05030124 CITY OF CUPERTINO *aI+Ya1a,S��a. rt� ].tr..yna��, d� y'•�� .��ay$��ary' c T/��
BUILDING DIVISION PL`l�lYSlK +�1\°yl[t1 •�v� iv ✓'" [��7 p�
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BUILDING ADDRESS: LOS GATOS ROOFING PERM -NO.OS
0 6 CAROL LEE DR
OW
NEWS NAME: PERMIT MME DATE
RICHARD BOOTH 888 FAULSTICH CT NE: SANITARY N0. CONTROL NO.
(408) 298-9399
ARCHI ECTIENGINEER: BUILDING PERMIT INFO
8LDO ELECT PLUMB MECH
0 0
Sop
LICENSED CONuneunGR3DECLARATIOH TINA
with
1 wrebY M.UW 1 am Ikenak under ryoviaians of Chapter 9(commencing Iltlif(jl�rl`V\rNIV�FIJ �1�1
with Smdo.7")of Division 3 of the Business and Profcoimo Code,and my If..is Il (�//"�\
£� lorwlrmmadenem REROOF W/SHINGLES
1 Z Limnm Clea Uc.
ARCHITECTS DECIARA71ON
l undersand my pints NW be used as public me,* MAR /Iy
2005
b Licensed Professianw
y OWNER-BUILDER DECLARATION n fl ®�
ZOO hereby alarm Jin 11.sumps from me Coboacmoc :An c law for the U
C p O which
moan.(Sedan]11313•Business ab Profansians Code:Any city or county
53�i which mqukan a permit no t mos the anter,wprow,h permit
fi mpwr ed mumom $5298
i'ye tprior hat he its iawne0.Wumg0 the theapplicantfor achpermit m0lea,Law(Caomcm
�p thetwislimnud lmmsam.the of Dmsnsor site camramrand Proflaw(Chager9 Sq.Ft. Floor Area Valuation
$ (eommemdcamps therefon rom
00)and
hands for le the Buatnmadon.Any
Code)or
.. seam he o axemPm timrefmm and W bub for We alleged exemption.Any vlaldan of
Section]0313 by any applicant for a Permh sebyems the applicant in a civil penalty of
not more in.Tom hundred dollars(S5WW), el' Occupancy Type
r,,,owmr of and
prapaty,a my wployca wW wagan a dab vele mmPrwd.,
and domeWWk,ab the he omsmtmLndd orafflandwdo Imampply In a1,Baer of
and Property who ba Codr 7w cnnt ermra ammo law doe,set apply m rt sough err Required Inspections
Own con who hWMserimpm sueb imgadwho dmswchwhhwr3forthmugh his
Own emr.then,provldnd mooch imprawreao art set intended moaned lm ale IL
builder me building orwPmwmebtUcamwithin one you of completion,the purpose of
WB wan the when of proving mal w did not hwm o improve(o purpose of
ale.).
O 1,as owmr of the property.see eaelusiwly conuSCUng With Omvd contractoa m
coasoum the project(Sm.7041,Business ad Profession Cade:)The Cmtraure U.
cenew law Joan not apply m an owner of propatywho anima or Improws mere.,and,
who morons for such pmjcca with a eunnater(O lmensed pursuant en the Commerce,
ldeeve law.
❑l un actopt under See ,B a P C for this mann
Omar Data
WORKERS COMPENSATION DECLARATION
I hemby arnm under penalty of Perjury,am of the following declarations
I haw and will maintain•CerdRcate ofGmem to alf-luure fm WorteesCompen-
m
memo.a pmvided fm by Section 31X)of the Labor Cede•fm the pmfomanm of the
wh for wMrth this Permit is iumd.
❑1 haw was will maintain Worker's CompensationImuace,u requited by Section
naoofineLabor Code.Jet ft edommmofthe work fur which this pami,is '
My Workers Corepead.Iwmnce ymier W Policy number am:
Grtler. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
o lost(This aced.road set be cemplcted Ifdw permit is for one hundred dollars is IMI
1 cadlY that in the performance of the work its which this permit is indeed.I"I am
croploy any Person in any mere ermu In become object he the worters'Compensd.
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this CenlOcam of Eumpdm,you swum
become Soblm to on,Worker's Compensation provision of the labor Cade,you most
.J O forthwith=reply with such pmWlom o this permit shall be seemnd mwle d.
CONSTRUCTION LENDING AGENCY
v
f•w hereby which
Upemembaed(Scetinmmndis.r_) yfor the peRumance of
a theLe wick icor which mi,permit b indeed(Sm.]09'7,CN.G)
�W lenders Num
=z Landers Address
U O 1 ratify that 1 haw red this application and sum that the show informedm is
U4 5 toren.I agree m d comply with all city acounty uNi.nca ad Some laws missing m
DSVbuilding construction.sed hereby aubodm representatives ofthu city m enterupm the
W slow-wo ntiomd property for Inspection I ur(waes.
G (We)agree to ave,indemnify ad keep hemle s the City of Cupertino against
CM liabilitia,Jdgmoeu.coas and expenses which may m men my way aagwat said City
U z in eomequeme of me gratingm
of this pnh.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signuun al
HAZARDOUS
Dam Applica
xnzAaDous MATERIALS DISCLOSURE Type of Roof
Willy t applicant.Muni building occupant am or handle Health
material
a ash.Sed by the 32(,)? Municipal Cade.Chapter 9.12.ad the HWm ad Safely
osis. Oyuection 33snw] All roofs shall be inspected prior to an roofing material being❑van ON. P P Y B ginstalled.
Will the applicant or future wilding occupant an equipment m dcim which If a roof is installed without first obtaining an inspection,I agree to remove
mit haabnu air concomitants u Jcfined by the Bay Amo Air Quality Management all new materials for inspection.
D sat TIT
❑Yat ON.
I haw read the haatdom ream ilhooluimmenes underCwpw6.95 of the Califon.
m2 Health!Swety Cade.Sections,35505.35533 ad 35331.1 understand thatif ft wilding
does not currently haw a Imam.mat It o my responsibility m mdfy the oaupent of the
mwimmebuwhich most wmrlprior missuance or.cenilcateofoccupancy. Signature of Applicant Date
Owner or outheriad agent Dam All roof coverings to be Class aB"or better