00110015 CITY
I uuu PING my RONNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO. '
10699 GASCOIGNE DRIVE COSMOS ROOFING
OWNER'S NANIF: APPLICATION SIZE DATE
MICHAEL SHILES 450 32/='
PHONE: SANITARY NO. . CONTROL NO.
G p a ARCIIITECTIENGINEER: BUILDING FERMI r INTO
z C BLDG ELEM PLUMB MECH
rWW
o� Z LICENSED CONTRACTOR'S DECLARATION
1 0 1I amby of arm that 1 at sensed made,pronsien,of chapter v mommenciag Job Description
rr,:Cw witL Se,pan9lllH))of UlvimmJof WO Business vnd Pmfessi,ns Code.and mylicense
ism full farce an
.a 'a uemtxe claxx._ Lie.a`I k5 -_N' T/0 BUR 8.& GRAVEL. -ADD 'BUR R• GRAVEL
s d y Date__Jd ICi no
ARCHITECT'S DECLAReQI
I understand my plan.,hull be mcd m public record, -
edw� p p Licensed Pndessionvl
OWNER-BUILDER DECLARATION _
1 hereby amen that 1 tar.raF
n ex,ntpn I the Cn ,Co License Law for me
3< following reuses(Section 9031.5,dusincs and Profession,Axle:Any city or eoumy -
S 5 G which requires n ectasia m conmmar,altar,lmpmve,demolish,or repair any%manta
3 t t I. q th Pel I I' h peon', f :gnml stamem
m
that
- -
' m n h e I I t o o p o nh Contractor',1: Law(n.,C erg Sq. Ft. Floor Area Valuation
or n t heei tg with Section IDefn of he v cion 3 or eye alleged
ss and ion,Ad,vicknde)
or that he is exempt mereGom and or .Vans For the alleged exemption.Anyh(ami family
�-�
of Section thniv anyapplicant forvpermit suhjevtstheupPlicnnt Inadvil penally
ornol mom man Eve bans„%doun,x(axlo). APN Number. COceupancy ype.
El 1,as owner of the property.or nay employee%with wages us their vole compoortion17,1 '/
will do the k d[lie stimanuo, :not t d i n r sale fa c.9,,a,
Business and Pr C - Required Inspections -
I Th C t t 1 I I rot.mi, r do ce, ta _
uwneral'property Who builds p th I h J h k himself
r ih cad his enc pl,,t,,prevded b ch mpro.e t art aar soared or .305 FRAME ,
- oftered Lor sale.If,however,the building or improvement is sold within one year of
mompladon,me owner-wader will have me burden of proving that he dm not wild or 307 INSULATION
mnrvehrr Pamaearawe). -._ - -
601 ROOF TEAP, OFF
coLus owner of me progeny,nm exclusivelynmmnctmg withodeI I h Comment's
combined the goosed tape.90aan owner ss sad Pror melon%coda,)The Co ithemo'x 604 — ROOF PI_YbI00D NAIL -
License Law does nm apply man owner with
a cont y who builds or improves thereon;
nae who contracts for such projects wird a contractor(s)fir<me<I pursuant m me 603_ — ROOF BATTENS
El I am exempt
pt under
Law.
❑lata ax,mgn%naso s,,. .BxrPcfor this reason 604 — ROOF ]'N-•f-'ROGRE_SS
Owner Dille
WORKER'S COMPENSATION DECLARATION _
I hereby affirm under penaltyof perjury ane of he following real...us
l 1 1 mm
d will nun a Certificatef C sem to self mare for Workers O'
p n.Vr i, as pmv'tivd far by Section 3700 of the LVhor Code It,, the
pef trecut in,work far whwhhis p r is restrol. - - -
hove and will malmain Worker'%Compensutioa Insmnncc,ns required by Section
)00 of the Lahor Code,for the performance of the work for which this permit is
I ,
issued.My Wor Compensation Insurance carrier and Policy number am: ,
Canter va Policy No:� ��tI ZS -
CERTIFICATION OFEXFMPTIO ROM WORKERS' ,COMPENSATION INSURANCE
f m...last need net he urmpleled if the pennon Is for one hundred dollars -
NHad or Ices.)
I certify that in the performance of the work for which this permit is issued.I -
shall not employ any person in any manner sn vs m become subject to the Workers
Compensation Laws of California.Date
AOua, a
NOTICETO APPLICANT:If;arm,making mos Cenificam of F.xemgtion,you should
hummc wbjcm ta me Worker's Cnmpudsvuun pmvisinnx of the Lahor Cod N.you mu.t _
Q forthwith i nmply with such m.,mo m nr this hermit shall be deemed revoked.
z
F y CONS] is.RUCTION LENDING AGENCY ..
T hereby wmah,hi,lherelxuuned(Sir, leading agency lonM1e performvnce
of me wo,k fm which this pcnnit ix issued(Sec 3097,Cie C.l
P. Q Lender's Nam,
Lender's Address
V O I certify that I have read this application and store than he above mfmmaion ie r
W F correct.I agree ut comply with all city and county ordinances and state laws reining -
0 V to building construction.and hereby uumorim representatives of this city[center upon
the M1w,rucalibradp p t,fornargaunat ems .
As (We)agree to save,indemnify and keep harmless me City of Cupertino galnst
Fr Vi liabilities,judgments,crisns and ex,bows which unny tY way accim,against said
APPLICJ z City m cousequeacu of the granting,f this permit.
SOURCE REGU .Ra NDS AND I[.[.COMPLY WITH ALL NQQQNNN POI -I' Issued . Be— p^'�7 Date
SOURCE REOU ON - - ����Q
Signature of App conal nonan, DaT .Re-rocs
HAZARDOUS MATERIALS DISCLOSURE r '
Will the appleant nr mum holding'�tipam-.Ince or handle hi>aiders material 'Type of Roof ..
as defined by me Cupertino Municipal Code,Chapter,9.12,and the Health and Safely - -
Cale. °tin 25532(a)^ All roofs shall be inspected prior to any roofing material being installed.
Will did...li,rm or future buildingaevapad use waipmem or de,I,a,whist If a roof is installed without first obtaining an.inspection, I agree to remove
'snit h:nnnloa,aircomnmmaids, deOne by the Bay Area Air Quality MVmigement ,
7,f
e � all new materials for inspection. Applicant understands and will comply with
❑.Yeeall non-point source regulations.
11 add hu rd u. act al,r qui,na at, t d,,ChdFit,6,95 of the-f n'a Health,@ Sfty C1 S t 2550525533 d 553% d tandthat �� �h TIgJ : I tlyh t t th tit s ny p .'bIlyt notify the s acupsaine
R t fah cqu M1eb nm tprio,mi c•ofa Certifeme of
Signature of Applicant Date
aiboth ad% at Dme ,,AIL roof coverings to be Class `B" or better
OFFICE