04040177 CITY Or CUPrMrINo
BUILDING DIVISION PERMIT CONT RAC1ORANFRMAT10„N i,
BUILDING ADDRESS: WILLIAMS ROOFING PERMIT ND04040177
NER'S NAME: PERMIT ISSUE DATE
O W
ERNY RAYMOND J AND CHRTSTE B4921 CABRI POTNT 04/27/2004
ONE: SANITARY NO. CONTROL NO.
408) 252-5120
ARCIIITE-T/ENGINEF,R: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
uo>p LICENSED CONI AAM OR'S DECLARATION
CVG 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
e zo, wilb Section 7M))of Division Sof the Business and Professions Code,and my limens is
n6a L easeull Ccsn' cff
5.on L;men.Kc sea - L „ 74o T/0 WOOD SHAKES, REPLACE
Data E.inmmr — WITH 50—YR. PRESIDENTIAL
Ct4 ARCHITECTS DECIARATI N
eKs I understand my plana shall he used as public records - MAY 10- 2004
W
Licensed Pntfeasinnal
am
<s OWNER-BUILDER DECLARATION
ya S 1 hereby affirm that I am exempt from Cite Contractor's License Law far the BUILDING
fi 8 A�A ®'{�Og�1
p O following mason.(Section 71131.5,Business and Professions Cade:Any city or oounty BIBJ L NG
e m� which requires a Permit to construct,alter,improve,demolish,or repair any svuctum
=_on prior to its iuuanec.also roquims the applicant for such Permit to file a signed sutomcnl
that he is hcu
enud pimmnn the provisions of the Contractor's License Do,(Chapter 9 Sq. Ft. Floor Area Vllu41ipA200
rr0 (commend ng with Section 7QXB of Division 3of the Bossism and Professions Code)nr
i Nal he is eacmpt lh ialh oro and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjecta the applicant lO a Civil penally of APN Number Occupancy Type
not more than five hundred dollars($5W).
p y yp
01,as owner ortire praperty,ormyemployees with wages astheir sole compensation, 36215013 . 00
will do the work,and the structure is not intended or offered far sale(sec.7W.Business
and Pmfcuiom Code:The Contractor's License Law docs not apply to an owner of Required Inspections
property who builds or improves demon,end who does such work himself or through his
own employccs,provided that such improvements are not mmnded or offered far sale 11.
however,the building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving that he did not Wild or improve for poorest of
sal,.).
❑1,as owner of the property,am exclusively contracting with licensed eonaaclors to
constrocl the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
came law does not apply to an owner of property who Wilds or improves demon.and
who contracts for such projects with a contracmr(s)licensed pursuant to the Contractor'a
Lice
as Law.
❑I am exempt under Sec. ,B&P C for this mazon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirmun der Penalty of Pi one of the following declarations:
s:
have and will maintaln a CertificateorcmawO to self-insure for Worker's Co.,..
soden,az provided for by Seniun 37f111 of the labor Code for the wiPo mmome of the
work for which this permit is Issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
37M or the labor Code,for d,Pormormence of de work for which this permit is issued.
My Worker's Cr msp�entsalinn lnsumn�c4�carrier and Policy number are:
Carrier: Sl/c la— T "5• Policy Hen: O•fb 'Use_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scfinn need nm Mcompleted file Permit is fosse hundmd dollars(SIR))
or less.)
I certify that in Ibe Performance of the work for which this permit is issued.1 shall not
employ any person in any manner an as it)became subject to the Workers Compensation
laws orcl inhoia.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenificale of Emmptinn, no should
become euhj,cl to the Worker Compcnmtion provisions of the labor Code,you must
.J z forthwith comply with such provisions or this perm it shall rte deemed revoked.
Z O CONSTRUCTION LENDING AG ENCY
the may affirm that there is a construation tenth ng agency t err the petformanec of
fL d,work fm which this permit is issued(Scc.3W7,Civ.C.)
!T7 Q Under's Name
7 z Under's Address
U O 1 certify that 1 have read his application and state that the above infnnnaliun is
Ig, F-' comer.I agree to comply with all city and county ordnanaes and stale laws mhting to
0 U building construction.and hereby authorim mprcumallves or this city to enter Open the
HILI above-mentioned properly for inspection pmImseS.
G. (W,)agree to save,indemnify and keep harmless the City of Cupertino against
N Iiabilities.judgments,costs and expenses which may in any way accede against said City
U in consequenec of the granting of this permit.
(CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
URCE REGULATIONS.
�rz��t9 Re-roofs
Signature of ApplicanYConvaemr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle ha'rardous material
az defined by do Cupertino Municipal Code,Chapter 9.12 and ft Health and Safety
code, action
y nzss3z(a) All roofs shall be inspected prior to any roofing material being installed.
Will the applicant rr fu> ildingOccupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it hvardous air comarnmants u defined by the Bay Area Air Quality Management all new materials for inspection.
7�i;
strict?
❑Yes No
Ihavc read do haaaNnus materials requirements unto Chapter 6.95 ofthc Califory {-kL.� /��
Health&Safety Coda,Sections 25505,25533 and 25534.1 understand da11 huilding s l//
a not curently Imw:a tenan(,that it is my res,ronsibi lity In neu ly me occupant of thecomment It Is,metprions)ismnanfaCom0cateofOccupancy. Signature of Applicant Date
s-) .
or
andaarmd agent role All roof coverings to be Class "B” or better
F Community Development
10300 Torre Avenue
{% Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
�UPEI�TINO
Building Department
11
JOB AD SS: ��4 t p54 LV PERMIT o /,-, O
OWNER'S Epay NiONE # -108 44 — SY r L
GENERAL CONTRACTO FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
T'
�ryz /og
r Contractor Signature Date C