01010091 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
7516 ORANGE BLOSSOM DR WESTSHORE ROOFING CO 01010091
OWNER'S NAME: APPLICAr10N SUB DATE
SMADER SCOTT K AND BROOK S 5869 WINFIELD BLV 01/22/2001
PHONE: SANITARY NO. CONTROE.NO.
(408)629-2100
G K Y. ARC,I11'ILCIA NGINUER: BUILDING PERM1'IINI0
00
C w❑ BLOC 0E BLOC, PLUMBMIiCI{
2dU I= I-1 1=1 1-1
SN j LICENSED CONTRACTOR'S.DECLARATION Job Description
OZ p I hereby afhrm th..I aon licenuvl nnakr pn.vi>innr of CTap¢r')In,mmem:ing
iin fall
eand of Divlslon3oflne llueines.mnA Podcssinns Cole.and my limn'
.,�6 i,mnluhr.caderreet. GERARD TO WOOD SHAKE
z e 2 LiCcase Class lite,p
S O n O Uatc Common,
ARCBI'1'LCI"S DECLARATION /
I rumbr land my plain shall be used tar public record,
wat p Liccnwd l'rnfex,innal
OWNER-11I311a"i i'lue R J ION
Ina,ur
t7i o herchy.ssel tnw 1 1. .liu,ia born the I ..nawr'x A.,c ty o liar the
H Z. titl owi..g ten wn.(Section 7U}L5.Bmai..ean cud,,v.Jamoli Code Any city or u,kiac -
{ d which itt i,iw n peril.n m canstmcc,cher.In,ptrrvc,demolish,lir repair any etntnure
K6tQ hatZslcense pursuacyoirce meappneanl the he Connisror,License
LawJaatpter9 '
than cavil. with ll,lhepfDhiiki I ocm,Best... andn,elywont,Cery Sy. FI. Floor Area Valuation
or that he is c with 5«lino 7(X10)of Division far
t the alleged
x and ion.ProAny vi Gxld
or Sec he is exempt any ,li and the basis fns the alleged exemption.Any l violation
of Saloon]1131n v any hundred
and fiar a pennic subjects the applicant m u civil penahy
actual route moor hnmma annaa,(ssa,), APN Number Occupancy Type
01.us owner of the properly,or my corployees with wages as their vole eompen,adon, 3661 1068. 00
will Jo the work,and the structure is not intended or offered for sale(Sec.7094.
Ihl.i les,and I'mfiessions Gale:The C....mica..,License Law does not npply ,,an Required Inspections
r of properly who builds or nalirnoes thereon.and v ho doe.such work his"elf 305 — FRAME
orthroughhis own emNoyees.prey that hurt such rapmvemers am no,immeJed or
mrered for mla.B'.I...wc<er,tee b ildue,of bnpnre,:em is whin one year of 307 — INSULATION
mtpletior.pie owne,lamIdmwill ties,the hackn of pmviog that festal not build or
npeot,to,bufpo.cof,ole). 601 — ROOF TEAR OFF
0 1.a-vocer of the praavmy.am exclusively enameling%th licensed cmurachurs 602 — 'ROOF PLYWOOD NAIL
eonxwn the nmjeo(Sec.7(44,Business and Ili ifieIdona Crsk:)'",Cc mmmor s
License law Jae, of apply to anownerol bri w@,builds or imprn.eslherenn 603 — ROOF BATTENS
and who contracts for such projects with a cnmmcte"s)licensed pursuant u,the
Contractors license Low'. 604 — ROOF IN—PROGRESS
01 am exempt under Sec. .B&P C for this reason .
0..1 Dae
WORKER'S COMITNSAI'ION DECLARATION
I herchy mann muter peahy oI'parjury oma of the following decluruJ..ne.
0 1 hove:..d will muintnln a CCra lCnla of Conical v,sclslnsure li,r Worker's
Cotnpcnsunnu, ns presided thr hY 9e.bon 37(X) A the Lubar Code, lee the
pe lhaturnce of the work for which Ilii.penuit is Issued.
❑I have mal will maintain Worker',Cn...wh aulinn In%wamce,as r,,ai,,d by Section
371X)of the labor Ede,for the perhuracheu lit the work for which this permit is
isnvcd.My Wur+er',CompenmJyl Inmrq¢ceN arricie am:
Camier._S_//—eT]G IC_�„1'rll_J !/C
CERT IFICATION Op LXIiMfTION F O O KERS
COMPENSATION INSURANCE
phis section need not be......leted if the permit is For are hundred dalluo
($Nn m lax.) -
I acnify that in the ped'onnunca of the work liar which leis Iwrocit i,issued,I
,hull not enpf..y any pare....it,nny mama, ,I an,to be....nc xhhE ,the Wickets'
Compo sultan Inw,A California.Dina
Applicant
NOTICIIi TO APPLICANT:IL afar making this Ceeilieate of Exemption.you should
bemnm eobject ,,the Wnrlet,Cong ca,mi...I powilions..f the lahor Cole.Yon mus
Q O bak with comply with such faros'ia...n or this permit,Lull he deemed r,olcd.
FCONSTRUCT ION LENDI NO AGENCY
> 1 hereby alLrm that Jure is a construction lending agency for the performance
oI the work for which this p.it 1,issued(Sec.3047•Civ,C.)
S Q Lcmler's Name
Q Z Lender's Address
U Q l certify that l have real this application unit scam that the afire information is
Gin correct.[r I ngtce to.oundy whh all city and snooty urdi..unco and state Lows rcwanp
Q O building e:n.loo .i and heresy unit I, cpec,crmd,asormi,a if,I,,enter upon
} iLc abovo-maatimmdrp�opany I...no,ellion nain.an ,
�.t pia (We)agree m..a.a.ardently and keep eoro.less tee City tic Cupanon,qunsl
F. Vi Iiabilide,,micurent,,cuss and expenee,'Lich tnuy in any way accrue againo,aid
V Z City in..... ncnec of the grunting of Ilii,p' nit.
^ A1'PLICNT UNDERSTANDS AND WE COMPLY WE ALL NON-I'OINI' Issued Dale
SQ cF 'S. /... Z2.� Y:
sign u—Applicu oma — - Dale Re-roofs
!A ti IXIERIAIS DISCLOSURE
Will the up east or utnmbnadingo.eupant sine or handle ha,:wous material Type of Roof
as defined by the Culmina Mntdeited Ede,Chapin,9.12,sad the Uvalth and Safety
Cade.Section 25532(a)^
Cities ON
All roofs shall he inspected prior to any rooting material being installed:
Will thetab,dicunt...came htrdding, .upnar use epaipmemne devices whim, If a roof is installed without first obtaining an inspection, I agree to remove
emir h:vantous air couti minaanx its defined by Ino(fay Arca Air Quality Monagencem
ni,tri.lI all new materials for inspection. Applicant understands and will comply with
0Ya 0 No all non-point source regulations.
I have read the he,i n oo,materials tai uitc a,it,under Chapter thus of the
GJif..ntiu Health A&del,Cade.Seation,25505,25533 and 25534.I understand Ihat
I `t the building Jaws not currcnay have a critical,that it is my essMmsibility to nmilyche
cepa t,of the"mournem,whim moa ben,,,prier m,issuance of It Cenireme of
O<upane>'. Date
Signature of A plica
owner lir mnthoa;.m agent Date II roof coverings to be Class "B"or better
OFFICE