01110027 CJ BUILDi GDIVISION
BUILDING
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
11561 LAKE SPRING CT OLD COUNTRY ROOFING 01110027
DsNAq 6sy2LUIALBERT S AND LAISHIM W 387 UMBARGER RD #B 11/0 / 001
'HONE: SANITARY NO. CONTROL NO.
(408) 362-1111
O O ARCHITECT/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MF,CH
at
o o u u
dad
zh Z LICENSED CONTRACTOR'S DECLARATION
N 1 hanky affirm that I am Hccnxd under provisions of Chapter 9(commencing Job Description
1=tom with Section 7(HX))of Division 3 of the Bmid,cawd Professions Code.and my license REROOF.
;xf� i.mmnromeana� t a 1, 73 T/0 SHAKES, ADD MONIER
O t U License CI z
Date cant =tar. CEDARLITE SHAKE TILE.
i LL LL G ARCHITECTS DECO , 10'
NO— I understand my plans shall be used as public starch
i i p O Licensed Profeseional
' OWNER-BUILDER DECLARATION
1 hercny aRrm,hat 1 tan aurin from the C onion oil License Law for the
t Z< following rwson.(Section 7031.5,Business and Professions Code:Any city or county
I E o which requires a permit,o constrves,alter.improve,demolish.or mpeir any swcwx
3 - w to isissuance.also require,gat applicant for such permit m mm
file a signcd uacnt.
m.-taJ,Iicusid pbtsdanl to the Provisions ofthe Contranots License Law(Chapter 9 �;. Sq:IFt: F1 rear•• r• 100 Yation
or" Bncmg with Swim700o)of Division 3 of the Busing.and pprfeasWns Crate) f„(j,a T'i,a. gl,f k>.°O�:l•..•rS.O ,:.f L�)\: $
or Mot he is'es=mpi dbemfr'o'm'and the basis for the alli6ed aFmptiW Any violation i,,� T��
-of not room than anyappli dollrs(apermit subjects the applicem coat civil penalty” 366VPb12�b@l0 1 p y gyp
iof not more then fivehndred dollars 5500). CY'J`SV `lY I'�'%':•'Jf of CCU anC e
❑1,as owner of the ptopcny,or my employees with wages as their sole compensation.
will;do the work.snit th�smctum is-nm Intended or'offered-for sale(see:70ad, 305 - FRAME :
�Businesi and Professions Cade:The Contmnor's License Law does not apply to nn Required Inspections">,'";, Of
owner of property woo builds or improves thereon,and who does such work himself 307 - INSULATION
or dromph h's own emply prosidId that n improvements t intended or __ _
ffe d I' Ifhwefir the buildingor improvement" Id within one f ----- - -- - —+.�w••
wnerbuhlerwill have the burden or that he did not build or b-OI - ROOF TEAR OFF tat;
m�°efor orposeofsal=) °corn° 602 - ROOF PLYWOOD NAIL
- -- - ----- -- - _._.... -------- -------603- "ROOF-BATTENS --
1,esownerofthegram"Y lusively connecting with licensed communcrsto ---- ----.__ -
construct the project(see.7W.Business and Professions Cote:)The Contracmr's 604 — ROOF IN—PROGRESS ' "(,
. •.' "
License Law does oat apply to an owner of property who builds or improves thereon, -
3. and.who s ls
untracts.for.sudu pmiec ,withmmn
.a-coor(s),hced
ur .pursutin to the
or
7.
and.who
s License law.I.,
❑lam n<mpt viMer$2c.
. ..:, �,i���: hsB:&PCfonhis reason
r. ... .. .
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hemM oRrm under penalty of perjury one of the following declarations:' �'
1 ha4c'imal ll ami niei.a CaitiROme of Cunxni'm self-insux for Worker's ALE D
Compecouton, as provided for by Section 37W of the labor Code, for the ,
p peon
performance'of the work.for which this it's tss ed-
`44 hee nil ilt' -' t WorkasCompc �o Insuranse.as required hyScifich DEC 2 0 2001
37W of the Lothar Codc for the lanomormance of the work for which this permit is
s_. a�suW M kc MCo}� t o 1 rn< a d Pol cy cone re
a _
somer.
CbwkfpelyN wc��F78s9�1a� {. /t :BUILDLNG . .tat
I'',,t,tI,CERRFICATI N OF.EXEMPTION FROM:WORIERSd" 'i L-s-J - �`*• . t,�}. i ,Ia.. .. -.T....
.,COMp AT10N,INSURANCE•_�:._.
fim3xn,ond=id ono,beto' m'plead itper
he mit.for on=handma donors •.'. 'r'1'iT rr ,•,kl i},I,
ISIW)orles;);. .. u. ., .Y:, I
r Ices fy iht'n Ne peawd c ofthe k( hchh K,-lrss dI ,' I' �,) ,I
'shall ,<mpl Y
my
n n nY muni r s m I+d me x h)ect i N<Wnik ri `
Co pen vo Laws
I•NOTICE TO APPLICANT
Z became
....t If ah makigthl Cnf am ofE pi you ihould - -' '
to the w
forth k'r C p=nset n p o von df th lobo Cade you must
with
chp sorthsperm tshellhd coed kit. _ _
Ith - ...
PCONSTRUCTION LENDING AGENCY ''
sw t 1 nil' gg uscncY f th p R rmantt
�:� ofthe lhk fa whidh thrs thrmit rs petl(Sc 3097 Cic.C)_ "" _• ..__ — _. ...._.. .__.
n ..
.u.._... u..:... ..... -'t
..�,L�:..1...c_
Lenacis Name..•.•.•..• ___
C6 z Leader s Address'
..s.v... r. .. .. .._. .. . .
I certify that I has read his iry ad c.aM nam thin the above information r
1.biddfagreetosvmplyadhoallcityens coumYrordinanccoandstem laws relating . .............._._.—___-.._...__...... .._._...._.
nil bidding consrua,ion:anJ h=rehy nuthuaui=prtscntmi4es ofthis city memerupon
W a „P.., Y pc. p rPo. ,.,.. .
the boa cm neo in f no
es,judgments.ge io sz e d mnify act kw y hamal w he Cly f C m agsn agemst
V1 hob Il ul c ss and i &,o us h ch y any y gunn said
U Z City c req fin=e of the grant g of th peon t S
OURCE REGULAHAcuimu MATERIALS DISCLOSURE - l Re-roofs fs Dale
'APP
ARD(
es defnedhb AthgCv tan tMpmn al Code.Chepmr912.hamdithe H=a 6undur Re-roofs �
SOURCE REULA:RSTAYD Dt41L WITH ALL NO Issued
and
jam/ r/ 6/
ih Wlly e.Culacnto faux Wal Ca ac pantmore handle Heardom mat eat Type.Of Roof.
Code'Sect Y 2553La) i )a f tr4 it ,fYIS 3 Safety "
�..
°Y I _ _.All roofs.shall.be.inspected.prior_to any.roofing material being installed.-
ding
nstalled.
,_--.-..tot -
, .,aw,umeappr=aptpr.rgmrebmldingoccupant.useequipmentordeviceswhich; If a roof is installed without first obtaining an'inspectiori;'Iiagree.to remove
m Jefnedn the Bay Arta Air Quality Management'
em,h b conte t y
Di m t - „•,all,new,materials,for inspection. Applicantunderstandsand,will comply,with
o Yea -,,r a+++'f ° 1 '._ (f' , all non point source regulations'.
I hove:read the haiardous materials regmrtmcnts under Chapter 6.95'of the
Cdlif aide Huha&Safety Code;Sections 25505;25533 and 25534,1 widersmM that -
.
of
rummuals which
mu cru ttht,rmyrspoce'ofI 6n atcdueOf �•(/yC'- ., ,
p q cots h h must M mei pn cols ce of Cemfcateof !liL l�—�^
Goo.Pm MM 114
; f Signature of pGcani, _ - -. Date.
6 � �%, _. . v r in g.
owner ,or aathon ,gem ,' " - - '. ; ,; � � All roof coverings to be Class `B" or better '"" •, ,
. - OFFICE.