01060004 CITY
BUILLDING DIIVCtISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10155 POTTERS HATCH FOUR SEASONS ROOFING 01060004
OWNER'S NAME: APPLICATION SUB DATE
CLARK ROBERT B JR 645 HORNING ST 06Z.0112Q.01
PHONE: SANITARY NO. CONTROL NO,
naeZ ARCHITECYENGINEER: BUILDING PERMIT INFO
da BLDG ELECT PLUMB MECH
'z LICENSED CONfRACfOR'S DECLARATION Job Description
0 Z,,,2 o 1 hereby off.'M thio 1 am licensed under provisions of Chapter 9(commencing p
f with Section7000)of Division 3 of Ne Business and Professions Code.and my liccnm
a qq
Lin full force and a(fa t.O
CC6u ironse las C��J U'.0 y tie RE-ROOF TILE TO COMPOSITION
Dae z —b Commi for
.�i ARCHITECT'S DECLARA ON
t a 0 g 1 mahodwnJ my plans Ball be red ax public record.,
- a
m i p O Licensed Proressional
is. OWNER-BUILDER DECLARATION
I hereby slims that 1 am exempt from the Contractor's License Law for the
t." ¢ following mason.(Section 70315.Business and Professions Cade:Any city or county
teo which requires a Permit to construct,alter,improve,demol'nh,or repair any structure
n 3 C proto its issuance.also reg the pplicant for such ximet to filen signed inatement
dim he I sed pursuant w the pm ono of the Comracmrs Ccenu La (Ch pier 4 .S FI. Floor Area .
(mmmen< g ithSect n]gNl)a(D'visnnlortheBuane. ndProfessonzCrde) \s \q' i •, ,sy�,` ;( ;u) $80glOuation
exempt or that he is theefrin bnd the basis for the alleges]exemption.Any violation
of Section 703 L5 by any applicant for a permit subjects the applicant to a civil penalty
or not more than five hundred dollars(S5 W) 3 4 2�RAYIYF'fD Occupancy Type
❑I,as owner cruise proany.or my cmpleyes,with wages as their role compensation.
will do the work,and the structure isnot intended or offered for sale(Sec.7014,
Business and Professions Code:The Contractor s License Law da,not apply m an 305 - FRAME Required Inspections
owner of property Who bolds or improves Merton,and who does such work himself
or through his own employees.provided that such improvements am neo intended or - 307 - . INSULATION--
offered for sale.If,however the buildin t is sold within f —. ... .. . . . .. .. .._. ..
amp= guburden firrovnng yeata 601 - ROOF TEAR OFF
1 tion,the of
f bale.),will have the burden of that he did not build or
improve for purpose,roam.). -- 602 ROOF -PLYWOOD-NAIL -
_ ❑L m owoet of the propeny,am exclusively mamning With lhxoscd coatrxtun to -
- - construct the project(Sec.7044.Business and Profession.cude)The Contractor. 603 - ROOF BATTENS
Licens- andwhLawd«snat apply orsuchpan owner of jectswth,acenywhohaimensedpdrimve,thtothe PROGRESS
and who contracts for projects witn.a commdar+f hoose,poromas mdse - 604 - ROOF. IN-
Col am exempt
License law.
❑lam exempt under Sec. .B&PCfor this reason
0.re, Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Ne following declarations: p
111 helms and oil maintain a Cenifcum of Consent r self-insure for Worker's FI�V ALED
Compensation, as provided for by Section 37W of the Labor CWc, for the
_ performance of rhe work for which this permit is ismW. O
t71 have and will maintain workers Comen
psation Insurance as required by section JUN 2
37W riffle Ldar Cade,for tte perfamance of the work for which his permit is
issued.My Workers Compensation Insurance carrier and Policy number am:
-a+s ,o afEXEMPTION�if .•. ..-, I. •.» :..,;:.,..BOLDING_.. :-. _ . .. ...
_,,. .,:
COMPENSATION INSURANCE s-
(This.section need not be completed if the permit is for one hundred dollars
ISI W)ur leas.)
1 ccnif that in the rfommanc _ •. ._ .. -. .-.-. ..._ .. . . -.. .� - .- .- _ . .. _
y a e of the work for which this permit a
shall not aonemploy any person in s. manner sat as to became subject to the Workers'
Compensation of Colifomia.Date
Applicant _ .. .. _
NOTICE TOctto the Warl IL Coon it,mi this Certificate of Exemption,youshnulst '
become subject to the such
Compensation provisionsll the cubndCWc,yi,u must
0 0 forthwith comply with tach provisions or this permit shall be domed revoked. _
E'er CONSTRUCTION LENDING AGENCY
1 ameby affirm that then is a construction lending agency for the Performance
r
of the work for which this permit is issued(Sec.3097.Cry,C.)
Lionder',Name
= z Lendcr',Addres
U (:) I certify that I have mend this upplicmion end smm that the above int'mmminn is
ia.0 U coned.I agree r comply with all city and county ordinances and,tate law,relating
U to Wilding mentioned
construction, frti inspection
ertposemaives o(thiwity to enter upon
the aW(We)oi to love,ndforinspection purposes.
F, y es judgme m scost indemnify dnJ see,hi hm may
in the ways ems,ags.ainst
aid
rn liabilities,judgments,costs and its,existi which may in any way m=me against said
U-i City in ANT/,ND romeR9TAgmnlingof this Admit.
APPLICE J!6U Ar1ASNDSANO WILL CONVEY WIT ALL V_gl,VT � 7,�
so��cuLA��i,at__ � tj..p j Issued by: � '�—' ��'' AJaJCL • Date
Slgnat cofApplicant)Contrrear - Date Re-roofs
HAZARDOUS NIATERIALS DISCLOSURE
Will the applicant or future building acupant store or handle hazaNar mamrial Type of Roof
is;defined by the Cupertino Municipal Code.Chapter 9.12 and the Health and Sately
s•
Cods.Seaton 3553'_lal'!. f ^ l 6 .• s
0 y'es ' �"° ' '•t " ' ..All.roofs shall be inspected.prior.to.any.roofing.material being installed._ . ...._.
Will the applicant or future building acupam use equipment or devices which If a roof is installed'without first obtaining an inspection, I agree to remove
emit brundom air contaminants as defined by the Buy Area Air Quality Management
Di...i'la all new m erials for inspection..,Applicant understands,and will comply with
❑Yes .' ❑No all non- int scypce regulations'.,
I have Health
the Safety
Code. omens 2 ser,r505,2 533 under Chapter hst of he
Coliform,ing di not cur Cntlyha atena5505at it
yrespond 3q.lityto noel that
if the building not currently ha<a rows.that it is my responsibility to notify the
uccupmn of t requir is which ort be met poor at issuance of a Cenifrcae of
G"r°°"`y' -o / Signature of Applicant _ _ Date
Owner orcrudionized agettt Date All roof coverings to be Class "B"or better
OFFICE