00080067 CITY,OF CUPERTINO v - MIMI, PERMIT NO.
BUILDING DIVISION - PERMIT ° : I ' T.
BUILDING ADDRESS:
SANITARY NO. ,APPLICATION SUBMITTAL DATE
WNERSNAME: .COSMOS ROOFING 11ZI IIZ1801D67
y r• , ' NIC CONTROL#
PHONE •. SRINI MURTHY `• 450 '' SAN ANTONIO RD 'Os' 08/0,91/2000 "
ARCHITECT/ENGINEER !N j[{ER �T b
('41.5) 493-=6373 -
LICENSED CONTRACTORS DECLARATION "' r • - '"
OZ E hereby affirm Ner I un licensed under provisions of Chapter 9(cnmmerwng I Job Description
P H G wif SM6607 00)OfDivisioh3of Ne Business am[Profession Cade.atedmylicenla is
In full force and effect. ' - -
p,'w IleelueGlala Lie#" '-SHAKE TO SHINGLES 3 k H Dare Contiaet« - ^
F Ovo ARCHITECI"S DECLARATION - l ,yJ -
I understand my Plans dull k usw as Public records,
Eaten ed Profe..Ional
0.nxi.^.o OWNER-BUILDER DECLARATION - ..
G T hereby-fi Net 1 am exempt from Ne Contr«tars License Law fm the
C fallowing mansca.(Section]031 5,Business need Professors Cade Any city or county - 1
3
which min 'Perrone to comrrua eller, p demolish,or repair an mmturc -' -
pnurm't s ,t mgmres da liantforx n y` S Ft.Floor Area
app a rail e.ofenseLaedsuteter9 9 r �V ]on
dust he licensed pus ntmilia of Divkru icm 3 rhe Connamrendproe Lion,Cont«9 - "r
(commencing pt tho Section]0n d O basis for the
ejadBtaiexe and on,Anyana Code)m - '�.�.v.
Net he is exempt therefrom and the basis for Ne alleged exemption.APy,viNmdt of ...APN Number' OCCupanq fbi O?
But ase Bee S five
any applicant for a gamut eubjate dm appGnnuo n civil penalty of ,
not mom Nan ff the property,
yempl.
❑both;woowner k,and
progeny or my employees orNwagaaateilate(Ses, B,PL Bushels uiL[$�6�IInspectlons�-
will dPerdework.endN The
is tot's Ludedmoffamd wdoesmtapply.]0a camera � 3577.44 . ILIQJ
' end Rofesuon.Cade:The C a.clumre,xed w taw dna not apply s lf own«of
Property who build.Provided
r vided B Narcan,epr who does such work himself.1 m tluough
`hu own employes pm Aad that men improvements lie not mundw ar oRered for 305' FRAME
sve.lf however themld ng m'mprovatiemusold wlNm ane yeuof completion,the
n Wlduwillh.tMbrdenofprovingthathedidbutWildcrImprovetorpor .�,07"— • INSULATIONr
'
❑Irwricrefurpropesbarrexclus'iwly commefirg wiNlicensed emiunictobe ' 601. — ROOF TEAR OFF ..
como art Ne project(S« 7044 B.Bumas and Profe.clons Code)The C nne o'l LI -'
.censeLaw dues trot apply toanownearof property who build%or lmpmva Hereon and - 602 ROOF PLYWOOD, NAIL
Liceme vats(orauch prof«u with acontr«mr(q licensed pursuml to Ne ConuectoYe
uanielaw. E03"— ROOF BATTENS
❑aero eaempr and«S«..'.' ',B&PCfa Ihk eon . .604 —.' ROOF' IN—PROGRESS - -
Owner Dare -
WORKER'S COMPENSATION DECLARATION '
1 h by ffrrn under penalty of perjury mm of Ne follow g dm,.,iom ' - -
❑I„ d ie rmiby
Section
3i7W of On LaWoCour,for Pored kern Coope
xmb es provided forpemi S«tion 3]00 or Ne Labor Code,for me per(mune of me'
'work for which Nle gamut is issued, - '
❑I have and will mvnuin Workers Compensation Insurance,as required by Section "
- -My Wr rhe Labor Code,ror the performance of the wart for which this permit is ia...d. _z. •
' MY Workera but
Insurance canter and Policy number are: '
Cnnva: Policy No.: _
CERTIFICATE OF EXEMPtlON FR(JMWORKERS'
H COMPENSATION INSURANCE -
mless.)This section need not&completedd the permit is fromm hundred dollars($100) _ ..ro .. '
I certify Nuin Neperforma«eaf Newmk Por whichNi.permit ie iasuw;lahall - '
"nm employ any pereon in any manner so a to become odn.to dreWmken'CWu en- -
Appitrant
ascot o(Celifomic Dam
' NOTICE TO APPLICANT:If,afar meting Nis Certificaie of Exemption.You should w .� - -
become subj«t to the Workers Compensation Provisions adults,Labor Code,you most -
forthwith comply with such provisions ar this peoah shall W deemed revoked.
4 ,
0`Q CONMUCf10N LENDING AGENCY
I hereby afion that Nem le constmcm,leading agency for Ne Perfomunce of - r
hOn..it for which Ni.permit is'asua l(Sec.3097,Civ C)
'a Lauder,Name ..
lenders MWresx
0 : 1 certify chat I have read this application and state Out Ne above infomuuon i.
correut.l agree to comply with all city and county mNnance.and sure laws relating m
building construction,end hereby autharize representatives ofthis city to enter upon Ne
•,C=.) above.menuoned property Tort uupecmn i urpo.ea. ,.
W.E„ (We)agree m save.Indemnify and loop haimless Ne City of C pert o against -
0 C) libihua,jmgments,costs and expenses which may in any any acmeaganst laid City -
tin consequence of On granting of Nis pnemi,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
V SOURCE REGULATIONS. '
e fAPD
Ianan U 0rmmr
Due' _
HAZARDOUS MATERIALS DISCLOSURE
Willapplicant or future bg occupantstore ha-ndle haai material
a ey the CuprtirmMdnicilml Calm.Chapter 912,and the Hevh and Safety -Re-roofs
coca,Section 25532a)] - s' ,,r ,• ,t'
'• -
Type of Roof.
[I yea C]No
Will the tuuid¢xnt or future building occupant use eryjipu�mt rde aswh;ch All roofs shall be inspected prior to any roofing. material being, '
"next h cath u auconandranu de6nwbyNeBay HcaAir O nl'ryManagement installedDomict? . If a roof is installed`without first obtaining an inspection
❑Yes ❑N I agree to remove all'new materials for inspection: Applicant
•.,„ave read On havNou mpunaii mynimmsme Me,Chapter 6.95 of thp edi- under*ofplicant
nd will comply with all non point source regulations.
forma Breda Jr Safety Code'Savoiu 25505,25533 and 25534 1 understand Nat if Ne
building does ran currently have a¢nenL Nu it is my responsibility to notify the occupant ��y�''�
of Ne regmremenu Much IW ren ins mane.«.of.Certificate of Occua«y - C56
Owlter or aallon=w agent , Date Signatu ' 'Date
• All roof coverings to be Class"B"or better
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t
OFFICE
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