01110028 (CITY OF CUPERTINO
'BUILDING DIVISION PERMIT 1 'CONTRACTOR INFORMATION:
BUILDINGADDRESS: PERMIT NO.
11570 LAKE SPRING CT OLD COUNTRY ROOFING 01110028
OWNER'SNAME:''• ' APPLICgTION SyB DATE
'TADA MICHAEL B AND LEE MARS 387 UMBARGER RD #B 11/ 06/2001
SANITARY NO. CONTROL NO.
(408) 362-1111
E m0 o ARCHITECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
5„?o' LICENSED CONTRACTOR'S DECLARATION
Job Description
ebony affirm tnmlam.fthe Border Provisions Pronsof Chapter my licamg. REROOF.
=t with5<nion,000)a(Divizion3 of the Business and ProfczsiongCme.and my liccnu'.
in in ten torte e t y-ly T/0 SHAKES, ADD ELK 40 YR.
rc cg •Liana Class J 9 ` Lic,p
Date- Conunnar
!0 u.t; SDECLA TION i COMP. SHINGLES .
.,� . ,,1 undcrsland my plwz shallhusedispublicnterr s '
1 p'O 'Lianutl Profeszi,n,l' •
o� - OWNHR-BUILDER DECLARATION '
W
- I hereby.(Seat Nvt I em exempt from the Congaci Co License Law for the
_-
,,!'to
Z G (nllowing reason,(genl m ic...cr Business and e,dere fi Code:Any city m county
which«quires a permit to connruct,eller,improve,tlemolisM1,or repair eny swnurt'
E3_'..p me, l rc9 res the applicant for such Permit to file a signed scto anti - - - -- - ---- -- - - - . . --- __,—_.,. — ______
tRlld el so$d pbr atlo Ilio bfo'vtslom of the Commxwfs License lsw(Che erg a ( IOOr'A eaation
( me ria irh5 pe iI0110)of0ivtuanlofthefluHneuaMPrPrgzs.. me), C(
$50
or that he m
a exept thart(mm the and basis for the alliI uempliLn.Any violation;
-of Secaon,031t5 byatryvpplicnnt fore permit subjects the aPpiic tit ton civil Familry-
1,if not more thnn.five hundred dollar,($500);-. _ :u!%tl"•6 DCCU anC e -
3 6 6V`blS15(!h94 It
P y 1YP
❑I;i s owner of the pmpcny,o my employees with wages as their sole compensation,
-walao thework,aiia'uenn;<Wt<'ia�nrimendMo;of n.d fier'saleISu 704e- 3 05 - FRAME Required Inspections-',-" `•rl•'r''r`
t BiAhoutLnd'Professiors Code:The Convenor's License low does not apply to an, -
owner of property Who builds or improves thereon.and who does such work himself 307 - INSULATION I
oat throw h his own employees.,provided that such improvements arc not intended or
_.o __ _ ____ _. eari __......___—_ _ _. -
l of(crea-oTmk.If,however,the building or imProvetmm III within ane yea,!
compluion,thcovener-builder will have the burden of proving that he did not Wild or
--- -6O I:_-- ROOF -TEAR`OFF
improve for purpose of sale.). _ 602 - ROOF PLYWOOD NAIL '
603 __.__ROOF'-BATTENS __. _... ...__.--.---__
y; co 1'as a pr the property am Basin ala c ntmcbng ns I ansede Contr cts to , ,lip - —,?�)
<anawn me project(see.,Du,Baainma and Professions sated The epntm<tnfa c
6 04 - ROOF. IN-PROGRES S t:r.;;': 'En' l •:,. . .n'
_ License Law does not apply property owner of propy who builds or improves thereon, '
_and wW,emenuats.foc such p
pcam with......rector s dlcemed.
P 1 P wuant to.the
Contractors Licimaj Law, ..
i p der Sec - B&PCfor this reason ili -} If iiF1JP.
❑1 e .m roti _
O nr VI , t Dam 'o ',:, d__L. .
x r_ WORKERS COMPENSATION DECLARATION
Zt
'a Ili hereby dr Penalty of perjury one of the.(oll mgdeclmations �-
FINALED
] 1 have lied'wi11'mdfnmii e'C<nifrcam of Conuni to self-imams for Workers
C pen t n 'ar;p tld f by-Section-3700'nf Ilii �bor Gme. for the JAN 0 9 2002
pert rata df the rk f r h h this Penni issued. l
I h d dhbia rmi N'drker'a Compensauo Ins...so,b required by,Sectiod
3700 of fi Labor.' for the performance of thek(r'which lh s . his
..issued Montefs Com usntlonlmirwkio6nw-nd IB eQe -
Cater ,, n aTf2d[P ley No.:
1.
Il
1 t'.:CLRT/PICATI FEXEMPTION FR <.
ORKERS I'l, 1-ri,� f 1Zin i.l4.lr F\ 115 }�. �1 tygs7tlF
COMPENSATION INSURANCE - _
Ohrsucaod need not tie'sompkWAitthe permit is for one hundrtd dollen
-v 1<eni( thnt n the Performance.zr T r ___�......_..___...wY..._.. ._.. ...��.,..._...,......,._,«t...�
y pe of the br16 rto ch Nis perm nes edl' 1'lClUt ll;,'ie u�)t�i;-i(^-`a-•_'s
eh n n t mpl,y any person In eny mann 1 ib i becom subject to theWI .
Compcn noon Laws of Cai fomla Date
'A Imani '•"'
cNOT10E TOedto he ANT r afiermnking this QesIof a Labors on:you should };tell "., (! .-1)11, <,
MebmesVeritty the!such provisions
Compenuuon Pervslo,nll the Labor Code,you must
'
Q forth uh m I _ this permit Nell be demand ked
PY ik such
I h by not Ihnl them is-a contraction len!Ikq lien y f th;pen T rdelacte pt i r, !,r:1 it z l' +i.•
�cr tiffhe kfor which mspcnnt sued
(See 309, Cs C)
-lender's Name ' m
i
___
lendefs Address' Y i
,. _
V � �) J certify th,i l h arced this application and state that the above f rmat on is
ctlnen begsee to<omPiy 'th alPcny.and....y ordinances and stn,laws relating. _-. ..__ . . _ _-_ _ _._—___. _ ....... .. .._
<U to building consWciicuWand hereby eutionv ofiremmatives of Nis city to enter upon
gp th ado e i and p peny for inspection purposes,tr _ •,:�„
Y 9° Bra l pe ms the Ory of C Fran no g insr •..... ..• - -. . . . . . . •..... _._.. ....-___...- . ...
U Cn «N once die ntn oflhis t tl
{..,,y twit) gree t v mdamnl dna k harm)
Fr f/Y liabilities, d nt c sat and expenses which a in any ay tic a eg i t i
souRGe R66U s i ` ov ' Issued by: _ Date
gm P Y
IAPPL'ICANT{1[NER hp WILL O\fPLYA17TH KC7.N
&P amk of APPI enVC m t r at "-Re-roofs-
rHAYA OUS MATERIALS DISCLOSURE "lJ �' // /mss_
Y`'r 114611 tn,awiicant w moue Welding occupant owe w Mmle huaNaus mnenal —,.Type of tIolf
az def tW0 by Ne Cupertino Mumc p,l Cvme Chapter 9 I2 am Ne Heald,and Safety
Cme Section 25A2(a) I)sAr '.I j' t r7 ri 11}fi F }+! Yf'.�'i�r��n �.� s4y,:.�It,�It:
❑No. f
Xoveafl ,l re bii�t la,,
-.All.roofs-shall-be inspected,priorto.any_roofing-material.being.installed. _..._____
;� P WdI aW pplicmto fu u Wild g c p ntuu qu pate t pe�«awn'<n; If a roof is ins'tall`ed'Without first obtaining an inspection;Fdgree'to remove
c n hexara u comm bents u d fined by the Bay Arc Art Quality MMelement
D m<o '.w .. all new materials for inspection. Applicant understands and will Comply with
'14 OYl sinix,l 1 u ❑No i,tl 1 '`it li 'l P,
all non-point sOUCCe regulal]ODS
ll hese Wadahe haiudom matenels'rtgw¢rmnulnder CWpler'695 of the - i V
Cil tom a HuliDk'Sarery Cme;Sectiom 33305 255J3 and 25539.1 d,wund that
H Y p rc /�t t nerdy the _-
a« t nn
s 0 Pmc L Q. . i D m c td'_f
Y P° Y
p p omenta Dmh teas(be ten nor tb_Iss a ee of,e Cen
asn c rtcn vee i t at nem
Signature o Applicant Date_
o emitsat ten g tit All roof coverings to be Class B or better
�,A 1 {Ic tO Y I „I,, V iI•
a F5`' . I „' ''i'. d , .'.�, - Lar•,. ' OFFICE