05010013 CITY OF CUPERTINO' - - , ^w`+t rir6,x• "" r«'s'"�' a=�z --_
_ BUILDING DIVISION •• - PERMTi' , CONTRACTOR INFORMATwION -
BUILDINGADDRESS: CONRAD ROOFING SERVICE PERMIT NCO 5010013
-7. 10776 CARVER DR
OWNER'S NAME: PERMIT ISSUE DATE
BEN GALVEZ 332 PHELAN AVE 01/04/2005
ONE: SANITARY NO. CONTROL NO.
- (408) 294-7615
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O
LOo LICENSED CONTRA R'SDCLARATION - JObDes
-
y u C - 1 rah firm thm I am littlucd undo visions of Chapter 9(commencing - _
n« with Sce on )of Division 3 of the Huron and Profession Cml%imd my license is -
_n„ mmiceum am err _ Ltl(,52. -- -REROOF W/30YR. SHINGLES
Z Da¢ Cl Contramor [[
ARCHITECI'SD RATION - JAN �, 2OOJ
u d mY 'la s shall W used a public -
006
3 C.
0 Licensed Pirdlicieshmal If�l p ®�11®II/I —
OWNER-BUILDER DECLARATION tILIyJsXI Ilt� Il pVp l\``/�jj _
y 1 hereby affirm Nm I i m ucmpt from the Contractor's License Law for the 11 "
S p O following maven.(Section?(n 1.5,Business and Professions Calk:Any city Or county .-
K m which muni=a permit w ennstmel,alter.improve,demolish,or repair any someone $4550
FiQ
He,to is ouncioce.alsureyuires tWappheild,forsuch permit m fileasignedsutement _
Ihmhe islicensed pursuancso the provisions ofthe Commcmr's License law(ChaplerY Sq. FI. Floor Area Valuation
SFO (commencing with Section 7")of Division 3 of the Business and Professions CnJe)ur - - -
i Nal W u exempt therefrom and the basis for the alleged esempu.n.Any violation of
Section?W1.5 by any application for a permlt subjects the applicant m ilesvilpenaBy.f _ _ - E - •.Oeeupancy.Type _
not mom than rive hundred dollen --
❑1,as owner of me pm scoy,to,my employs with wages as their sale comparison..,
will do the work.and the strucw¢is not intended or offered hold.(So,.?Baa,Business - - Required Inspections
and PrOmssioas Code:The Contractor's Lime law ds not apply m an owner of 9 p - - -
proPcnywho builN or improves tWmon,and who dssuch work himttlfor through his -
Own employs,provided that such improvements sm notinembed oroRcmd forsale.If. -
however.the building or improvement is sold within one Your ofcnmpleded.the owned
builder will low the lordmt of proving that W did not Wild or improve for purpose of - - -- _
sok.).
❑1,a owner of the,proper&am.,I.iwly contracting with licensed Contractors to .. -
Construct the pmjcct(Sec.7000,Business and Profcssioa Cade:)The Conerecmr's Li- ..
cense law ds not apply in an owner of property who Wilds or improves IW man,and _ .. - - ... - _.• -
whocontractsforsuchprojectswithaCommemrH)licensed pursuant to the Conuaeto's --•— --License Law.
❑Lem uempl under See. .B&P C for this reason
wrier Date
WORKER'SCOMPENSATIONDECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I ha ve and will maintain a Cenifiure of Conamtto self-insure for Worker's Compere
Cation.as provided for by Suction 3700 or the labor Code,for the perfatmame of the .. ._
.,it for which this permit is issned.
❑1 have and will maintain Wokefs Compensation lasmano,in myuimd by Secuon z „ ..
3700er Ne labor Code.for the performaneeofthework for which this permits issued. _-- ---
MyWorkee Cyompetwdon ln�w'nn¢plamia and Policy number am:
a r. Tt 9�-•c , Polity No.: !gSS
CERTIFlCATE OF EXEMPTION WORKERS'
COMPENSATE SU NCE
(Thu section need not WcomplcteJ ih rmitls fromic hundred dollars($iM)
lir less.)
I certify that in the performance of the work for which this permit is issued,I shall not ,.
employ any person in any mannerm at to become subject to the Workers'Compensation -.-
Laws of California.Dam .._.
Applicant .. _
NOTICE TO APPLICANT:If,after making this CeniBeatc of Exemption,you should
Wcome subject to IW Worker's Compensation provisions or the Labor CMe,you mind
�Z undwith comply with such provision or Nis permit shall W domed rewind.
Z O CONSTRUCTION LENDING AGENCY
;. I Inneby affirm that them is a construction lending agency lar the performance of
x > the work for which this permit u issued(Sue.309?,Co,C.)
LQ
In lender's Name
a.Z Lender:Add.
V Q 1 sonify Nat 1 haw mad this application and note that tW above in(oout.do.is
I2.Fcorrect I agree so comply with all city and county Ordinances and state laws mining to
V building construction.and hereby autholne leposematiw of this city to enter upon the /
W above-mentioned property for iapectien purposes.
(~6r (We)agree to saw,indemnify and keep hasmlcs the City of Cupertino against
rq liabilities,judgments,costs and expenses which may in any way accrue against said City
U z APPL CANTcof the granting of UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Ds permit. ate
OURC UL ONS.
-pr Re-roofs
Si um of Applie on'Conummor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupaml stare or handle hmalloa material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
mk,SoToom 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Totem building occupant use equipment or Jcvices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havardous air Conduction.as defined by We Bay Arta Air Quality Management all new materials for inspection.
Disurn,7
0Yes
Lhave mA,Serti the havndous Sectios 25505lnmyuiremcns underdehmm6.95ofthc Wilding
ria He,hh&Safety Cale,Sections n,it i§5533 and 25530.1 to nosily t e Occupant
e Wilding
Jos not currently have a tanant.Nat it i y responsibility In nndly the necupanl of the
require hie mustWmetpdorwi aofaCcrufcako(OccupancY. 1 IureofApplicant Date_
7 own n ar,amoria<d ascot ^ D,. All roof coverings to be Class "B”or better