00120122 CITY OF CUPF,RTINO
'BuamNc DIVISIONPERMIT CONTRACTOR INFORMATION:
BUILDINGAQDyYS78 RIDGEWAY DR FOUR SEASONS ROOFING PERMIT"('00120122
owNER•n NAr-M.1-HAN KnLLEN - 643 HORNING ST nrrl.lov'lop tiyl%ut;E3l::0'10
PDO"& SANITARY NO. CON'IROLNU.
(408) 278-0330
C W V ARCH1'IECIIENGINITIR: BUILDING PERMIT INFO
w O 111.DG ELECT PLUMB MECH
FzE LI IUI IJ I-1
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�_ um thatIait unci edunDRSuIiCno,ofCON Job Description
0 G hereby n0inn nitro 1 am IicenneA under prnviunm of Chapter 9(comntecense
aa„�w widrseeaurrnNII.Idlmc ihnt3armega.me.,::ndrrta'a i..r.ac«Ieamen),1hf1 T/OFF INSTALL 1/2 CDX 5PLY AND 40YRS 001
K<S J is In full force nlu�¢' ry
Is,
License Cln, lJ— _5 hies p e7 p
a i U Dale_�
R d� Cmnracwr�
vj 3 u G All'IECT'S UECIARA'I N
�m�,j Iundervxnd my plum shall he nmJ as public reu+Ns
r�
w roa O�O LiccmcJ Rnhsxional
OWNERBUILDLN UECLARAI'10N
`R— I family am...I tem I um ase In from the Crnrmerm's Licunsa Law far the
follex'ing mason.(Suntan 7031.5,business and Professions Code:Any city or county
cwhich requires a perntil m conMmcr,alma ingnrve,demolish or repair any arncturc
nam priano is ismance.alsorequi—lheapplicart fursuch ieriniuo lieu Signed vlaemenl
that le is livened pursuant In the premi.ionx of the Coatmaters License lAw(Chapter 9 Sq. Ft. Floor Area Valua i 0
commcaSir, .In See, 7kXr)of oiviaon 3 ns Thu Poaincue ural Prosvu,ior,Code)
or that be is coarpl henchman and the breis hur the alleged excmpllrn.Any violation
of Section 7031.5 by any applicant for a permit sul the applicant to a civil penalty
ar aal...m.n Ill:Ove hundecd dollars($500). APN Number Occupancy Type
34241009. 00
01,as downeroIIncod the SSornn employmwith wages fe MeirsaleCompensation.
will do Inv work,and the Snucl oro is not cio,', J or offered Law Gu snot(See VMJ,
Badness and erty Who s wild
-ur improve,
caa,there 1Jcv:txe Law J such not apply m m, RR {aired Inspections
r. property rr,build,nr impi,d b,de,,h land ,cn dtex such wink himself
305 — FP.gM
„rvnrroagh his awn ae,everet. Wildin mut,am i+ernrnt�s Sol are nor one year ar 307 — TNSULATION
comple lar sale.IL er,had r,the Wilding e burden
einem n Sold he did one year of
nrpron n.funpomrvhall ) will hove the harden of proving mm he did not build or 601 — ROOF TEAR OFF
improve hr pupnev nsnrde,),
0 1.Its owner(It the pro,wo,,am exclusively contracting with licensed commarom to 602 — ROOF PLYWOOD NATI
,mmrcr the prnjuo(nae.7(94.Bmine,s I d Prmtx.iam Cada)The Cmnm
mcrs 603 — ROOF BATTENS
L,menx idoor not apply m an ouaar of pmpeny who builds or improves t rose. '
and who contract,for Such projects with a eontmcmrn) wenad punuanl es the 604 — ROOF IN—PROGRESS
Caimaemrs Lim nxe I.a'e
01 am exempt under Sec. ,it&VC for this ninon
Owner Dam
WORKER'S COMI'I:NSA'IION DECLARATION
I hereby W'linn ander penalty of perjtvy one ,I h,following Jedarwlon+'.
❑ 1 have and will maintain n Cenificae of 3700 1 Il ue Lahsare for Worker's
Conn r' pm I J 1 1y SYr m7ou s 0 L h C I for he
,crifurnmaccol thavok forviluch this farmil is issued, Z/
011 d ''ll int' Woke,'L np ori a ' - I JbyS 'ion 2 ,
37W I the I M 1 the performancef the A s which M-M I i.5
iswal,MyT�WorAersCon pens:nion Insurance wirier and Policy numMren.
�
Carrier: ICII�pL� policy No.
C17RI PICATION OI:HXEMPTION FROMWORKERS'
COMI'LNSAI'ION INSURANCE
(Thi vection recd not he conrple¢d it he Sol i,for one bondred dollars
(SI00)or 1es%.1
I ccnily thus In the pnrivnnani of the work for which this perant is issued,1
,hail not could,any Mann in any manna sn os e+w,ar le,tfbjctl m Ow Wn kc,,
Compen..tion(AWS ill California.Dale
Applieanr
NOI ICE TO APPLICANT:11.alar making this Cenilcam os Excitation.you Should
weome subject to the Worker'.Compensation provisions al the IAhor Calve,you must
Q O lmh wirh comply with such provisions nn his pcmtit shall be devoted revoked. '
FN CONSTRUM ION TI; DING AGENCY
5 l beery uiin,mut [,are is n amatmer ion landing agency lar the persnrnwnce
ill the work for which this Marson is issued(Sec.Vile.Civ.C.)
0. Q I<rderl Samoa
5 Z I.cndI, Addy...
f.7 0 1 sen lfy that I have read this application and Stam that the aMnc information is
ks t... cancer.I agree ,,comply elm rdl city and enanry ordinaace.[I I ,are law,rd:aing _
Q V us Wilding amamction.aid hereby uumorim expressandve%of this city u,enter alum
} W the abovontenrioaed prol nor insMminn puri,we,.
F G% Oxc)agree n,x"',indenmd'y and keep hrmde”du,Cd,et CUPenino a,lino
fn Iebirtics.judgntems,env,and expenses which ilia),in any%sty accme against Said
C.7 City in consequence of the granting of this permit.
APPI.ICAN'1UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
signatum of Anplicao/Cam nasus Dam Re-roofs
HAL\RDOUS MATERIALS DISCLOSURE
Will dm applicant or future Wilding¢capmt store or handle baeamnus material Type of Roof
as dellncd by the Cull Municipal Cod,,Chapter 9.12.; it he HrAlb mid Sufery
Code.Seedinn 25.5 R(.)?
21 Yes / All roofs shall be inspected prior to any rooting material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit n:tordous air conmmin:mtx If defined by the 11 ey Area Air Quality Management
Dhtrin'1 all new materials for inspection. Applicant understands and will comply with
0 Yee _n'1711 all non-point sou regi tions.
1 have read me hamolou%materials requirement,undo Clutter 6.95 of the
Califnmia Health ds Sudety Code.lection%25505.25533 and 255311 understand that
iflhebuilJing da mlcorwu have amntml,that I I IS rry re, on,di lily ,,not fy the D '
r cuptm of the quirearn hich roust W met prior m/issuance ill'a Cenllicac of
(7ic y' ! Z -1 o� Signature f pplicant Date
Owner ora/I ed agent Date All roof coverings to he Class "B" or better
OFFICE