01060005 CITY OF
NO
BUILDING NG DIIVIISSIIONPERMIT CONTRACTOR INFORMATION:
' BUILDING ADDRESS: PERMIT NO.
10135 POTTERS HATCH FOUR SEASONS ROOFING 01060005
OWNER'S NAME: APPLICATION SUB DATE
JOY MICHAEL D AND JOLENE F 645 HORNING ST 06/01/2001
PHONE: SANITARY NO. CONTROL NO.
408 278-0330
r<a ARCHITECT/F.NGINEER: BUILDING PERMIT INFO
Do BLDG ELECT PLUMB MECH
Z H= LICENSED CONTRACTOR'S DECLARATION Job Description
O —O I hereby affirm that I am licensed under provisions of Chapmr 9(commencing
F v,t-to with Section 7UW)of Ovision3 fthe Business and Professions Code.and my license
a0. i,in Tall Tore=ane u. _ ..3 12/6 % RE-ROOF TILE TO COMPOSITION
z cs i< License Class Li<,a _ '��
H a u.H Date COotma
ARCHITECT'S DF,CLARAT ON
as
G� I understand my plans shall W used as public recoide
.cap O Licenced Professional
°'Xa OWNER-BUILDER DECLARATION
o m I hereby offirm that I am exempt from the Contractor's License law for the
F Z? following reason.(Sealon 703 1.3,Business and Professions Cade:Any city or count,
Y x O which requires a pemat to con.wet,alter,improve,demolish.or repair any structure
oa�a 3� prior in't issuance,once,al q the applicant for such ennit to file a signed statement -- - O - --- .
War t . spurstion N v elision the Conamthe Business
L Law onsCost) S Ft. F1oor-Area ♦ $$ O'®luation
or(commencing;awith Sen 70001 f Division di ProfessionsCosts) _ t(;19
or tear her;exempt Nerefmrdand the basis fm the cts the
dement to Any violation
of Section than
anyapplicanttisrapermitsubject the applicum mucivil penalty
of not mgre mad B.e hundred aroma(ssoo). 342MIS 448m" Occupancy Type
❑1, a,mer:ole cow,nsmion.
will do the work.and the stmcwm is not intended or offered for sale(sec.7063, 305 — FRAME Required Inspections
Business and Provam
Professions Code:The ConcmCs License law encs not apply an
owner of property Who Wilds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements are not intended or . . 307-..— -INSULATION
offered for:ale.B,however,the building or improvement is sore venin one year or
completion.the owner Witcher will have the Widen of proving that he did not build or 601 - ROOF TEAR OFF
improve for purpose of sale.). '
6.02 - - ..ROOF...PLYWOOD. NAIL__ _ _.. ..
❑1,as owner of the por,ny,am exclusively mntmcting with licensed contractors to
_ eonnmet the project(sec.lou.Business and Prore:sions Code:)The Cormw orf 603 — ROOF BATTENS ..
License Law doea not apply m an owner of pmpeny who Wiles or improves therceo,
and who exionat,for such pr.jaco with o ccntmcmn,)licensed Passant-to the .. .6.04 7 -ROOF IN-PROGRESS_._._ _-. . ..
Contractor',License Law.
❑1 am exempt under Sec. .B a-P C for this reason
Cora., Data
WORKER'S COMPENSATION DECLARATION ��
1 hemhy a(f rm under penalty of perjuryons of the following d whin ons:
NALED
❑ 1 have and will maintain a'CenifLate of Consent to .salt-insure for Worker's
CompcnsaJon, as provided for by Section 3700 of the Labor Code, for the JUN 2 0 2001
performance of the work for which this pandit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section p�
3700 of the labor Code for the performance of the work for which this permit is BUILDING _
issued.My Worker
Worker's Compensation Insurance carrier and Policy number are: _-
rrr'idrANatnfmaY 4'A Policy No.U/GZ�� -
-CERTIFICATION OF EXEMPTION FROM WORRS'
COMPENSATION INSURANCE . .._.. _
mei,section treed not W completed If the permit is for one hundred dollars '
(SIM)os less.)
I certify that in the performance of the work for which this permit is issued.I
shall not employ any Person in any manner so as to become subject to the Workers'
Compensation Laws of Califomia.Dae
Applicant -
Il ICE TO APPLICANT:If.slier maWng Nis Cenilicatc ar Cxemption.you should "
become subject to the Worker's Compensroon provisions of the Labor Cole,you must
'J C forthwith comply with such provisions or this permit shall W deemed revoked.
-CONSTRUCTION LENDING AGENCY "
� � 1 MrtbY alarm that Nerc iz a constmaion kntling agency for the performame
Ls7
Lender's
the work for which this permit is issued(Sec.3097.Civ.C.)
LsnBcr's Address' -
V C 1 eenify Nat I have mad this application and state that he above information is
W"E. cum".I agree in comply with all city and county ordinances and state laws relating
Uto building coostrvnion.and hereby authorim representatives of than city toenrorupnn
the above-mentioned property for inspection purposes. 3
y (we)agree to save.indemnify and keep harmless the City of Cupertino against
sr� (n liabilities,judgment,costs and expenses which may in any way accrue against said
U Z City in coo- uence of Ne gmnting of this permit. a
APP ICAI UND" kJDS AND WILL COMPLY WITH ALLNON-POINT ✓ S e— iv7oK.v CC Date 0—Ct—J�
sr rc EcuL vs. C ��� Issued by: T /-)
Signards,nfAppllcantlContractor ^ 'I Doc Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will Nc applicant or iliwm Willing acuptm store or haoLk haaaidaux matuial Type of Roof
as def ed by the Cia,nino Municipal Code.Chapter 9.12,and the Health and Safety ) t.
Cola.Section 255J2(a) ,'
0 Yes, 2k. All roofs shall be inspected.prior to any roofing.material being installed..._._._.
Will the applicant nrfuture building occupant use eg,dpmentordevices which If a roof is installed without first obtaining an inspectifin, I agree to remove
emit hxaardous air mmaminams as defined by the Buy Area Air Quality Management
Dism"7 _ all new materials for inspection. Applicant understands and will comply with
11 Yes - all non-point source regulations.
1 have read the haavtlous matenaly requirements under Chapter 6.95 of the
Califomia
Health Safety le.Sect5505t and 255Ja.lunderstand that
ifthe buildindcs not curtmlyhmxaenannhaitis
myssuancsiofa abifi'fy the
ucupnm nl th s-
whicM1 nwsr be mut prior m issuance o(a Cenificac of Occu nays s -
� SLgnature of Applicant Date
ownatoroamoraadagem Date All roof coverings to be Class `B"or better
. - OFFICE -