01010095 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESSPIIRMIT NO.
10641 N PORTAL AV ANTHONY ROOF SERVI E ' 01010095
OWNEMS NAME: APPLICATION SUB DATE
LAPPIN ALAN S AND PATR' CIA 1655 FORMAN AVE 01/23/2001
HONE: SANITARY NO. CON"rROL NO.
(408) 265-5147
n O 7O ARCHI I'EC IENGINFIiR: BUILDING I'IiRMIT INFO
E BLDG ELECT PLUMB MliCll
Ni 1=1 1.I 1=1 CI
pN= LICENSED CONTRACOR'S DECLARATION Job'Description
- I hereby affirzn that 1 am licensed under Provisions of Chapter 9(commencing
wish Scorn 7(XX))of Division 3 of the Business and Professions Core.unit my license
¢— I,infall hreeandeBcer. 40 YR PRESIDENTIAL130LB FELT
C z 2 J Liecne<Ctrs, Lie N
xa LL Date Comormor
to ARCHITECT'S DECLARATION
u.O g I understand my plans.nall W used o5 public record.
N
w p O LimnwJ I'rol<s�inn:J
°'Pj (IwNI?R-ItIIILmI r rm the IontraAi ON
u� 1 hereby affirm that I a efnpl Irons IM1e Contractor's License Irw for the
C Y< following reason ISsator 7031.5.auxins and Pml'essions Code.Any city or county
F p what requires a permit LK)Construct.after. p dcnrolh,or ri any shorebrom
iZre
pro to itsto requiresthe applicantf h Permit toFile 'g d.ta<ment
- thatb 'l In rsua tr thep res c I t r,License r IChapmrA Sy. Ft. Floor Area Valu•do
¢est
occur, it a e 70(Xr 11) i Iles Bale.. dI l .'' is Code) 18800
or that he is exempt Ihcreimin and the hroi lir the alleged exemption.Any violation
of Section 703 L5 by amy applicant ht a pernil sit i<ns the apphcam to a civil prally
of nm more than live hundred dollars 65001. A PN Number Occupancy Type
01.a,owner III the pmpny.omyemployees with wages their sole compensation, 31632055. 00
will do the work,and rhe stinnnm is urn intended or offered I'or sale(Sec.70,14,
Business Inns Podc.lnns Cotte:The Cmmmcm.,License Law does not apply to an Required Inspections
r of property Who Ladd,or impmx'e4 thereon,and woo does such work yourself 305 — FRAME
or through his own employem,provided thm such improvemenm arc nal intended or
aRerod tot sale.If,however.the building or improvement is sold within one year of 307 — INSULATION
completion,the ow'nenbuil iCr will have the burden of proving that he did not build or
imPeove ntpmrpme clod'.). 601 — ROOF TEAR OFF
❑1,t,owner of the properly.am c,W.no ly eanoterin,with licensed ca.traala s to 602 — ROOF PLYWOOD NAIL
consumer the project(Sime.AWE.Business and Prolessions Codu)'Due Commemr'z
License low docs not apply to an nw'ncrofropny who builds or improve,Immon, 603 — ROOF BATTENS
and wbo contracts for uh¢b prejeas with a cohnmcmr(s)licensed pursuant to the
„
CommmI.ieen..Las. 604 — ROOF IN—PROGRESS
LlI:nn eacphIn older Sea. .B&P C lin this reason
Owner Date
WORKER'S C'O.MFENSAI'[ON DECLARATION
I hereby affirm under Penalty of perjury one of the lidlowing declarations: ,
dillI loor and will nainurin .Cerifie,b,iI C rt ,II - Worker',
imparsation. asprovided f by Section 1701 of rhe Labor Code. fur the
performanceflh rAl Mp
heli . n r I
1
❑ li" J will ate Worker's C nar t I ee 4 hi by Section
,ri M Worker
Cxl t a Pel' m, 1e kfwhicht :prnik G/
i.xucA.My Worker's'Cunni>Lnxatinn In,urnnee enm<r nnA 1'111icy nAAnnhher now /
Carrier: T Iblicy Nn.: 7 �u
C.RT119CAf1 NOFESEMYr10NFRoM WORKERS' /
CDMPENSAI'ION INSURANCE
(l'his scefon need mor be vru p,let if the liernuit i,bounce I'll liect dolhrs
obb odes..)
I crnify that it,the Icrfommnce of IM1e work for which this permit is issued.1
shall not nmplay any Person in any manner w as to became wbjeet to the Workers
Compensation law.of California.D:ne
Appbrmr
NGr1 CB Iv APPLICANT:If,anal maklne chis CenlBeee of Emmplimr.you snmdd
lrenme subject to tat Worker'sCompen.wrion pmvi,ions of the Labor Gale,you must
Q Q forthwith comply with such pmviii m,m Ibis prod,hall be he mel revoked.
.Zi N CONSTRUCTION 1.17.N DING AGENCY
aI hereby mirror Thal there No conslmcrian lending agency lin the perinm,ance
!s7
it the work Ibr which thlx pe'.nir is lowed(See.3097.Civ,C.)
6. 0 IcnJer's Nome
Q 7 EenJ<r's Address
t..) Q I eerily that I hove rcud this application and s,am that the above informaiun is '
W P correct.I ugrce to comply with all city out cowry o foresca and xrole laws relaxes,
Q V to budding ucram,lor,unithereby mnlmde<Npm.eruaivex nfIhis city m enter upon
ryt
the altova-nmtnioned property for inspme, I purgru.
y OVe)agrecor roi indemnifyand keep lmm,les,hbe City of Culmtino against
In lu bilhEe.)uJgnmes,coats and expense,which may in any say accrue against said
U Z City in cor equence or the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COM PLY WITH ALL NON-POINT Issued by: — C. Date
AT
SOL RCR REGULIONS.
Signamre of AppreamlCommclor Dale Re-roofs
HA7dRDOUS MATERIALS DISCLOSURE
Will the applicant or furore building receptor some or handle hvardou,material Type of Roof '
o deruod by the Cupertino Noolied Code,Chapter 9.12,and the health and Safety
Code,Section 25532(a)1
❑Yo, 1po All root's shall be inspected prior to any rooting material being installed.
Will the applicant or future building occupant use equipment or results which If a roof is installed without first obtaining an inspection, I agree to remove
emir haeallous air contaminants as defined by the Bay Aura Air Qhmliry Management
Di,trita all new materials for inspection. Applicant understands and will comply with
13 Y- YNo all non-point source regulations.
I have read the humrmm,materials oaluimmanr,under Chaplin 695 of the
California HmIb&Slimly Cale,Sections 25505.25593 and 25534,1 understand ohm 11/f1
Bthe Wilding does re no only have a mirror.that it i,my responsibility it)toffy the
occupant ofthe re4uirenunr,which must the mer prior to issuance Ida Certificate of -b
O"°pane?' _ _ Signature of Appli u Date
All roof coverin rs to be Class`B"or better
owner or aamod,,e nam b'
OFFICE