02050142 ` CITY
DIVISION
PERMIT CONTRACTOR INFORMATION:
Bti'Meg'MINTREE SPRING CT OLD COUNTRY ROOFING PERMITNO, 02050142
OnX'THUNG S STEP ET AL 125-3 GROBRIC CT Tn'?S152
PHONE: (707) 564-5557 SANITARY NO. CONTROL NO.
ZO O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
u- BLDG ELECT PLUMB MECH
¢d
LICENSED CONTRACTOR'S DECLARATION
Z H z 1 hereby affirm that 1 am licensed under f Cha her 9(commencing Job Description
sEi-c nPriffen p REROOF
m(_m with Scniome and mf Divisimn3of the Business and Pmfcssions Code.aM myliccnx
ExE� rxmrml rnree arta er T/O 1 LAYER SHAKE, INSTALL MONIEN
Izma Lives.Clax,� Li,.. G.2a73i
'oaG Dat Cnmracmr CEDARLZTE TILE ICBO #2656
a0 w ARCHITECT'S DECLARATION
un
I undertmnd to tlln9x s1)nIl 1Y Jc ,�.ublis rec rthy 6ut-f ,
ia o o LiccnscJ PrrRsxiowl
c LL OWNER-BUILDERaIamrom he RATION
1 hereby,(Seen on 1 1. cBusin from the Lotions C's License Law for Mc
t 2 0 following reason.permit
]031.5.Business and sae,de o demolish.
Code:Any city or county
toD which requires v permit re emncwn,xlme improve,h Permit t or repair ed ,wemrt
i 3 m poo t t B q theapplicant for such Permit fl signed mmr«m _ .._ ___ _ _ _ _ _ _ _
wtn< f« edp tt thep ns nr the c«aa<tnr.1: (cnapmr9 ,r`, -, .Sq.-Ft-Floor Area. ation
(commencing with Section 7")of D.iron 3 of the Business and Professions Code) (, ,• N . e „e �'.• - tI a„({'V� '1 Tft
or then M1e is exempt thcrcfnrm-und th<ha.us for the alleged cicmpuon.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(SSW). 3 6 664sl0f4u7nbl0r0U . `.0 Occupancy Type
°I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.]Odd,
Businers and Professions Codc:The Cnntmcmr's License Law does not apply to an Re fired Inspections
owner of property Who builds or improves thereon.and whodocs such work himself 307 - I NSULAT I O
or throu his own employees.provided that such improvom
nes arc not intended or
-, h affamd ,sale.IL however,the building or im,ovemem i,Sold within one-year of _ - - 601 - -ROOF--TEAR-OFF.
completion,the own<nbudder will have the burden of proving that he did not build or 602 - ROOF PLYWOOD NAIL
improve for purpose of sale.).
ol.as owner or IAB property:am exclusively cnmraning w_” m . .- .. .603 --'- ROOF-BATTENS _. ._ ...-
w Cachensede mncmn to
ear.Law project(Sol.7044.Business adProfession,who b CudeJThe Cnmraaors 604 - ROOF IN-PROGRESS.
Lieenu Law does noirapplysuch
man.,at,of property who sonde se improves thereon. ..
Co who cnmmns for projects with v contractors)licensed pursuant to the
Contractors License Low.
- ❑I em exempt under Sec. ',B&P C far his reason �
Owner Dam F0N LE 0.3
WORKER'S COMPENSATION DECLARATION
•..I hereby.(firm ander penalty ofperj.,one ofthe following declarations: AUG 2 3 20OZ
° 1 have end will maimzin a Ccnmcate of Consent to self-insure for Worker's
0VCompensation, as provided for by Section J]W of the Labor Core, for the
0V BUILDING
performance of the work for which this permit is issued.
°1 have and will maintain Worker'.,Compensation Insurance,as required by Section
3700 of the Labor Codc,for the performance of the work for which this permit is
issued My Wo cr C pe t 1 coeur.carrier a Policy numf�er are
. :. Can< K s Policy Nn - P
.CEWIIIIC HUNNU UEMPTIONROMWORK +Iles A� r_ _ e'• ..`�':i.0�`C.1,: tk^
._COMPENSATION INSURANCE
(Thissection neN not be co nplemd f the permit is f r ane hundred dollars ` i h
(SIC(r m lcssJ
I certify that in he peiforrihantt of the work for which th s permit is Issued,l -
shall not employ any Person in any manner so is to become subject m the Workers' "
compensation Laws of California.Date
-Applicant'
'NOTICETO APPLICANT:If.after making this Cenificatc of Exemption,you should - h
tourism Subjectto the Workers Compensation provisions of the Labor Code,you must
Z O l forthwith comply with such provisions or this permit shall be deemed revoked '1
Ln ' ' CONSTRUCTION LENDING AGENCY'
C > 1 hereby aRrm that a conswctmn Icrmmg agency for the performance -
W r of the work for which this permit is issued(Site 3097,Civ.C.)
Q Lender's Name -t_ .. .__. _ _._... .
�,z Linda's Address
U Q 1«nify that 1 have read this applicainn and stem that the above information is
coast'.I agree to comply with all city and county ordinances and state laws relating
rJ rebuilding construction.and hereby suthoriu re eenta cas of this city to enter upon
>,'W the shove-memioncd property fm inspection p ectise
F.t 0. (W<)agrcah,coe,indemnify and k hmmle."In,City of Cupertino against
V] liabilitim.judgments.c cid capcns s ich may in any way accrue against xaiJ
U Z City inconsequence the coming of premia v J
APPI.SCANTON S ' SA' CLCOMPLY\YRH,A I ON Issued by:
r Date a v
SOURCE as REGI'.. S
Signmureo A ifan .on""'a Jam' Re-roofs /
MDOUS'MATERIAIS DISCLOSURE. f '
L _ '' Wrath pplicu t irfuture bildingoccupantstore or handle haaadous material Type Of ROOF..as carried by the Cupertino Municipal Codc Chapter 9.12.and the Health and Safety _
.: Code Semi.o 2553241 t _rJ i•. :- t '/ �,' i�,. .I.) .
Dyes, ,yC'' All.roofs shall be inspected,prior-to-any,.roofing material being.installed..__,.
Will the pplica t or Culture buildingocc pant a equipment
q v ho devices which If a roof is installed without first o ming an inspection, I agree to'remove
em t M1 d e s coma 'n Is de ci d by the Bay Area A Q l ty Management
Daniel? a� all new materialsnspec[iotY. phcan[understands and will comply with
l r ❑Yes u all non-point-s cc egulatC
t Ph cvJ.the h -
ran art.t a en¢under Chapter ti 95 of the
Cal,
al f N' lot
y S<ctiom 2 S 33and spons 1 ity m mmnd that
if the hu'm gd«s c fly M1av<at t it my rcsponsibditymnotify the �!
occupant of the tic rats which t .t he at prior an issuance f a Cenifc m of
Occupancy. / l]Z Signg ure o Ap can[ Date
Owner orauthoreena cit Date All roof coverings to be Class"B"or better
' 'OFFICE - '