01040112 _cl TYOFBUILDING NPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
0800 HOMEBT-9AD RD 2 P1 QT111111M ROOFING Mir 01104 1A 1 1 'P
WNER'S NAME: l APPLICATION SUR DATE'
• PHONE: SANITARY NO. CONTROL NO.
p p'ro ARCIIII'ECIIENGINEHR: _ BUILDING TERM]('INFO
kL" RLDO; ELECT PLUMS MECH
LICENSED CONTRACTOR'S DECLARATION
1 heathyaRinn that 1 am Iicemed under provisions of Chapter (
a Job Description
�mtW with Section]IXMIj of Division Jufthe Husinens and Professiomde.' drmyiccnsc
Qm —t Is in fall force and cf t. Ia,
re C Licemc C r n Lic.
oar oate camtonfor _IR77 , A REROOF SHAKE 70 COMP CONVERSION
3 u. ARCHI'I ECT'S DECLARA'1'ON -
C�w g 1 understand my plans shell be used as public III -
.W6 O Licensed Professional ,
= _ OWNER BUILDER DECLARATION
1 wrathy affirm that I ant exempt from the ComrucmrN License Law for the
6 following m;sou.(Section 70.31,5,business and Prnlda,irn,Code:Any city or col ly
O which requires a permit to contact,aI¢r,improve,demolish,or repair any.structure
ce prior to its issuance,also requires the applicant for such permiuo rile a signed statement
that he is licensed pennant to the provision.,of the contractors License law(chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section]DI0)of Division 3 of the business and Pmmssiom Code)
or that he is tempt therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicam till it pemtit subject the upplicam tO a civil penalty
Ofrotmaremamfivclmadrad,m11an(s500) - APN Number Pccupancy ype
❑I,mnwncr al he property,army cngiloyces wit wage,arc theirsole el ifen,mlou,
will dO oat work,and the structure is not intended or offered for sale(Sec.704. 65 905 7
Business and Professions Code:The Contractor's Licence law does not apply at an 22 0 equired Inspections
owner of progeny Who builds or improves thereon,and who Ices such work hinaw f
or through his own employees.pow ided that such improvements am not intended or
offered for sale.If,however,the Wilding or improvement i,sold within one year of 305 — FRAME
completion,the owner_uilderwmhavetheburdenotflowingthathedidhotbuildor 307 — (NSI-ELATION
improve purpnccn
El 1,as owner of the property,ant axclncively contracting with licensed contractors to 601 — ROOF TEAR OFF
nnstmet the project(See.]Data,Business sad Profession,Cde:)Joe Contmctr`, 602 — ROOF PLYWOOD NAIL
LiEeme Law docs nor apply it)an owner of pmpeny she Wilds or improve,thereon.
Crima c ntract% or such projects xiih a crmrvctorea licensed punuant m the 603 — ROOF BATTENS -
OlamexemptunderSec. ,B&PCfor this reason 604 '— ROOF IN—PROGRESS-
saner
Dam
• WORKER'S COMP,
iNSATION DECLARATION
1 herebylinr under penalty of p jury one of the fallowing declaration,:
0 1 have and will maintain a Certificate Of Conant m self-insure for W'orker's
Compemminn asprovided for by Scalar 3]1X1 of the Labor Cold. lin the
-.pemmic of the work for which this pemtit is issued.
❑1 have and will maintain Worker's Cornluns;nion Incumutsx,m required by Section
3700 of the Labor Code,for the Wrlormanee of the work for which this permit is rtiMAY 1 O 2001 .
issued.My Workers Compem�adon Insurance carrier and Policy number are:
Caer �f�t A,Iicy No.: -
CERTIFICATION OF EXEMPTION FIt IM WORKERS'
COMPENSATION INSURANCE
ffhis section Oman.,he ennoplreal ifthe permit is far One hBUILDING
undecddollars
(Sl Wloele") .
1 certify that in the perfommnce of the work for which this permit is issued.I
shall not employ any person in any manner so as to became subject to the WmkcrC
Compensation Law.of California.Dam
Applicant
NOTICE TO APPLICANT If,no,r omking this Cenibearo of Exemption,you should
become subject re rhe Workers Contemn,ionphs,kil sof the Labor Ctdc,you oast
Z0 Q forthwith comply with tach malieion,nr this pemtit shall be deemed revoked.
F CONSTRUCTION LENDING AGENCY � -
.'14 > 1 hereby affied Nat there is n construction lending agetcy further perfnmmree
L>a of the work for ishich this pemtit i,issued(Sec.301 Civ.C.) ,
6. ❑ Lender's Nome
`7 Z Lender's Address.
V 1ecoilymat l have madthis uppllcadon and anordut he serve inhanunion is
E.. omme.I agree to comply with all city and county Ordinances and state Tawe relating
V to Wilding construction,and hereby authorize nymuntatives of this city meterupon
} ta7 the above mentioned progeny for inspection purpose..
UL (wclegreem sax,indemngolhiseeco harmless the City Of Cupertino against
IA liabilities,judgments,costs and espenco which may in any way acme against said CCff////��///////J�
V City in comep¢nn of the grating of this permit.
APPLICA )ERS NDSAbg)WILL COMPLY WITH AL NO Date y _
so EIU ArI s. --(///{���� �,� 3 Issued by: Date 23
Signae101 nate Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will ter applicant or future Wilding resupanutwe Or handle hazaNaus material Type of Roof
m,defined by rbc Cli eninupal Code,Chapter 9.12,;ad the Health and Safety
Code.Section 25532(m?
OYa No All roofs shall be inspected prior to any roofing material being installed.
Will the.,,loammmmre buddingumcapmn umequipmem mdevice,which If It roof is installed without First obtaining an inspection, I agree to remove
emit MeaNOm air eontami tem de ant, M1y the Bay Area Air Quality Alanagemmnt
District] - all new materials for inspection. Applicant understands and will comply with
0 Yes t No all non-point source regulations.
1 have read the hamrdous lioneriuls requirement under Chapter 695 of the
California Hersh Cs Safety ecale,Secrinnc 25505,25513 enA 25531.1 unJernand that
If rhe huildingd sat carientlyhtoveu moral,that It is illy responsibility to artily the (/
occupat n r ryir which mot W tact prior to locative of a C,r ilial,of
Occupzn
er Signature of Applicant Date
owner or oat orireJJ agent Date All roof coverings to be Class "B"or better
OFFICE