01100109 CITY OF CUPERTINO - -
BUILDING DIVISION PERMIT CONTRACTORINFORMATION:'
BUILDING ADDRESS: PERMIT NO.
10364 DEMPSTER AV RESPONSIBLE ROOFING INC 01100109
DATE
M1 6 owt?q •gyupME: 2882 SPRING ST A10/19s/2001
VBis
PHONE:
Ii (650) 969-6151 SANITARY NO. CONTROL NO.
A W z0 ARCHITECf/ENGINEER: BUILDING PERMIT INFO
kC�u BLDG ELECT PLUMB MECH
Z LICENSED CONTRACTOR'S DECLARATION
y�` 1 tonally ofirm Ilial l am licensed under provisions of Chapter 9(commencing Job Description
3N ttj will Section]000)of Division J ofthe Business and Professions Code,and my liana REROOF.
;xf_1< smfullfo <aadeRal. �� a T/0 & DISPOSE OF EXISTING ROOF,
:Oas.�S Licenu s - Lu.
APPLY NEW 40 YR. COMP.
7 3 a Dam f0-H /J I' Conwclor
0 ARCHITECT'S DECLA A
to
1 understand my pions shall o,used as public records
i to
7 6 p o Licensed Professional
' $ OWNER-BUMDER DECLARATION
t 1 hereby pmt that 1 am exempt from the Contractor's License law for the
L
?a following ruson(Section 7031.5,Business and Professions Code.Any city or county
D
which requires a Permit to construct.alter,improve,demolish or repair any structure
$ +poor to its a ce,also requires the applicant for such permit to file a signed statement. -.. -
°' - Nat haul arced pars hl rd Prep Jrvons of the Comnamors License Law(Chaprer9 ,.is r Y Sq.•F[ FIOpoI`gaea ss fs' p ation
(commencingwrN Sccu n]000)of Division Ja(the Bu,aines+and Professmrrs Cade) <. �, 4 +..„5�f. .G.,l l_Ci s! t�`� 1A1.[.J_ $83fYG"
or that he is exempt therefrom and the basis for the alikied exi mpdon.Any violation
of Snvon]031.5 by my applicant fora permit subjects the applicant m a civil Penalty
I of not mart limn five hundred dollars(5500). 3 2 6417tr1LP.b®10 Occupancy Type
0I,as owner of the property,or my employee with wages as their sole compensation,
win do the work,and the urvdmre is not intended orofferedfor'sole'(Sec.7044, 3 0 5 - FRAME Required Inspections
r Busimas and'Profcssions Code:The Comramr's License Law does not apply to an
owner of proprnbunds or Who bor improve..Ihacam,mm who does such wart himself 3 07 — INSULATION
or througgh his own employees.provident Nat such improvements am not intended or 1
offered for'ule.ILti _ _
owerer.,h ill building improvement pimana that within one year of .601 = ROOF TEAR OFF
improveifonpumpseo1'susl ),will have the Wrden o(provingthat he did not build or 602 - ROOF PLYWOOD NAIL
improve purpo
......._ . . .a _ _. s. 603 - ROOF "BATTENS'
' as nrof N< ro n � -
p Isms. exdas ly tmctatimin licensed Contractor's
Live
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Livcone sm owthe Profen(sea.]1.a Business anderty wrens cacao Thrves,mm�o 604 - ROOF IN-PROGRESS•' '•
Licenu Law does nes apply m an owner of property who builds m improve Norton.
.and who contracts.for.such,projects with a contmcmKs)licensed pursuant to Be, _. __ .1.-.... . .. . ..
Contractors License Law. . - - - -'
B
Distant:xempt antler Sec "' &PC for this mow ,.
n .I t .,
Own Dem'" '.,.
�� - WORKER'S COMPENSATION DECLARATION FIV ALEG
-I hereby afrm under penehy of pvjury one of Ne following daleretionx:
❑ I have and will meiniein a Ccroficam of Consent to self-inure for Worker's OCT 2 y 2001
Compensm00 iaq.'as provided In, by Section 3] of the Labor Code, for the
_ 'performance of Ne work for which this pemtir is iuued.
- - D 1 have and wili'nummus Worker's Compensation InsuinMq as required by Section BUILDING
3]00 of the Labor Cade,for rhe pawles once of the work for which this pe con is
.- issued.My Workermi
s Compenxon Insurance carrier and Policy,number art:'
{Polo No.�/3'7.1/rte
s l✓^ - Y
.CERTIPICATI
, OFFROM W"O'R"R'
COMPEN,SATION INSURANCE 't
(This union need not be complaM if the pemtil is for are hundred dollen x " `'f �'i, 's•�{I„
(I101B or less,)
I
calf thnt in rM1 f f the ark f hi h tti
tetiar not em,to 'an .� pmrmr snaued,l
y y m son in any manner so as In hecome'suh3en m the Worker%
pariation la___ California.- _ % --
'Applicant: !__ .. „._ ,.'
•'NOTICE TO APPLICANT:If,alter making this Certificate of Exemption;you should - v
Obecome subject to the WmI ce.Compensation provisions of the 6ebou m Code,ymust )
forthwith comply with such provisions.,,his permit shall be deemed revoked.
z Garin i - ._.._. _. ... .. .... .. .. ;,... _
F�VJ ENDING AGENCY f t
rCONSTRUCfION L 't
tot the lhereby affim ark toh h th,t there is a construction leading agency for the performance
I
Under,,
f 1 f
cd(S Jn9] C' C)
a_Q li dr,Name - .. . ” " -'
Icnder's Address• ..._..
V ,I certify Nm 1 have me'"is application and material the above information is
correct.1 agree m comply with all city and county ordinances,aad one laws relating t
,�. •Iobuilding construction:and hereby amborim'rtyrtuntdtives ofRhi city tomberunw:
� tai .Ne above-mentioned properry,for inspection purposes.
. L54' (We)areal.save,indemnify and keep harmless d¢City of Cupertino agmma
Z) liabilities,judgments.costs end espaues which may in any way..a is
gainst sai'
r U�i Cry in consequence of the gmalar,of this Formic', _""'
:APPLICANTUNDERSTANDS AND WB,I,COMPLY WII'HALL NON-POINT" Issuedb
SOURCEREGULATIONS. ". y: Date
Signature-fAPPIicmuC nI cr `:'t ^.' 'r, Dam'." RB-roofs f
HAZARDOUS MATERIALS DISCLOSURE, t' / p 7 q��
WilltheaPPBcamo Potwcbulthvgmc pmt I mnmt'leluamdwmumtl Type of Roof- (__
as defined by the Customs Municipal Cod Chapter 9.12.and Ne Hee1N and Safety - -' v- '
Cd' Semon 25!Q2(.;?tin 1,4' It^ t r 3..�)�', s ;! tr ^'r4� AIi I' .
❑Y. ,. oNo �, f". 5 t 1^, . All roofs.shall-be.inspected-Frio'nto.any.roofing,material being.installed...
W'llth applicanlo future building occupern use equipment or devices which If a roof is installed without first obtaining an inspection,Pa ree'toiemove
ennI haaard s an commutator as defined by the Bay Area Air Quality Mom's mans g p g
Disrrfe6.: ,, .t „ . all new materials for inspection. Applicant understands and will comply,with
`.' DYr, �. pNo; •fir - - - ` -. all non-point source regulations,,, ... ._t a I
1 have rend the hamrd us'materials napiumsenk older Chapl r 695 of the
Cal f mm Health&Safety Cade Secl ons 25505 25533 ad 25534.,l understand that _A s
ifthebuilding doecurrently e tly havem.Imathat itt my responsibility t /'notify the ✓
occupant of the requirements which must be met poor to isivarce-f a Certificate of / AnaY C
Occupancy. k . .
Signature,of Applicant. _ .. -. Date .
.Ow ramhodaodagent,' Date All roof coverings to be Class "B"o'r better''
OFFICE