04100071 "f CI•I�Y OF CUPIi TING
BUILDING DIVISION PERMIT + CONTRACTOR INR,ORMAT-ION �&.
BUILDING ADDRESS: LOS GATOS ROOFING PERMIT Ng.4100071
0284 CRESTON DR
W NER'S NAME: PERMR LSSUE DATE
MARTIN SORENSEN 1771_ SMITH AVE . 10/12/2004
ZONE: SANITARY NO, CONTROL NO.
(408) 298-9399
ARC(IITECflENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Lop LICENSED CONTRACTOR orders vimurs ATION
fChir - TTTIII,,,,,,..�..
aw 1 hereby arum Ihm I am rime u under prnvis fest of Chapter 9 oommensing Job �IY tl, \b
t with section]otkR of Division Jof the Ousincsv and Pmfcxsinns Cak.antl myliccnsc is I'llll(r�� �®
'rte„ mmufomeandof gpJ�p REROOF W/SHINGLES
o g 3 License C{�s Lic.N
F O
Date
Cummcmr
at ARCHITECTS DECLARA' I N
�i c u 1 understand my plans shall he used as public records DEC G
2004
'' s' Licensed Professional
aO J OWNER BUILDER DECLARATION I� Ice
a S 1 hOutte affirm on 1 am eBcmpl from the Contractor License haw for Inc 11 11 11
0 o following rcamn.(Section]IDIS.Business and Pmfessioras CrWe:Any city m county I„�/( '111�"/jyf
�„ which requires a permit m construct,alter,improve,demolish,m repair any slruclme u Q 2 Q 8
FZ� prionn its comnee,also requires the applicant for such permit to lilcasigned smtemenl
mathei.reented parstim oithe provixomouf WCmtnerors Li.mcl-mv Chapter9 Sq. Ft. Floor Area Valuation
y i-O
(commencing with Section 7000)of Division 3 ofthe Bu&ineaoad Professions Cate)or
i Nat he is exempt therefrom and the basis for the alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of bC OCCD T
not more than five hmOccupancy dted drdlars(S3(k). P Y YPC
❑ L as owner or the pmpersy,or my employees with wages act their sole compensation,
will do me work,and Ne suucturt is not intended or offered for sale(Sec.71144,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of Required Inspections
property who builds or improves mercon,and who does such work himseRor through his
own employees,provided that such improvements are not intended or offered for salt.IL
however.the building or improvement is sold.4hanon,Year ofcompled.m.the owne-
builder will have the burden of proving IAv be did not Wild or improve for purpose of
sale.).
❑ 1,as owner of Ne properly,am exclusively contracting with licensed contractors to
Conswet the project(Sec 7044.Business and Professions CWc:)The Contractor's Li .
case Law does not apply to an owner of progeny who Wilds or m pmwa Ihemon,and
who contacts for such projects with a contractor(&)licensed pursuant to the Contractor s
License Law.
❑1 am exempt under Sec. .R&PC for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury not of the following declarations:
I have and will maintain a Ccnificme of Consent to self-insum for Worker's CumPcn-
smion,u proviticd for by Section 3]W fir Ne labor Code,for this performance of the
work for which Nis permit is moodt
to
rl have and will maintain Worker's Compensation Insurance,as required by Section -
3700ofthe Labor Code,for the performanceorPre work for which box email is issued.
My Worker's Compensation Insu`mmce carrier and Policy number art:
Camcc�(p1 r ��/�4 Policy ba:fU7 �AOOX
CERTIFICATE OF EXEMMON FROM W ORKERS'
COMPENSATION INSURANCE
(This w0ion need not W completed Ethic perm'n is for one hundred dollars(Slot)
n less.)
1 certify that in the performance of the work for which this permit is issued,1 shall not
employ any Person in any manner.so as to become subject to the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should '
become subject to the Winker s Compensation provisions of the Labor Code,you must
�Z, forthwith comply with such provisions or this Permit still he deemed revoked.
?O CONSTRUCTION LENDING AGENCY
1 hereby affirm than there is a construction lending agency Ent the performance of
C( � the work for which this pmmit Posited(Sce.3W7,Civ,C.)
W 0 Under s Name
Lenders Address
J U 1 certify Nat 1 nave real this authorize
repo and state(hal the aWve inrerror upon t is /
Iy ^� correct.I agree m comply with all city and county ordinances and state laws relining to
V above mentioned property
hereby of this city to ender upon the
d
above (We)are progeny fur inspection purposes.
(We)agree a.save,indemnify and kith harmless the City of Cupertino against
FZ in cuiscs,jatlg ofthe raising of this camit. may in any way¢cmc against seam Gtr
U2 A APPLICANT
ofthe this permit.
'^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
' OURCE -0 -ATIONS
- Re-roofs
Signator ppl, am/Co .actor Datc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle harartluus material
a defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code, Iia 25532(an All roofs shall be inspected prior to any roofing material being installed.
ex
0Y
Will thea applicant building Occupant If a roof is installed without first obtaining an inspection, I agree to remove
PP 6 P equipment or devices which g
mil harardnus air contaminants as define by the Bay Arca Air Quality Management all new materials for inspection.
utrict?
❑Ye, NU
I have mad the hrrardm&materials Icquircmems under Chapter 6.95 of the Califor
oielleolm&Safely Cale,Scctions25505,]5533mJz5534,Iundersmndthinifam W'ddmg ) lUs •-��'O
dkax nm currently havx a mrmnL that it is my mspunsibil'ny m notify the occupant of the
mquo.ore0 ti,fmun Wmelprionn tommuccofa CCJficam ofQellpaney, r
' � Signature of Applicant Date
ownnr fir¢¢mini<tl¢gen Data All roof coverings to be Class "B"or better