01040111 CITY OF CUPERTINO,
BUILDING DIVISION. PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: - PERMIT NO,
PLATINUM ROOFING MIC 01.040111
OW
NiiR'S NAME: APPLICATION SUR DATE
853 S 7TH ST 04/23/2001
]ONE: - SANITARY NO. COSTROI.NO.
(408)280-5028
Vre0 AkC111'I'EC TIGNGINF.[R: - BUILDING PERMIT INFO
he"z BLDG ELECT PLUMB MECH
rFi.6� �� CI IJ IUJ
LICENSED CONTRACTOR'S DECLARATION
Q y r3 I hereby ufnml]hal I urn licensed under provisions of chapter 9(eonmmacing Job Description
wens i 7000)of a rn B .a nPi l . crer and urease
o.a �;te ul me #JC1f 790 39 REROOF SHAKE TO COME' CONVERSION
F LL c.a A CHIT ECT S�CIDFCI ARAI'ION _
y S 1 undeclared my plats shill he Used as Itself,records
j
d�as
CO Lie e1P f:.' al
oI OWNER-BUILDER DECLARATION
v 1 thereby affirm that 1 am tf tl Contractor's 1' e 1 for the
Cx< toll g (Sem ID31 S.H sinri e ds C I.Any at ay W
zF Fh s, refund s t, s, dieUnloose,demolish,or rept r say simulate,uts , _T IIapplies.,
.... l( hpe nonoc .best Imnem .
math :tip m n„,hep rn of C liar I' La,tChapicr S Ft. Floor Area Valuation
(tut g with Section Salm f Division l fab 1limitlessour Pn fess ons Gale) q' .
or mol he 7 exempt xray oppli ur� the Loris rates cts t heican is)Any rotationSA 134
of Sermone thf,5 e mayred ons G,rnpern,il sngluls the upplicmn toncivil Penalty '
nrnrn more Inns ave bawre dollars Issas) APN Number Occupancy Type
❑1,asowner of the proper.or.... ctnployes worn wugeses theirsole contpemmion. '
will an me work,and mw
e structure is not]meed or offers r ec
s sale(S .7044, Required Inspections
Business and Professions Cole:The Contractor's Licroc law docs not apply to so
imrov
r of properly Who builds lir pef rorrmm,slid who does.vuch work hinoelf - `
or through his ownemployers.provided shot such improvements are not immured or 305 — FRAME -
offered for sole.If,however,the building or imprnvemrnt is sold whLin one Your of, -
mnlrpleton,the ownebbmlrtnr wit have the lardernf pro+tog that redid lot build or 307 — INSULATION t . .
pol ler Purpoweof lime.). _ ' .
❑L Eta owner of the .are exeiescoll 601• - .ROOF TEAR OFF
p(Sec.7 ye„mmessions beet,ehenmmelomi.o 60c — ROOF PLYWOOD NAIL
” License
construct the passed(See. to al Business and Professions Codep The improves
the mr'x
icenmLawdnesfur such
poo with itropoaywen,) licelif,sed Urovesl to the
603 — ROOF BATTENS_
and who comrac¢far such P leets with u n,nhhmnrt,al licensed pnrsuam to the
co, namods License law. '
❑I ran exempt under Sec. .B&PCrin this reason - 604 — ROOF IN—PROGRESS I
:g
Owner Date ,
WORKER'S COMPENSATION DECLARATION '
-I hereby afore under pemAty of perjury one of the following declumlimn:
❑ 1 Love and will moimain it Cestinam a of Consent to self-insure for Worker's
Compesodium as provided for by Stolon 3700 of she Lobar Code, for the
performance of Olework for which this proms is issued.
1:11 have and will maidedo Worker's Compntsafmn btsurum,us mined by Section
3700 of the Labor Cale,for the pedamance oT de,work for which lhts lc mit is
seed,My Workers Comperoalimt Insurance carrier and Policy mm�bcr ore.' -
Center:_ IA�fst�ICY No.: i 3�9�3 +
kl'IFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE, - -
(This section nee of be completed if the permit is Gtr one hundred dollne,
($100)us lens) _
1 cenlfy that in the performance of the work for which this permit is issued.I
shall not anploy any Prawn in any manner so as to become subject Ir the Workers'
- Compensation Laws of Cmi E,mlu lime '
Applicant
NO)ICE[O APPLICANT.If,after nmking tills Cenifeule of F,xempsimm you should ,
become subject to the Workers Compeasmfon provisions of the Labor Code,you must '
0 turthwah comply wish such prey cen
sions or this p,ricis shall he dnd reveked.
z
CONSTRUCTION].ENDING AGENCY '
I hereby dr..it sherfhem is n canxlas lending ogency for the performers.
H of she work for which this per un is issue(Sol.3097.Civ.C.)
Q Lender's Name '
.7. z Lender's Address ,
C.) 0 1 certify that I have mad this application and state that she above information is -
f31 Fy ar rrect.I agree m comply with all city and county ordinances and slam law.relating
lebudding eonsrmoilum ane horehy authorize represcnitnives rfthis it,m enter upon .
�]
mariner useniancd property for no,wOmn puq,osea. .
Fy p,l (We)ales I,, n't,indemnjfy and keep hooldro Ihn City of Cupeninn egainst
r CC liabilities,judgments,cots slid expenses which only in any way rictus against said
6J City in etnomp.cnee of the gn ming of this permit.
APPLICANT UNDER DS D WILLCf�IPLY WITH ALL NON.POIRf , i
SOURCE REGULA ONS.- .P Issued by: Date /^
Signimmot ARAicuntlUmnU,or !/l^_ `T Doom Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the ippbemn lit ruture Imildirg tceupam stoma!handle Ii.annus mmerial 'Type of Roof
is,deire by the Cupeninn Municipal Cale,Claim,9.12.and the Health nod Solely -
Code Section 25532(N!
El Yes IN, All roofs shall be inspected prior to any roofing material being installed.
wiUoth
ue phheanlmmtti iialdingteenpark col,"Innemor ill which If a roof is installed.without first obtaining an inspection, I agree to remove
mil!cf. sairs� outum
ins as dented by the Buy Arco Au,Quality Muno,enum,
i.,IdrtP - all new materials for inspection. Applicant understands and will comply with
by" INo all non-point source'regulations.
1 mo,read the nizardons materials ,, m I:under Chapter 6.95 of the
Crisfulau Health&Safety Cd Section, 5505 5539 and 25534.1 mid leadIhit
ifthe out II' ddoes limcourtly tr houred.lhll is crym:p lkhyl mildly she
o"pt of Ib re t 1 I sl tui met p l issuace.nf u Cen I rule of
anry. 1;_1011, a + _ Signature of Applicant - Date
Owner or nn all ii,en, nl,� All root coverings to be Class"B" or better
OFFICE