00070136 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMITNo,
8
OWNER'SN1g111 PRUNERIDGE ALLIANES ROOFING APPIA"'ONSM11161.36
nouE: HP 1250, CAMPBELL SANITARY'67/2472M'6.
ante ARCTITECO iNGINEER: - 10 BUILDINGPERMIIINFO
kC LL_ (408)261-2595 e1.Dc F.LECI' PLUMB AIIiCH
9�C CI CI 1=1 I_.il
=z . hi,LICENSEDCONfRACI'OR'5 DECLARATION Job Description
m I hereby afrrm thio I umIictnmJ under provisions of ns Codc 9(commencing
!z de with S,ohn]fXXgofOivi.inn 3ofthe Rumnessand l'ndcxions Calc.and myliecmc
a .e inl'unfall and t�q ���,,,"
g it In< ILmmt.e Clues Li`" l('1/N/Lc_r5•_ds .
3°a V Date 7.j y.-deS commemr_ _ RE—ROOF
ARClI1TECl"S UECLARA ]OM1
C= ; I understand my plans shall he used ac public records
no p p Licensed Professional
e. ino, OWNER-BUILDER DECLARATION
n5 in I hereby affirm that 1 am emraw from he Cnmracmr,License Law fm the
t z< following reason.(semina 71131.5.Business and Ptofosiom Cale:Any city or county
S i C which requ fres n Permit hi mnswcl,nller,improve,dentol ish,nt repair any structure� prior m its lsmenme.elso requires the uppliraut for such permiuo f len signed statement _
mal he is licensed puracen it)the prommons of due Commetor's License Law Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Seefinn 7 00)of Division 3 of the puniness and Pmm"ionx CtNe)
or that he is exempt lherefmm and the basis for the alleged exemption.Any violation
of Section 7031.5 by any npplitan fora tenni)euhjecu the nppllc m to a civil penally
moot tuna into ave toacted dollars($ionto APN Number Oc$up40t00ID e
EI L as owner of the property.or DIw
Y tomployces inrcm
,wages as their snit cotnnron. I .
will do the work,and the structure is net intended or offered for sale(See.]INi.
❑dentes.uml Modwitu s Cosh,The Contrnnnts License Law dew,no,apply man g quired Inspections
r of property Who b,rdds m imin scs Immon,and who due,such war hiatwit - 31607@4E. fLlleh
orthrough his own employees.provided that such hnpmvemcros arc not intended or '
oB ncol for sale.If,however,the building m improvement is sold within one year of
ncompletion,the owner-huimerwin have theburka ofprmingtha be did not buildor 3@5 — FRAME
ap"eve an pdrpn,e nf.:de.t
❑I.asowneofthe proptny,am eschmiselycentme]ng with r«rmocentmeur,to 307 — INSULATION
eonsmve, he pmiee(Sec,mu.Bomat,,and Profession,Cmc:)the Camowdw l 601 — ROOF TEAR OFF
Liccme Law does not apply to an owner of property who builds or improves theaonr
and wonn"Iraaln tat such pot eel, with,a nnmdctm(t) becmed Pur",not to the 6@2 — ROOF PLYWOOD NAIL
cmnracmis License I.uw.
0 l am estmpl made,Sec. .B&P C our bite reason 603 — ROOF BATTENS
-
owner Done — ROOF IN—PROGRESS
WORKER'S COMPENSATION IIECLARA'I'ION
I hereby affirm under lemill,of perjury not of the following declamtionx: ,
I 1 have trod will maintain a Certificate of Consent to wifinsure for Workers
mpenendnis as pmv'uled fo, In, Mesion 3700 of the Labor Code, fist the
perlinmuntc of Int work ror wnich,hiv po'n n Is issue.
01 have and will maintain Worker's Compensation Insurance,as required by Section
37p of the Labor Cole,for the performance of the work for which this Permit is
wed.My workkerrsCCoongxensadoen Insinuate carrier and Policy number arc:
Cowie S�A (.pW�Islay Nn.: ��V 7_�1 •O�
CERTIhICAn( OPE%I:MPTION FROM WORKERS' I
COMPENSATION INSURANCE. -,/to
(This section need not he c roplaud Inhe permit i,Air one hundre dollars
(SIM)or less.) / (/
I certify that in the performance of the work for which this pcm,il is issued,1 a/
,hall not mnplay un,person in any nenner w as to become,able.to cot Workers'
Compelmdnn haws ol'Culilomia.Duna 0
Applicant
NOTICE TO APPLIC N P.If,af¢r making this Certificate ml Exemption,you should
become subject as the Workers Compensation provision,of the Labor Calc.you must
Q O Iunhwilh comply with,rich Pnrvlpin I,or his permit shall he deenoxi revokal.
z
E• ^ CONSTRUCT is a ct1NLENDINGructinen AGENCY
a > 1 hereby afro,that mere i,s construction lending agency for the perfnnnmee
of the work for which This permit is issued(Sec.]109].Civ.C.1'
Q LeadrNoma
p" IsnJer*,'s Address
U0 1 ma ify that l base rem m this application and sate that the uhoindentation i,
II- F. correct
I 1 agree to couiply with all city and county ordinances and state Jews Ielamng
Q U to building' vI t i hereby aullourin,repmrscatatikesIDI:cityI nmruq'n .
rye the rhos c-olet Lowd property I :P I n t I
E" O. (We); a tindecentlykeep11,dl I: cot way
we pun against against
menu t nJ ,es h h any y 6 imp
U Cly tete f g in nl this pe t
A PLI
IN R rA S U WILL COMPLY WITH ALLNONPOINT Issued by: Date
.E I ,R - as) . 06
sig art of App mm 'ommaur Doc Re-roofs
HAL%RDOUS MATERIALS DISCLOSURE
Will aeappbeom Dr rnmt building ac,mam store or handle bcamms mmerim Type of Roof
as defined by the Cupan'mn Municipal Code,Chapter 9,12.and the ileuhl,and Safety
Code Section
do 25532(a0". p No
All roofs shall be inspected prior to any roofing material being installed.
Will the apPlic:nnmmturc building ocmmnmuse cy,dpinentordevices which If a roof is installed without first obtaining an inspection, I agree to remove
enlh t 1 ircon I:" Ilndbyt 11yArea A Q li M d lett
Di.. erialis for inspection. Applicant understands and will comply with
OYa ON all non- u S 'ce g lauons.
II' 'derd 'Ir I" I I. J Chapter(d5 foe
Col f 11 Id S,Sc Iy C sle, I 25505 SSM13 J 25514.1 understand hat
Idit idac,a urrcmlY mem,that it is my apo,i billy to unify the
wee., t of he reyo ams ucl mmIL-11 prior to issuance of a Certircate of
)c@' ' Signature of Applicant Date
own m�modred asem Dme All roof coverings to be Class "B" or better
OFFICE