00080085 CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTORINFORMATION: 0
BUILDINGADDRESS:
21005 LAURETTA DR COSMOS ROOFING SAN'TARYNO 0 ,hRPLI&O(d�BM1TrALDATI
OWNER'S NAME: 1YA C51L�IL�CI
PxoNr. MITCHOIER, . 450 SAN ANTONIO RD NO 00/J. ��c�ll0
3RCHITECIENGINEER (415) 493-6373 BULDING PERMIT INFO
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yLICENSED CONTRACTOR'S DECLARATION
>.O w— I hereby aRrm that 1 un licensed under provisions of Chapl.r 9(commencing Job Description
r4 C w with Section 7")offtivision 3 ofthe Business and Rofessi°m Code,<d my license is
�x^<� in auforce rude eg TEAR OFF SHAKES, ADD 30# FELT AND 30
d a a umnn a Lie.g
Due Convector
a O gARCHITECTS DECLARATION
m
i 1 Ondenund y pWs awl w mud m pubs remora.
ivo O Licensed Professional
OWNER-BUB.DER DECLARATION
1 hereby affirm don l am exempt from the Contras o's License law fm the
l:z a
FC following resume.(Section 70313,Business and profusions Code:Any city m county
m—m • m consl
which requires•permit mbet, ut,improve.demmpay an
olish, repay structure
— priortoitsissuance.alsorominestheapplic. formehpemtitmfrleasignedsmemem Sq. FL Floor Area alua[lon
m
Nal he in licensed puaumt to Ne provision of the Convacmfs License Law(Chaplet 9
,(commencing with section 7000)mf Divieiml 3 oldie Buainen and professions,Code)or APNNumber CCU anc
dust he is exempt therefrom and Iw basis for the alleged eureption.My violation of P Y P
Section 703L3 by my applicant for a permit subjects tw applicant to a civil penalty of
m mart Nan five hundred dollars(g500).
I.nowmerorthesprmperlr.mrmyemway<e,wiNwages,nlxo-.mlemmmpem.tim. M655�ojnippjnspections
will do the boob,mild a rimmure hem intended moRered fmsa.(Sec.7044.Buancss
and Pmfessious Code:The Contractor's Limnse law does nm apply to an owner of
property who builds or improves thereon,ad who does men work himself or through 305 — FRAME
his we employees,provided that such improvements are sew intended Or offered for X07 — INSULATION
role,If,however,the building or improvement is sold within erne year of completion,the .+
.-Wddcrwdlhave N.wNesofpressing do,the did nmWild or improve for par- 601 — ROOF TEAR OFF
you W sale.).
ni,uowncr of da pmpcny,am eadu.ivefy cmvmting with licensed convacmn to 602 — ROOF PLYWOOD NAIL.
eonslral me Wifoc1(See 7044.Eusinw ad Professions Code:)The Contractors Li-
cenn law do.not.pplym an Owner of property woo wilds or reproves m.remn.and 603 — ROOF BATTENS
who contracts for such projects with acmmgctm(e)licensed pun®nt to the Comvecmrn
504 — ROOF IN—PROGRESS
ucenselaw.
❑Iameumpluder Sec. .B&PCforthisrcaum
Owner Dov
WORKER'S COMPENSATION DECLARATION
1 hereby affirm underpenally of perjury one of the following d Isgn tion:
1 have ed will maintain a Cenificae of C.'to self-imua for Woker's C-1--
non, provided fm by Section 37W of the Labor Code.fm the perfonnanoe of the
ork for which this permit is issued.
❑1 have attd will maintain Wm me,Compensation Insurance,se«9uired by Section
3700 mf N<Iabor Code,for the performance oldie work fomu trw�hic�hg rethiGs pcnnil is issued.
My Wmk li°R�urenc comm and Policy wmtrryre cg�
J� Carrier T�Policy FROM
�"Jy
1/ CERTfFIC COMPEI`EOFNSATION
ATION ON FRANCE WORKERS'
COMPENSATION INSURANCE
(Thi.union Deed not w completed dine permit is foronchundrd dollen($100)
or Ins.)
I send,mat in the perf a manor of the wmk for which this penoun is issued,i swl
not employ any parson in my manner so as to bec.une subject to the Wmrl mf Coman.
a nimn taws of California.Date
Applicmt
NOTICE M APPUCANT:If,ager making Nie Cenificam of Exemption,you should
become subject to the Workers Compensation provisions of the labor Code,you must
forthwith comply with such provisions or this permit shall to deemed revoked.
CONSTRUCTION 1,ENDING AGENCY
Z Q I hw dre
ereby affirm teis a combination lending agency fm the poefomance of
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the work for which this permit is issued(Sec.3097.Civ.C.)
Lenders Name
p; } lender's Address
[� 1 candy,Nes 1 have red Nis application and gone that IM above mfmmatimn is
1 z rt.I agree t°comply with sell city and county ordinances and state laws relating to
Z abuilding aomwctim.ad hereby mlwrlre representatives or Nis city to enter cpm the
U above-memiond pnryeny rot inspection purposes
(We)agree to save,indemnify and keep ha"nless the City of Cupertino against
0 U Rebiliues.judgments,cos.and eapemes whichma,in any way accrueagaimt said City
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Win
tncomsrgusnc.of the g.dng of this permit.
r A. AITIACANI'UNDERSTANDS AND WII,I.COMPIN Wl ul M.I.NON-POINT
� SlSURCP E'.. ' IONS. '
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Sign.mn ol App]Vk UContaclm laine
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumrc wilding occultism store or handle hamNous material Re-roofs
u defused by the Cupertino Municip.l Code,Chapter 9.12.and It'Healm and Safety Type of Roof
Cade,Section 25532(x)7 YP
❑Yes 0N .
Will them iami or future wilding occupml use wuipment m devices which All roofs shall be inspected prior to any roofing material being
emit hazardous au contaminants as dented by the Bay Area Air Quality Management installed. If a roof is Installed without first obtaining an inspection
°i'°a"
❑Yea ON. I agree to remove all new materials for inspection. Applicant
l have read the hazmdsws materials retuiremems under Chapter 6.95 of the Cali. un erstands and will comply with all non poitoree regulations.
ramie xnlm&s.ferr coo.sa-tim4 usos.user and 25534.I nndelstand wt it sal. —�— 60
wilding dens m tly wviceumn6 than it is my rn,orta,ny.many occupied //
of the�ylaw h muse be 1 prior to leenance mf a Cenilleal f p y
�n..T� �er or audrotgpe uW Signature of ApK]cant Date
go
All roof coverings to be Class`B"or better
OFFICE