00080164 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PFRMI'1'N'O.
OWNER'SNAh ' ROOFING APPLICATION. ' ;\
42 'HONE: GROSVENOR VHI%IIJLN WAY SANIIARYNo, c ,( ,
a c% ARCIII fECI'/ENGINGER: � — OJ BUILDING PERMIT NFO
w00
m❑ BLDG ELECT PLUMB171hiECll
F jI ICENSI U(ON'IEACTOR S DI CI ARAI'ION Job Description
11 by ll ' IIt,,I r ,educt sal'Chrl 9f t enc'' .
pmCw will,S n 70XI fD ', 30 f0 Broin and I ' f,sln .Cd 1 111,h1loe _
"an full Tarte and
I.iecne 39 N_7_(9�75
eau Dmc_ `_- ob Commeror - B. U. R W/ CAP SHEET/ADD GENFLEX/60 MIL
u O G ARCHITECT'S DECLARATION
ceg 1 understand my plan.shall W used as public record. B. U. R
ce S p i0 Licensed Professional
e. oWNEWHUILDER DECLARATION
m I hatch acorn,Imo I i n(ucm,t ren,,he Comneou",Llccnse Law for the
b Z 4 Iblluwing ran no I.(Seen 71311.5.Bunn,,and I'min„'ionv Gem:Any city nr,oumy
`^F p whir Ialial rv�lruu 10 Itualtaret, ller,inilative, ,Bal p y arllIn e
i4� prim , aHI y :dl rrlic Ir. 11 tin 11 y d.wteneu
Immhlicensed P r,u ll to the romikinas ofth C tor's License LIov(Charter9 Sq. Ft. Floor Area Valuation
(commencing wish Section 70(X1 ol'Di,bion 3 of the Hu,n,,and Pox esaons 0,40
or that he is exempt n,ercfmm and The basis for the alleged exen,p,inn.Any sinblinl,
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally
of nm mare than five bandred datim,x500). A PN Number Occupancy Type
ol,asownet ofthe property.tor myemploy,,,with wages beit.nleenmpeownon. 4108000
will Jo the work,and the structure i,not intended or offered for,ale(Sec.7044.
Irl, and[I I . ,nn Code:The Contractor',Liacne I.:I,doe,sol ofd,1..n, Required Inspections
ina�,i pmpeny Wim I Id, a inra-e,Jlcl..,n,and who 11111,110111 wail,ldm,ell 357'2004 2. 00
,it through his.,on m,mloyee,provided mal some ilnprvvnoenls all not inlendcd or
offered for sale IL however,the building or improvement is sad within one year of
completion,the nwnerhuilder will have the burden of proving that he did not build(itnapm,eforpropoveof,alco 305 — FRAME
01.as owner of the property,um exclusively collowing with licensed contractors u) 307 — INSULATION
construct the project(Sec.7044.Liminess and Pmdiamn,Cute:) Me Contractor's
License Law doe,not apply to an owner of property who bairn,or improves thereon, 601 — ROOF TEAR OFF
and who contracts for.such pn,jecP with it eon,rvepa(O limnsed pursuant,,the
c..lnlmefor',Licene Law. 602 — ROOF PLYWOOD NAIL
❑l eon exen,pl code See. ,B de PC far H,l,rax"II . 603 — ROOF BATTENS
°w°" rIc
WORKER,C( PL
M1NSATIONDECLARAIION 604 — ROOF IN—PROGRESS
1 hereby ammo muter penalty of perjury one of the billowing declaration:
I I have and will maintain a Certificate of Consent m self-insure for Worker's
,mpensa,ion, a, provided fur by Section 3701 of the Labor Code, for the
performance of the work bor whichth. perms J
II" 1 ,If .I I,,W k :C P 1 1 n,,idhy Section / /
so NI Ib -tu1 t tl 1 111 . of 'I M1O':l ,it lx
I,weJ.My W'nders Cu y}n.eai of In,uomac un'cr I al cY ,umber are. r
Carrur:e . � r�aP y Nn.:5fB/20_D 23ttfJQ� ��/
CER rIFICAI'ION OF E%PJa1PTION FROM WORKERS'
COMPENSATION INSURANCE: �^
(This section need not be completed it the pem,it is for one hundred dollars
HIM I or Eco.)
I certify that in the Is rloreance of the work tar which this pencil Is ks av,i,i
.hull naI mnpioy any pees....In Imy mnnuer ars it,m fecona,unjm 1a dee Wolk,,,
CompcnsoGn I Laws of Cal leroia.Dole
APPlicam
NOTICE TO APPLICANT:If.after making this Ccnilicmc of Excmplion,you should
Incentive subject to the Worker's Compcation provicinn al the Libor Code,you mus,
Q 0 forthwith comply with such provisions or his permit shall he formed revoked.
FCONSTRUCTION LEN OfNG AGENCY
1 thereby aliirm,hatthem is a construction lending agency for the performance
of the work for which this permit is issued(Sea 3097.Civ.C.)
Q Lender'.,Nunn
Q Z Lriucrk Adds%,
U Q 1 amity tbn,I hail rand Ill a application and mole mm the alaor narnrnunion is
Tae F. correct.1 agree It emnply with all city and county ordinances and state laws relating
Q [) :(1 Wilding mnwetion,and hereby authentic mpmsenm,ives of this city fa enter upon
Ls: the above-mentioned property far inspection fulfil
(We)agree m save,indemnify and keep harmless l¢City of Cupeninn again.a
Vl liabilities,judgments.costs and expense,wmeM1 may in any may nerve against said
7J7z Ci,y in con,"nence of the gm min ofthi<perp" �2 r'k�a�
'—' APPLICANT UNDERSTAN AN WILCCO IPI-Y WITHALL NO' IN7r Issued by: Date L :—
SOURCE REGULATIONS
si.natnmornppheamrcontolaa,� Re-roots
IIA%ARDOD$MATERIALS "'I I.OSURI?
Will the applicant or I'mmro building necup a slow or handle haterduus material 'Type of Root'
as)dined by the Culmninu Municipal CWS,Chapter 9.12,anti the Health and Sal cry
Cute.❑Yen 25532010, .
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment mdevicee which If a roof is installed without first obtaining an inspection. I agree to remove
out Washes air cunl:nnman,n as defined by,he Hay Arca Air Quality Management
rorc, .�-B,� all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have read J f u:roulliak cipliluouroll under Chaurr(.JS.l the
Carr U hl KS ,,C 1 Seen 25505 5511 15534.1 d .nnd,em �y�
'dm FU Id' 1a e I dhc y�
wnupvm of that rcyui mots which muse be tan prior m n.anvnn f a C 'f rn'C of
`,vupan`y 7�/ Signature of pplicant Date
Il—er5t!mh^pitied ;eT—-- ane�J All roof coverings to be Class"B" or better