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' CITY OF CUPERTINO ---'---
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DIVISION -PERMIT'
=CONTRACTQR�INkURMATIQN
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BUILDING
BUILDINGADDRESS:
RESPONSIBLE ROOFING INC
PERMIT"°04120149
10700 CLUBHOTTSE IN
OWNER'S NAME:
PERMIT ISSUE DATE
JOHN TELISCHAK
2882 SPRING ST
12/21/2004
NE:
SANITARY NO. CONTROL NO.
(650)969-6151
ARCHITECT/ENGINEER:BUILDING
PERMIT INFO
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BLOG ELECT PLUMB MECH
LICENSED CONTRACTOR'S ilCLARATION
Job Description --
Phi y affirm Nal I am limnsed oak, ions Of Chapter 9 (commencing
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withScction9aID)of Diviskr3ofiWBusnas and ofoundrsCode,andmyliccnmis
m full fo¢e and eff e} — 6 Z (�
3 r 3 `a y �
TEAR OFF COMPOSITION
Lia^ c�h —. Lica
Da¢y COntracmF ��NL/',
ARcwTEcrsDECLARwuoN�7Z,; s�o.�.�
,,;NSTALL FIBERG P
Its crwnd my plans shell M usrd as public ¢cords
EP CLIFF GOLF O�SE/ NO
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Limused Pmfcssional
OWNER -BUILDER DECLARATION N
I hereby affirm al I am exempt fmm the Contractor's likens=Isw for the
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AN oa5
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following reason. (Section 703 1.5. Business and Professions Calc: Any city m county
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which requires s permit to construct, alter. improve, demolish, Or repair any swcwm
Prior mils issuance. aro requires the applicant retrench immiuo lilt a signed statement
that he is licensed pursuant in the previsions of the Connector'sLicense Law (Chapter 9
Sq. Ft. Floor
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Valuation
(commencing with Section 9(100) of Division 3 of the Business and Professions Code)
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$20135--
that he ra esempt thamfrom and the basis for the allegedexemption. Any violation of
--- - APN Number
----Occupancy Type -
Secfion90JI.5bymnappliantfor aPermit subjects the, applicant inacivil Penalty of
mu more than few hundred dollars
p I, as owner of the propersy. or my employ oea with wages as Ober, to emn, u don,
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Required Inspections
willdo Newark.emish strucurmisnot imm�dctl aroRered forselc (Sec.90d4, Business
and Professions Cada: The Coniaclor's Licenum Law dims not apply In an ^wncr of
property who builds or improves deacon. and who does such work induction through his
own employee, provided Nat such improvemena art notinmMcd aro@red for sale. If.
however, the building or improvement is to within one year of completion. Ne owner
builder will have 0m burden of proving Nat he did not Wild or improve for purpose of
sale.).
❑ I. as Owner of the property. am eschodvely contracting with lianud contractors to
consoua the pmjca (Sec. 98x4, Business and Professions Cade:) The Convectors Li-
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Co. Law does oro apply to an owner of pmpeny who Wilds or improv ilaeon, and,
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who contracts for such projects with a eonvactor(s) licensed pursuant in the Contractors
License Law. --- -
❑lamex,ninumm'soc. .B&P C for this lesson
offDam
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WORKERS COMPENSATION DECLARATION
edition-....
1 hereby eunder penally of perjuryro oof the following declarations:
I have and will maintain a Cenificate of Consent to self -insure for Workers Compen-
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sation, to Provided for by Station 3900 of Ne ISWr Code, for the performance of Ne
work for which Nis permit is issued.
1 have and will maintain Workers Compensation Insuranm, as required by Section
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I'M of NC Labor Cmk,.for the performance of the work for which this permit is issued.
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My Worker'sCompwsa inn Insurance can ier and Policy num W r am
Ca S Policy..
CERTIFICATE OF EKEMPTION FROh S'
COMPENSATIONINSU NCE
(Thu section wed not wcanpleted if the permit is for one hundred dollars (31 (10)
nr le..)
I certify that in the performance of the work for which this Permit is issued. I shall not
employ any portion in any manner so as to become subjmt to NC Workers Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cornfield. of Exemption, you should
become subject to the Worker's Compensation provisions of the labor Code, you must
' forthwith comply with such provisions or this Permit shall be dimmed revoked.
i CONSTRUCTION LENDING AGENCY
Ino the perfurmam:c of
thi Natthere issed(See
0Icndingagency
forwhich
' the work fur which this permit is issued ISm. J(199, Cl, C.)
Name
Lendm's
r's Address
1<ndeAddo
I mnify that 1 have lead this application and sum Nn the W. information is
'
• corms I agree m comply with all city and county ordinaries and state laws relating b
building convection, and hereby authoriaa representatives of this city to enter upon me
hove mentioned property for inspection purposes.
(We) agree I. save, indemnify and keep harmless the City of Cupcnino against
j liabilities,pilgmcnu, costs and expel•^• which may in any way acetic agrunst saidCity
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in consequence of the granting of this Permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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Issued by: Date
E RE ATIONS.
Re -roofs
Type of Roof
Se�UR
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sig err ApplicaHAZARDOU � Dam
HAZARDOUS MATERIALS DISCLOSURE
Will Nc applicant or future building occupant stow or Mndle hanrdaus material
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as defined by the Cupertino Municipal Code, Chapter 9.13. and the Health and Safety
,
ode. Section 15533(a)?
All roofs shall be inspected prior to an roofingmaterial being installed.❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future budding Occupant use equipment at devices which
troll henrdnus so- mu
nminants defined by thcm e Be,Bay Ama Air Quality Managc
all new materials for inspection.
District?❑Yes
No
I have marl the hopardmts materials rcyuirenenrs mul Chapter 6.95 of da, Califon-
laa1N
H& Safety Cade, Smvav 25505.35533 anal 5534.1 undersand Nu if the Wilding
does not currently have a mount. that it is my reawrobility in notify the occupant of the
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requiremerts ichMust W lPoor to issuance OraCmGBateOfOcapmcy.
areofApplicant Date
Si tu
All roof coverings to be Class B" or better
Owner
oraoKofiredagent oma