01100022 TY OF
CI
BUILDING my siONPERMIT CONTRACTOR INFORMATION:
BUIIWG ADDRESS: PERMIT NO.
201'62 RODRIGUES AV MARTINEZ ROOFING INC 01100022
OWNER'S NAME: APPLICATION IIB DATF.
YUTRONIC VICENTA 4640 TAMPICO WAY ' 10/032001
• PHONE: SANITARY NO. CONTROL NO.
(408) 269-8901
-Z ARCHITECr/ENGINEER: UILDING PERMIT INFO
�', _ BI. ELECT PLUMB MECH
6 i I_I 1_.J L__I
f 6.a
- = LICENSED CONTRACTOR'S DECLARATION
1 reb frnn that 1 am Fi.maea ander r cna I 9 Teommendn Job Descrip ton _
7 z= rat rwviai.na. vin t, REROOF.
rntu�i with tinn]f)(q).f Divisionlofthc Business and Profcaions odc.and mylicense
sin unnrsa. cff N7i REMOVE SHAKE, INSTALL 50 YR. COMP .
Com .r `
`LLO Ie ARCHITECT'S 2 L ATION
SI undcrsu id my plain shall be uwd as puhlic reco s
7'd p 2 Limnsed Professional
-•'o OWNER-BUILDER DECLARATION
=`y I hereby affirm that I am exempt from the Contractor's License Law for the
following rearm.(Section 7031.5.Business and Professions Cade:Any city or county
ae S o which requires a permit to conswcl,•her,improve,demolish,or repair my strvcmm
imam 'prior to in;ismanou,Jao"areas thepplicant for such permit to File a signed statement -
math,iHi aedparsontuiViesionsuftheContracmrsLma.L•w(Clup¢r9 SFt Floor'Area i Valuation
(coin nt,gwim Section 7000) f Division 3 of the Bupriess and Professions Cade) fj19.; {_��,„ txv< V
or that he rs exempt thekm th
frnand the basis far e alleged eiemption.Any violation 1
of Section 70313 by any uppliconl for e.emdt subjects the.............o civil pcndty
.r not.,ban five hundred dollarsS5W). APN Number j Occupancy Type
❑Las owner of the propery,.r my employees with wages a Nein sole compenation, 309 - FRAME
will do the work,and the structure is not intention or offered for sale(see.7B.w, 307 - I NSULAT IB»juired Inspections'
Business and Pmfessi.ns Came:The Contractor's License Law does not apply to to
m of propcny Nbo builds or improve thereon..rd who does such work himself
601 - ROOF TEAR OFF
or through his own employees.provided Nat such improvements am not intended or - -- _
..(Rind rnr axle.If.however,die wilding.r improvement is sold within one year of 602 - ROOF PLYWOOD NA I L
cumpliumir me ownenbmlder will have the when of proving that he did not build or
improve for purpose ofs•Ie.). 603 - ROOF BATTENS
0I:as owner of Ne property;am exdusi:dycontracting with ticenxed eontraetea to - 604 - ROOF IN-PROGRESS
constmct the project(Sm.71314,Bunions and Professions Codc:)The Contractor's m ..
License Law does nut apply to an owner of property who builds or improves thereon, i
ard.who convects for such projects with a corrosions)licensed l u mind a two
Commemfs License Law.
' ❑Iain exempt under$tt._ ,BAPCfor Nis ma. n �' .. `:I
OwnerDate .
._ WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
FIN
yLp^.
❑ 1 base and will maintain a Cenifimte of Cunsem to self-insure far WoderR A m
Compensation, as provided for by Section 37W of the Labor Code, for Ne N�
performance of the work for which this permit is issued. O 2001
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
the Iawr Code,in he pe'Samance of Nc work for which,his s perm t
Is _My o um sauon s d P.cy number a
ranmearteran BUS� DING
.m«' t 'Pol¢y No.' �/ � r a1 ' Itr l.�aT.Af lj,
IFlC TIO OFE%EMPI'ION FROM WORKERS'(
COMPENSATION INSURANCE` ...... ... .. .... .
(This Rttliun rand nm w svmplced if the .it is for ore hundred dollen
(5100)Or(GSR.)
I citify'that in the performance of the work for which this permit is issued.1 - y,, •'
andl'tmt employ,any person in any manner w n io become subject to the Workers
Compcnsstion L mvx of California.Data -
Applicant - — -NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you most
z 0 fonhwiN comply with such provisions m this permit shmed
ill b,deeravaked. . - 'I
r:In 'CONSTRUCTION LENDING AGENCY'
^' 1 hereby affiiin that there is u constmction lending agency for the performance
of the work for which his permit is iswed(Sec.3097,Civ.C.)
Q - ..._
�- LeMv'a Name
a..z Letdn's Addrim,
V0 1 mnify that 1 have read this application and sure that Ibe above infurmati.n is
Try..Fy correct.1 agree to comply with all city and county ordinances and state laws relating
Ca to wilding construction,and hereby authenze representatives of this city to enter upon
the above-memionM pmpeny for inspection porpo
GI.,t twat agree to save,indemnify and keep harmless the City of Cupertino against
(Zliabilities,judgments,costs and expenses which may in any way accrue against said
[„).y Airy i sequence of the gaming of this permit.
SOP CANT ULA ANDS AND WILL COMPLY WITH A LNON-POINT Issued by:
Date
cna wnfiltea Icamor DOUwildingRIALS commit DISCLOSURE .Date Re-roofs
. to be Iehamaarsmaterial Type of Roof - . _..... - .
onJ .r ✓
HAZARDOUS MATERIALS DISCLOSU
as defnidby,the Cupcmno Municipal Code.Cwpter 9.12,and the Health and Safety \ _s a .. .. ,, y. �;, : --
C�dYes'255321.17- Otho t. l.•_i<' s l j '• f: "..r�..�t•,r��k "i .
All roofs shall be.inspected.prior to,any roofing material being installed.. .
WiiOtheap.liemt.rratorew0afog«mp.nt.m egai.ment.r devfo«wNph If a roof is installed-without first obtaining an inspection;Ilagree to remove
emit hawrd.us an contaminants as defined by Ne Bay Area Air Quality Management
Districn all new materials for inspection..Applicant understands and will comply with
Ye:
ON. 11 no oin[source regulati s.---'
f
I hive read Nc Safety
Code,muens 25505.25533
550under Chapter 6.95 0(N<
d'omie Health&Safcry Calc,Sections 25505,2553]and 25534.1 undersand that
i rebuilding dins mol curma which..trots, e, ii is my responsibility to notify the Y/
Ominim ,usuremsahich must w inn pnono issuance of a Cenific re of _ --
m pin ati _ Date
raathn easent Date - All roof coverings to be Class."B"or better
I . - OFFICE . .