01070054 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS PERMIT NO.
22670 LIBERTY OAK LN JNSJ, ROOFING INC 01070054
OWNE�SNAME APPLICATION SUB Dji7M
WE TRIDGE H.O.A. CIO CMS 1268 LINCOLN AVE, SUITE ?0907/13/2001
PHONE: (408) 279-6171 SANITARY NO. CONTROL NO.
ARCHITECTfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
j L= =j L7—j_
LICENSED CONTRACTOR'S DECLARATION
I hereby affirion that I am licensed under provisions of Chapter 9(commercial Job Description
C is ilh Sectors 70 REROOF (CLU OUSE)
P Woof Division 3 of the Business ad Profession,Code and my license
< -7Z-( 9 00
is in fall force oil cffi%
License On Lic 0 NALED
OWU
I Data civarmcm, T,gL 31- �m Ps I
p.t; ARCHITECF'5 DECLARATION
jzi 0 1 1 understand my plans shall W used as public mrordi JUL 2 4 2001
on—
asma�
.. :5
S:�C, Licensed Pridw,,i...I
6 E� OWNER-BUILDER DECLARATION
I hereby offirm that I am exempt front the Contmtor*,s License Law for the
following mason.(Section 7031.5.Business and Professions Code:Any city or county 13UILDING $12000
2 a which rrqaim�a permit it)canmoract.alter.improve,demolish.or repair any structure,
as
ca thealm is licensed putmon to the provi.sions of the Contractors License Law(Chapter 9
prior to its issuance,also rac,umes;the applicant[at such part 10 file 2 signed victameno
marronamem,with Section 7000)of Division 3 of the B.,im:,a ad Pmfro,ior,Code) 34�213
Valuation
or Chat he is a�cmpd itherefoontund the basis for the alleged aimarianna.Any violation
of Section 7031.5 by any applicant for a fermit subjects the applicant to a civil Penalty Occupancy Type
of or more than live hundred did In,,S500; 305APN VFM�IIE
0 T.as owner of the property.or my employees with wages as thei r sale compensation, 307 — INSULATION
wil I'do the work.and the structure is tint intended or offered for sale(See 7044
Business and Professions Code:The Cormanor's License Law does not apply to an 601 - ROOF TEARqQBF Inspections
ow.net of pro,eny Who builds or improves thercom and w he doe%such work himself 602 - ROOF PLYWOOD NAIL
or through his.,a employees provided that such improvements am not intended or
.Iffirsed for sale.If,However,the building or in provirom is sold within one year of 603 — ROOF BATTENS
conda,lim, haoimr-tWiddr,oill I...a he burden f,mvir,that he did or Wild or
arprowe fco'w,amf sale.), 604 — ROOF IN—PROGRESS
0 L Cororct;j wnh licensed ciamomomi to l
commus,the proper(Sce.70�.Busitim,, ad Proba.mrs odhe:)Tha Ccommust.r',
License Low does not apply to an owner of mFamy who Wilds or improves,themor,
and who contracts for such projects unit a commarri licensed pursuant to the ......
Continence.,License Law. . I I. 11 1 . � ,
0 1 ma cocoon,order See B&P C for this reason
Dome, Date
WORKER S COMPENSATION DECLARATION
therchytiffiran undercaralty0fFearjury onum of ffi�jol lowing declarations:
have and will maintain a Certificate of Consent to salf-insurs,for Woduct
paimation. as provided for by Section 37W of dia Lather Code. for the
'rimmintoe of the works,for.which th I is 7"is i..raL.,
M',e and will maintain'Worker s Compensation Insurance,as required by Section
is he Labor Code.far the of.maimme of the work for which his NmIlt I,
issued:My W.,kat,C.,rmati
T2Wc�ca it
iles�- , ?P�.
I� k 10
C _0 4 Policy Nw:IPJ
CERTIF -ATION OF EXEMP'TION FROM WOR
COMPE
�SAT,IONINSURAN CE'.11:,''
M!, ,,aina need not he completed if the permit is for one hundred dollars
SIM or less.)
I sandy,that a the"foranar" f,hc wd'r which 1hi, cannii ,ii,wied:I
sicall not employ,.., ,-.I.any nommer an.1 fit hacmnc,spbjc�ct to the Workers
Compensation 1-mv, fC.1iforati.Date
Apfdic�m
NOTICE TO APPLICANT If,after making his Cardifficam of Esearnmr.you should
z become Subject to the Workeri;Com,smation provisions of the Lalsor Cade.you must
0 0 foinhwidn comply with v ties provisions or this permit shall he dicound revolocal
14 CONSTRUCTION LENDING AGENCY t
I thereby affirm that there is a consmictioni lending agency far the erforromman,
> of lhiisco,k far which his crom,is mued(Sic 3 1 Civ.C.)
Fz Leader',No.,
Under s Andres, -1,
z
U have read this application and state that the above information is
I eanify than I
smrest.I agree to compl)with all city and county ordinances and state laws nalming,
C) U haildim,commuction,and thereby authorize reparconotatives of this city to enter upon
:the above mentioned por,pany for inspection psm,)ws, I I I
Ovc)agree to otyr.indemnify and keep harriesi the City of Cu,,coino against
liatilian.,.j.d,rrant,, ov,and,,va,l, both alnil in my IcaY al�Cmoa alair"vaid'
z city in consequence cf,h, .r1mg to this canaria. IN.0 PIT. —�?;p
� I �I . r 4�2--/ 3
APPLICANT UNDERST Us AND W LE PLY WITH ALL N
SOUR I Issucd by: 4z"
I lc= . _7fiv�Pll -
Si,raom.orA,dirmnlContractor —Da's Ke-roofs
...... HAZARDOUS MATERIALS DISCLOSURE
.—NWI do,-"Items,or future ,am an handle Wasislous romermL Type of Roof -
defired hy he Ca,lmim Municipal Coca.Cha,m,9.12,and he Health and Safety
Codr.SaaW2553'(a)!
0 ye, IN i u All roofs.shall be inspected prior to-any.roofing material being installed.
Will he applicant or watim,Wilding occupant �a equipment or devices which If a roof is installed without first obtaining an ihspectiClii� I agree td remove
is a,
Thinner? all new materials for inspection. Applicant Understands and,.will comply with
0yes No
all non-pomf source regulations.
I lcmie,read he haourdmi,in....wh mciiimanomt�order Chapter 6�95 of he
California Health&Safety Code.Sections 25505,25533 and 25534.1 understand 1h.ja
if thia Wildin, loccno,stinnotly Lica so,rart,that it kna,re,,orsibiliyo,rantif,the
ceimparn,of the requirsomati which must be In owramea.f.C�mifirma.f
O'capaniA
lo-do I Signature-of Applicant. Date
Dare All roof coverings to be Class "B" or better
Gore,a,mothorried.,an,
OFFICE