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02030079 r CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: BUILDINGADDRESS: PERMIT NO. 822 MILLER AV RESPONSIBLE ROOFING INC 02030079 OWNER'S NAME: APPLICATION SUB DATE PEARSON ELEANOR J TRUSTEE 2882 SPRING ST 03/15/2002 IPHONE: (650) 969-6151 SANITARY NO, CONTROL NO. y O O ARCHITEC(ENGINEER: BUILDING PERMIT INFO E sal❑ BLDG ELECT PLUMB MECH O U IJ IJ I--1 L_7 ni LICENSED CONTRACTOR'S DECLARATION Job Description i Z_G 1 herebytion70 ufnrm that I am ofthe J under pod Profe of ns Code. (commencing P :ar; with smion7000)ofDivision3ofineBusinssondProfessionsCoJe.andnryliccnse REROOF. s in ruI1f( elf«t.me en .owe 4«nslLass 4 c,p r A T/O & DISPOSE OF EXISTING ROOF, i3 Dte cammw" APPLY NEW TAR/GRAVEL ROOF u.O t' ARCHITECTS DEC TI S I undcrsmnd m,plans shat]W used av pu tic mcoMs i e O Licensed Professional a." OWNER-BUILDER DECLARATION DECLARATION u� to 1 hereby affirm that 1 am exempt from the Contractor's License Use for the C?4 following reason(Section 7131.5,Business and Professions Code:Any city or county which requires a permit in construct.alter,improve,demolish,or mind any stmclum Poon t also req __the Applicant for.auch person rile aigned statement - -- - of the Commcmrs License Law Chapter 9 ---� _- - - nnam r aid pursuant n '" provisions;. ( P S . Ft:Floor Area- , $ !.�Ilgation (can, exempt Shthe om an The iamnoonheland Pen.Any ns Code) , i L�j�}:._L"q k .JVs .sY k'Vt.."I� 'i i , " �'t'. 6d'Y� or Shut he 731.5 bthemfrom and me basis for the subjects thalleged exemption.Any l Penalty - of Section 9031.5 iv any hundred um for o permit xubj«ter me applicem m a civil prnahy .or not more than rive nanama aonars($slw). 37Mf2'd;Y8tb`U0 t .. Occupancy Type 111.as owner of nhc pmtixrt,or my empleyces with wages as their role compensation. will do the work,and She structure is not intended or offered for sme Sic.](W, - - --- - Nesmesn and Professions Carle:The Comment,a License Law does not apply to an 305 - FRAME Required Inspections' nwre r of corm,Who builds Lir in:pinves mereon,Lind who does sacs w,,,k himtdr ar tpmagn his own however.employees.the Wildid that such improvements are not intended or 307 - INSULATION :ortemd rt],vle:u,nawevei,me bddein t:,oma wimin one .. or — - _ -. _._-- _ _ _ -' _ - . -.....- -- gorumen ofpch Year ..._. - I _ _ -. .. ca:npler:,n.menwner-baJaerwiuhave menareenafpra.mgthat nedid not wimar 601 ROOF TEAR OFF .." . .. improve to,palpa.e eferale.). 602 - ROOF PLYWOOD NAIL � .. °I,as owner nnneprnperty,amexclusively contra6mgwith licenaccontractorstn _. - 603 ROOF BATTENS. .. - - construct the project See 704,1,Business and Pofea.amrs Code:)The Contractor s 6 0 4 - ROOF IN-PROGRESS, :' , License Low does not apply to an owner of property who builds rt]improves merean, ' and who comrai s.for such.projms with,a eomractor(s)Iicetsed.pursueal to be, .__--_-_ - CommctorsLieenseLaw. ., -. ❑l am exempt under Sec. .B&PC far reason �B��Nts�® _ Owner' - Data WORKER'S COMPENSATION DECLARATION I hereby AM.code pcnah,of pe�I r,one f,he fallowing declarations: APR 19 2002 i•° I have and will maintain a Certificate of Consent to self-h ure for Worker's Compenandon, us provided for by Section 3700 of the Labor Code, for the Performance of the work for which this permit is issued BUILDING °1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for She performance ofthe work for which this permit is issued.My Worker's Compensation Insurance lamer std Policy number are: QaIpI r I O 4 (icy N /7 �.c� fZ/7o// r f• k P� ;..-rr:� v ^j . +' CPR IPICAEXEMPT'ION F OM.x'OR/gER� :;:COMPENSATION INSURANCE-"• " (This section need nm Ive completed if She permit is for one hundred dollars s "� .t :' t($100)or less.) 1 certify that in the performancenn the work for which subject permit a issues.I .hall not employ any person in any ate' ,xo as m become nvbjea to the Workers' Compensation Laws of Culil'o. .. Doc" ; NOTICE TOctto APPLICANT,Worker L after Compensation this Ccnins of of Labor Con.de,you ticcomeh comply the Worker's Colons or p.honer of ed Labor Code,ydu must 0 Q forthwith comply wim such provisions or Shier pertain stall be deemed revoked. ' - '� CONSTRUCTION LENDING AGENCY ' a", thereby affirm firm mere is it consomelom lending agency for the perfomArAe - '- ef,ne work for which miap mtit is issued(Sec.3097,Civ.C.) QLender's Name.:...._ ,.. ... L.:.. . .._._: .. . .. r..... :. ;D,z Lender's Address - ..1 .. . U � t 1 certify mot I have read be application end store mm the above information is cotrcn.1 agree m comply with all city and county ordinances And state laws relating to buildin6 eonslniction;:rad hereby:imhoiim representatives ofthis city to enter upon the a.vc%o,'m1oned Procan,for inspection purposes. . r0. (we)agemlo save.indemnify and keep harmlessme City ofCuperdona agaimt Vi liabilities,judgments.cosier and expenses which may in any way accrue against,said U z City in consequence of me granting of this perhin. B . PPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT. y:Issued by: r Dale _ tk'RCE CATIONS... . ' - 'Stgnu urc orAppl cant/ amntenr r . '. ,' Dane. ' Re-roofs HAZARDOUS MATERIALS DISCLOSURE " x n me a Coon f tam Wilding lCo a.Chapter Wore or natal n salt materia Type of Roof as def d b the 3 t] M Cad Ch pt] 9 12 and m Health tl Snfcry Code S i an 25532(el i� P � n l 1 :.' � t�� ' . •, 0y. •• ❑N ' I t. '�i 3^ •• ' 1 All roof§_shall be inspected prior to any roofing.material.being.installed. - wt]meappl c..,t a.mw en la g txcupam Liu equip t a <er which If a roof is installed without first obtaining an inspection, I agree to remove emit hoaardous tar tom naris As defined by the Bay Arca A!,Quality Management Dismicl7 all new materials for inspection. Applicant understands and will comply with °Ye °N all non- oint'source-regulations. P g 1 have'cad'he h x rdoui'marcnals q it ems under ChapleAgi of She Califomie Health S Safety Code.Sections 25505,25533 and 25534.1 understand that ifnhcb, ildiag does not currently have,tenant,that it is my responsibility to notify the - ' " occupant of the requi,emenrs which must be met print W issuance of a Certificate of Ciocepancy. - Signature of Applicant Date All roof coverings to be Class "B"or better Wirer uthor¢ed ag n OFFICE