03090097 CITY OF CUPER'11NO +ts»ani 7b�u�,m,.t
Bult.rnnc DrvlsloN PERMIT VCONTRACTOR INF,ORMATI,ON.
BuaS rvc ADDRESS: FOUR SEASONS ROOFING PERMITNOO 3090097
OWNER'S NAME: 645 HORNING ST PERMfIESUEDATE
NE: SANITARY N0, CONTROL NO.
(408) 278-0330
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
I
00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
1 hereby arnme that I am licenmd under@ �''um nr Chnptcr 9(commencing p
with sect5 Rn10fNBef Division 7of NC Busincas ayrymfcssinm Code,andm license is
l�i in ¢m�s� /
�p LieeolscoCYasa>'eH�Ai Lie.a D REROOF FINALE®
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IC ARCHITECTSDECm
pIunderstandmyplansshallwuaedasmdNs
SEP 2 5 2003 -
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''C Licensed Professional
OWNER-BUILDER DECLARATION
2i1£ I hereby from Out I em exempt from the Cannel '.License Law for the BUILDING 0O following mason,(Section 7151.5,Business and Profeadam;Codc:Any city or county wY sail
<m�. which requires a permit to construct,allot,improve,demolish,on repair any structure
poor so im issuance,also requites the applicant for such permit to flc a signed statement
s0 that he is licensed pursuantintheprovisionsoftheContractoriLicenseLaw(Chapter9 Sq.Ft. Floor Area Valuation
RF (commencing with Section 70007 or Division J of the B usimns and Professions Code)or
that he is exempt mcnefrom and Ne basis for the alleged exemption.Any vial ,soon of 36913021 . 00
Section 7071.5 by any applicant for a permitsubjects the applicant to a civil penalty of
not mom man five hundred dollars(SSW). "- -- - - -ApN Number Occupancy Type -
❑I.u owner of the properly,or my employcu with wages as their sole compensation,
will do The work.and meatrunue iso at intended or offered for sale(Sec.7W.
and Profession Corm:The Contractor'sLicense Law dues not apply to an owner of }py, l
1�IJ�d Inspections
property who builds or improver deacon,and who does such work h 3 O 7 — INSULA 1
imselfor mmugh his j�f
own employees,finished Oat such improvements are not intended or offered for sale.If. 601 -ROOF TEAR OFF
however,lie building or improvement is said within mm you of completion,the owner
bander will ban the homed of proving mat M did not wild of improve ver purpose of 602 — ROOF PLYWOOD NAIL
m.). 603 - ROOF BATTENS
1,as owner of me progeny,am exclusively contracting with licensed contractors to
aonwet the project(See.yOan,Business and Raniresames;Cmm:)no Commuter's Lt. 604 ROOF IN—PROGRESS
cons,Law does not apply to an owner of property who wlids or improves themon,and
who conducts for such fmjecss with a commuc orad licensed pursuant to the Counselor's
License Law.
(:]I am exempt under Sec. ,B&P C for this..an
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affixed under penalty of perjury one of Out(allowing declaration:
Ihave and wills inoi n a Ccraficam of Consent to self-insum for Workers Compere
,on,
as provided for by Section 7700 of the Labor Coum,far On performance of de -
weak for which Ois permit is isoa d.
1 have and will maintain Workers Compensation Insurance,as required by Section
7100 of the Labor QINC,for me performanceof the work for which this permit is Issued
My Worker's Cn tpenuti humane artier and Poli mbar art:
cr. ppt✓J 6 �2
CERTIF LATE FE%EM ONFROMW R ERs'
COMPENSATION INSURANCE
(Thissectled need not w completed lithe permit is Tarmac hundred dollars(SINB
or ins.)
1 certify Oat in the performance of me work for which this permit is issued.I shall not
employ any person in any manner an as a become subject to the Workers Compemation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If atter making this Certificate of Exemption,you should
become subject to the Worker'a Compo nation prevision of the Labor Codc,you must
,Z forthwith comply with such provisions of this pernei tshall to,deemed revoked,
z O CONSTRUCTION LENDING AG ENCY
1 hereby eluant that them is a construction lending agency for me perfufmanct,of
Si the work for which this permit is issued(Sec.3191,Civ,C.) -
37 Q Lender's Name
z Lender's Address
.-J Q I codify out 1 have fend this application and sou that to above information is
y F COMM.I agree to comply with all city and county eminences and sum laws totaling to
U building conduction,and hereby summits,mpreunutiw a(this city to enter upon me
4 above-mentioned property for impaction purposes.
y
(Wo)agree to save,indemnify end keep harmless the City of Cupcnita to City s
liebilitie;judgments,costa indespcnsend keep
itauto /
J do conuqucncco ranting spermit.
APPLICA DERSTANDS A D WILL COMPLY WITH ALL ONPOINT Issued by:3 Date
•3Re-roofs
Sib u looser au
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant m forum building occupant atom.1 or handle ha�oua d Safer l
as defined by the Cupertino Municipal Code.Chapter 9.13,and the Health end Safely
code. on
EDY.25532(1' a All roofs shall be inspected prior to any roofing material being installed.
Yu No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haxardnue air conmminanr u darned by me Bay Area Air Quality Management all new materials for inspection.
orictl
❑Yea
I have mail me hoardeas materials requirements under Chapter 6.95 of the Cali
tis Hua &Safety Cade,Seeuon 5577 12557x.1 undetsmM mmirdm wilding
does currently hate a u responsibility m ratify de occupant of de
to - piMm et aissuanccof.conificido. cy. Si tureo Applicant Date
Owner., mivedagent All roof coverings to be Class "B"or better
eE CITY OF CUPERTINO
REROOF 6 3
CUPERTINO i PERMIT APPLICATION FORM
APN# Date: r�
}
Building Address:
Owner's Nam : Pho a#:
E Lu c��2
Contractor: --� License#:
Contact: i `glia Phone#i '� ���i_�3
Applicant/Contractor: I Fax#: `t O
!Sq VIM01LID& 3q --0333
Buildin Permit Info: /
Bld Elect Plumb Mech
-J66-Description:
/�wa
.lard+.�/
Residential: C �'E � S
Sq.Ft. Floor Area: $/Sq.Ft.:
Archi[ecdEngineer: I Valuation: m»�
Type of Construction: Occupancy up:
Qty, if
AP is le Fee ID Fee Description Fee Group
BPER!
MFEE Bld Permit Fees BUILIDNG
BENERGY Ener BUILIDNG
I
BSEISMICRE Seismic Fee Res BUILIDNG
BSEISMICOM Seismic Commercial BUII.IDNG
I
BPLAINCHK Plan Check Fee BUILIDNG
BUSLTC Business License BUILIDNG
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