00110086 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BU ILDINGADDRES SPERMIT NO.
10551 N PORTAL AV ALL SEASONS ROOFING 0011008E
OWNER'S NAME: APPLICATION SUB DAlli
STAVANG CURTIS W AND TERESA G 2:103 MIDDLEFIELD RD 11/15/2000
111ION17: SANITARY NO. CONTROL NO.
(650) 369-7536
Z ANCf11TECr/ENGINIiIiR:
BUILDING PERMIT INFO
❑O❑ BLDG FiLF:CI' PLUMB MLCH
FEW IJ t-1 f-1 1=1
SN N LICHNS170 CONTRACrOR'S DECLARAI ION Job Description
JZ 1 hereby anion Ih a I am licensed under,000 nnx of Chapter 9(commencing
mtw with Smlinn7l"nafDivismn gal the uminev'r.and Prm'c,,imI,Gds,and aryl wc-c
r x z i.,a Iul fomeand / SHAKE TO GAF COMP ROOF
L 3 N : Cooum:mr
-`O g ARCHI I LCT S OLCLAHATION
1 understood l my PI shall W .cd u public n rd.
�} �eso Lccn IPrf 'I
oldNI 11 lex ILDER Df CI ARAI'LON /
Iona
C < GIlox g IS ctiu 711115 Busime,sandl " sC. I Any a sr county -
Z ❑ which n'ywree a permit m connruch al¢r.Improve,demolish,or repair any slmewrc Q
i5�_oprionnit.is+uance.ul.o rcquirc.+rhe applicant for wch pcnnino file a.igneJ,man,em '
n,at ere i.umnxd puannm In me pnn,.aon:Dose eommemra.ieen.+e taw(o,amer,l Sq. Ft. Floor Area Valuation
aummencin, all Seen,,.7000)atDivision3offheBu.me.,aadProfe..in.,C.de) $ 12598
err but he is comia therefrom and the basis hotline alleged exemption.Any vinlmion
of Section 70315 by any applicant for a pcnnil whjects the applicant a.a civil penalty
of ata mom than five hundred dollars($50). APN Number Occupancy Type
❑L osueronhepmpmty.ormy employee,will,wages a,Iheir+ole en...Pn"I'lon" 37.630099. 00
Mill do the work,nod the amauoc I.and imrnd,d err I.Rood to,caw(See.71119.
runic...fail Prnrnim,e Gds:'rhe Co.hath r.Liccnm Law does ,I,,apply h.an Required Inspections
norvr of Pmpeny who build.or..nprove,mcmon,fad who docs such work himntl1 305 — FRAME
ihnn,ogh his owemployees.provided that such impmveens am nor intended err
nered hot sale.If,hownce the building or improver car is sold within one year of 307 — INSULATION
icompletion,rhe owner-hadder will have the burden of proving that he did Dor build or
,apmve for pnrynwnl rule,). 601 — ROOF TEAR OFF
01.asosoerothe pro,sm,an,«cwnivelycamnienngximlicensed connote rm.rn 602 — ROOF PLYWOOD NAIL
Cinartio the pmjan(See.7Ma.Haom-,unit Pml'esnnno Clde:l She Cnmmnod.
es eLnwdoe ,maPPI, " elIne,ertyMobnddnotimproe%thercon, 603 — ROOF BATTENS -
I 1 who .R,. ori, .....�jecl—ire,.a cmmomor(.l lilec Il pa.nua..I o,me
,vast.
cn„n'aemempiemak,Law. 604 — ROOF IN—PROGRESS
❑lam exempt under ties .ii,@i'C for this reason
Owner - Dam
WORKER'S COMPENSATION DECLARATION
I hereby officer under penalty of perms,one of the following declarations:
❑ I hu and will n ...titin a Cv,ilicae onn
f Cot velf-ine for Worker',
Compensation, as pidcl lar by section 3701 err rhsur
e Lobor Code. for the
perli,ranacu of the work rot whidt his pcnnil In i.,acd. -
❑1 have and will nuintaia Worker',Compenaminn Inom or.a,required by Section
1710 of the IaWr,Gale,tin the pen menowe of the work tar which this pen,ir is
issued sly Worker's Con,pensmion Insurance carrier and Policy number arc:
4114-1.(D.VOL—Policy No.: -(.(J(_ �O_Q -01,f
E 911dCAl ION OM1 EXEMP'NON PRIM Wl KERS'
COMPENSATION INSURANCE
(This on raced not be em.nplenrl If the pet nu.s for one hmalmd dollars
(E Iko err le+a)
I certify thou in Ilie per]i,mmnec of the work liar which his permit is issued,I
.shut]nor employ any Irrson in any manner so:u n,haonm object to the WnAer<
Compensation Irw+of Calitamia.Dare
Applicant
NOTICE TO APPLICAN'il IL after nuking this Ccnillcac of Exemption,you should
heronre object to the Worker's Comloemmion provisions of the Labor Cale,you must
Q O Gnlwith comply whh such provi.vionn or this perrair shall W deemed revoked
y CONS'I UCTI ON LEND I NO AG ENCY
a > I heshy affirm Ihul Ilem is n eo...I...Ii I loafing ager,for the perlamumcc
of the work to,which this,permit..+issued(See.3x97,Civ.C.)
y q Lender's Name
z Lender's Address
V Q 1 certify that I have mad Ihi%application and sate that he oboa information is
Ire. F. comet.1 agree to comply with all city and county ordinances and state laws relating
Q C.> rebuilding a,osuuction.and hereby authorize representatives ofthis city In enter apin
rhe aA,ve-mentioned properly liar Inspection pur,ocs
F�„ a
(We)agreeu,.me,inicrrify and keep lwnaless the Co,of Cupenininquinst _
fin lixhiliticn,judg.uv.ns,oras Ictal ev Pens,whi,l,may in any way accrue again”said
V City In coevc4uonco of lhegn.mi ignf this pcnnil,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS, y•
Signature of Applicant/Conteacror Dae Re-roof$
HAZARDOUS MATERIALS DISCLOSURE
.\ill the applicam or]hare Wilding ecculanr ams err handle hucminus material Type of Roof
m defined by the Culrnlno Municipal Csde.Chirpier 1).12.and the Health and Safety
Code.Section 235321a17
❑Ye. El No All roofs shall be inspected prior to any roofing material being installed.
Will the appheantor1armholding«a.pnnltoe celoipummordevices whiel, If a roof is installed without first obtaining an inspection, I agree to remove
= ,a m—doe.our eon en,ilann,as d,T od by the ray Area Air easily Mnnagc.nem
r+tdn7 all new materials for inspection. Applicant understands and will comply with
1
L3 Yes MNo all non-point sour regulations,
L have read the haardous materials requirements under Chapter 6.95 of the _
California Health k Safety Code.Section.25505.25533 and 25531 1 undemlaad that ^�
if the�uil of the era nnawas w h h must bel
are, my ,tioncsiof.Cry fn0e the Q {dtp•y,� �/ /sy
rccupam of the mqulrmncnb which must W mm prior n,iswuna of a Ccniticxtc of
Occupancy. .
Signator of Applicant Dale
Owner„ramhorimdngent Date All roof coverings to be Class `B" or better
OFFICE