01090015 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20032/42 RODRIGUES AVE PRO ROOFING 01090015
OWNER'S NAME: APPLICATION SUB DATE
O' KEEFE DANIEL P AND DORIS C 100 BLOSSOM WAY 09/05/2001
PHONE: (831) 440-9100 SANITARY NO. CONTROL NO.
o z z ARCHITECT/ENGINEER BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
¢6
z LICENSED CONTRACT OR'S DECLARATION Job Desc pt _
_o A,,amro mat I mo li,cn.m order pro,rsfor,of chancr 9 rcnm,ne..cmg REROOF.
w tl,'•aion]OWlnf Uivision3 ofthc Busincsc unJPrnfessinmC Je.and n,ylicenne
bel force ami fe
�'n n�-r� uc.a9C� 3� INSTALL 25 YR. COMP. JUN gI, S ZOO2
o a-O a me s � Cut, nor
3 w in ARCHITECT'S DECLARATION
.w 0¢ I midenaod o f
y p:ann.,nrdl be..nw an paroro records BUILDING
i d o z Licensed Professional
•L O\vN'ER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contmctor'.s License Law for the
h?< following reason:(Senion]0315.Business and Pmfesslonn Coce:Any city or county
<'—D wmrhi°tz rrsa"mn,tocnncntitt.ala,in1lix anon tomcod,a.,...come
yu peas move, vaso rs nr rc y.
i 3 c prior quires pv man peri signed statement - - - -- - n -
- femndisranwithSerrimmtnbofDimnanrtneecBusinessadr<wwtnsCor9 „ - .Sq.,FLFloor-Area r�.i . - , 'I aluation..
(eohil,he ngwith Sati,firmb )of Division thehilinessrnd YmfAd,vi Cade) _ -- .
or tom he is 31.5 b rna aPiponond the basis for the subjects
thel ertmpnt to Any violation
of Section]031_5 by any
homd"dicant fora petit subjcns theapplicam m a civil penalty'
•nrcut mnremanr.en..ndreamoImrstssWl. A N um er • � Occupancy Type
O 1,as owner of the propcny,or my employees with rages as their sole compensation.
will do the-worm and me gm....a is cost amended or offered for sale(Sea.7041.
Business and Prnre..ions Cede:The Cnnnaetnr:,Licensew aMa not apply to an 50 GAS TES Hired Inspections
nw c r p I ty Whobuilds pro. thereon, d was J n work himself
n.ri gho rxmem'I i provided mt eproven , tintended,.,if 507 - F LUMBING
offered fn I.if,herthbuilding 'improvement i id within on year of _ . .... F. _ ..
completion,the ownerhailder will not, he bunden of proving that he did not build or
mprove for pu.puve of sale).
❑I,as owner of dye pmpcny,am Businesseven,ocl,a d Professions
with licensed eommci co 's
mens et theaw pojm(Sec. oc. Business and ny who
Cruid,m The Contm neon.
cost
who
Law docs not apply man owner with
a contiy who halide se improves thereon,
aM rano contracts for wen Projects cairn a ormrstogs)licensed pursuant to the
_ ❑Tom exempt under Sec. ' ,H&YCfm this mason' •- •
Owner - " Dare - -
WORKER'S COMPENSATION DECLARATION
1 hereby affirm order penalty cf perjury one of the following declarations:
❑ 1 Imve and will maintain a Cen Berle of Consent in selbinwre fur Worker',
V3.7Mof
, as p.,idcd for by Section 37W of the Labor Code, for the
_ of dre wok for which this permit is issued.,
on
_ will maintain wmk,,s Cumreivalion hmi arec,as iequined by Section
..
Latin Code,for the perroim a of the work for which this permit is
rrzkcr's Compcnsntion lndurancc canter and Pnlicynumne.arc:/ polcy No: I�9G''.3CERTIFICATION ZI EXEMPTION FR M WORKERS;.': COMPENSATION.INSURANCE'•.. .__. . . ..._..--...- . _...-.. _. ...._. .._..._. _..___�..... .............._.._._ .. ..._..._......__._.__
(To,seen'on need not tic completed 11 the permit is for one hundred dollars " `a • 'r a h - `
(Sind).1 less.)
I cemployhan in the perfunn,ma c the as i for which his object
rithe issued,I .i P p '•p.;;
shall not employ any person in any manner so as to became mbjen to the Workers
Compensation Laws of California,Data
icrn
NOTICE TO APPLICANT:the Work IL CricPc king..ti this Certificatestiof Labor io d you should'
Q OInchme Su oinp to the such pr Coons or ti is Permit provisions til rhe IoM.Calc,you must
fdnhwith comply with such pro visions or this peril shall be deemed revoked. -
. CONSTRUCTION LENDING AGENCY'
a > I heretiy hlBnn thatthere is a constructor,lending agency for the peifonnance .
of the work for which tnik .it is issued(Scc.3097.Civ.C.)
P.-Q Lenders Name - -
_ .Z 1<Mcfs Address '
V 1 cenl(y 0m I hove read IN,application and nam that he shove infnrudon is
W F' .cones[1 agree m comply xith nIf city and county end.nunros and state laws reading
t) to buildingO ..inion,and hereby authorize representatives ofthii city oemef upon
pj ,the above-mentioned
roe to save.prvoep.indemnify
ndemi,fy and i keep
pmhpaous. h
City OCupertino against
Woipl%,Lindgmencosts ad xrewhish may in any way accrve again,.said
A , Ucthe o,cf1i
, AN NDERSTN;SANDWILLCOjLY WITH ALL NON-POINT
Issued by: Date/ J
- Si awreufA,pInzmmCommc,t,r ... Dale Re-roofs
HAZARDOUS MATERIALS DISCLOSURE' '
' Wih,w,,af,liksm or ft building on,cupanizonce or handleo -nd mmedal. TypeofRoof . .. _. .. _ .. .. _
.ns defined by the Cupanlno Mun dial Cade Ch purr 9.12,and the Health and Safety
Code,Section 25532(.)'.. r
'OYcs . 0No,' z1s
, �'^ . . . ..All.roofs shall be inspected.prior.to any roofing material being.installed.
lPapplicant
_. .._.
ll to pplica t o r t e buildig ptam useeq ip de cps Mch If a roof is installed'without first obtaining an inspection, I agree to remove
Ir 'c ream ,. ,derndby the Bay A.A Q ldyy Managebot derstands and will comply with
n t,n at ,. all new materials for inspection. Applicant un
e OY ElNo - •all non- in[ ource regulations'. -
`"� I ave .it the hazmdnus but
r.1,requircm tic,under Chapter 695 of the
Cold.. Healtn&Srely c.Sections 25505.25533 and 25534.1 understand that cto
F dice Jdingdrcsnotcuncn,lyhavcamnam mthis my rchpnnsinility nr notify the e ` of
awcdp ill of me regal mcni which must o I'do,to issuance of a Cenircale of
°cc "" Si nature of Applicant Date
Owner or moons agent „- Date All roof coverings to be Class "B"or better,
.OFFICE .. . . .