDING ADDRESS: OLD COUNTRY ROOFING x_ PERMIT NO.
POOL HOUSE ON BUBB RD 03010108
NER'S NAME: 125—B GROBRIC CT APPLICATION SUB DATE
W
PARK VILLAS CIRCLE HOA 01/21/2003
No DNR: (707) 864-5557 SANITARY NO. CONTROL NO,
ARCHI'IRCT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION
to¢r I hereby
affirm that I am licensed under provisions of Chapter 9(commencing Job Description
in lull fnrtpUlfd dffecDivis'I�rrn Jof Ncftus sa and Prgfcssir^s C,1d�nJmyliccn:c is REROOF
z0`($ Li se C1xsa hic.p AXrL
Fy�u� D ��- REMOVE LAYER OF TILE, INSTALL 1/2 " PLYWOOD & -
qq ARaBTECTs CLARATIDN
a� 1 understand my plain shall he.,Oil as public record., 30#FELT & US TILE
FINALE®
X�dD
ou Licensed Professional
affirm that I am exempt from the Contractors License Law for the FEB 0 4
OWNER-BUILDER DECLARATION 203
<f I hereby a
ca 0 following reason.(Section 71131.5,Business and Professions Code:Any city or county
x$ which requires a peril Or ciourtal,alter,improve,demolish,or repair any structure
f cprior m its issuance,also requires the applioard for such peril In f Ic a signed mmemcul
that he is licensed puration to the provi.sions offfireCtionacturs License Law(Chapter 9 Sq. Ft.Floor Area BU'LDIwlUpluation
(commencing with Seetlon 7(XXq of Division 3 of the Business and Professions Code)or �•�a
a, $ that he is exempt therefrom end the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Peril subjects the applicant lo a civil Penalty of APN Number 4i0k9oky Type
nut more Nan the hundred dollars(5500).
❑
1.as owner of the property,or my employees with wages a their sole comPensadon.
will do the work,end Ne structures is not intended or offered for sale(Set.7W.Business 35610094 . 00
and Professions Codrue e Com aacmrs License law does not apply to an owner of Required Inspections
property who Wildsor improves thereon,and who doessuch work himmiror through his
man employees,provided that such improvements are not intended or offered for aide.If, 3055 — FRAME
however,Ne 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 307 - INSULATION
sa'e'1' 601 - ROOF TEAR OFF
❑1,as owner of Ne property,am exclusively contracting with licensed contractors to 602 - ROOF PLYWOOD NAIL
concoct the project(Sec.7044,Business and Professions Cadc:)The Contractor's Li.
cense law does not pply to an Owner of property who bonds or improves thereon,and 603 — ROOF BATTENS
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License law. 604 - ROOF IN-PROGRESS
0 1 am exempt under Sec. .B&P C for this mason
wncr Dow
ld
WORKER'S COMPENSATION DECLARATION
1 herchy a M.look,Pcrudi of perjury one of the following declarnimu:
❑ I have and will maintain aCenifcare of Conwntto self insure for Workers Comped
astir,as provided for by Seeion TAXI of the labor Code,for the performance of the
work lot which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
371XI of the Who,Cade,for the performan¢of the wart for whf hth' permit isissued.
My Worker's Compensation Insurance carrier and Policy num
Cartier. Xl� Policy No.: L
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhos section need not M completed if the Peril is lotion hundred dollars(S IBI)
less.)
I certify Nal in the perfitrance of the work for which this Permit is issued,1 shall not
employ any person in any manner se as to become subject to the WorkersCompensation
Laws of Califnmia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccaifcatc of Escmption,you shnuW
become subject to the Workers Compensation provisions of The labra Code,you must
OO forthwith comply with such provmotion,this perit shall N docmcd revoked.
z CONSTRUCTION LENDING AGENCY
[r r I hereby altar Nal there is a construction lending agency or the performance of
a the work for which his peril is issued(See.3097,Civ.C.)
Q bender's No
z lender's Address
Zoo)U O 1 certify that 1 have read this application and state that the above information is
Ito P correct.l agree m comply with all city add County oNinanecs and alto laws relating,.
OU building concoction,and hereby auburn representatives of this city to enter upon the
r W shove mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hatless Io,City of Cupertino against _
rV) liohilities tul'onn ,cos ial..'nses aIuch mayor any way aecmc against said City
U Z, inconsequence 0 gin goflhispe ' Issued by: Date
r APPLICANT DER ANDS AND LLC PLY WITH ALL NON-POINT
SOU CC NS.
Z✓ Re-roofs
ngnnmrc of Applicant Dare
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will she applicant or future building nnacupam store or handle harmdeus material
as definee pino Municipal Cole.Chunmr 9.12,and the Health and Safety
Crate.Secd tionby 2th55Cu)2(.ert)7 `/ All roofs shall be inspected prior t/tai ng material being installed.
❑Yes �N
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first on inspection, I agree to remove
•� ami t havardnus air contaminants as defined by the Bay Arca Air Quality Management all new materiaViatrITMection.
District) 1
❑Yes
Ih�vo mail the ha te�1""'2m!q
iu2P
Chapmrfi95of Ne Califor, C^
niallcalW&Solely .Scctinn S511 ndcrstanJthatifthehnildingJrce nm curn0 a tens Nat rem notify the cewpant of Ncmyuimmcnraw mus, m doan e oracap. y. Signature oFApplic Date
wncr or amhorivcJ agent All roof coverings to be Class "B"or better