01100020 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20212 RODRIGUES AV MARTINEZ ROOFING INC 01100020
OWNER'S NAME: APPLICATION SUB DATE
TSU REX K AND TERESA C 4640 TAMPICO WAY 10/03/2001
PHONE: (408) 269-8901 SANITARY NO. CONTROL NO.
;%Z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
O BLDG ELECT PLUMB MUCH
.8 z- LICENSED CONTRACTOR'S DECLARATfONJob Description
'„_5
IM1crebY aKrm mat l am licrnscd under provisiow of CM1aprer 9 kommencing
x; REROOF.
is 4 fail,room oil tt+ 7 �rZ REMOVE SHAKE, INSTALL 50 YR. COMP.
izw< L' Lica
ate Cn "'forz+”-
RATIO
ARCHITECT'S DECLAN
�g 1 undcrsmnd my plans shall la meJ m puMlc reu,Ns
I O C Licensed Prnfosi°am
OWNER-BUILDER DECLARATION
w I hereby affirm that 1 am ucmpt from the Comructor i Licert law for the
I-z Q following mawn.(Smion 703 L3.Buli lla,and Pmfc..iom Code:Any city or county
Y�C is hich requires a permit to construct,alter,improve.demolish,m repair any moisture
n 3'el n -pror m its isssuance_W.m requires the applkam for such pumiuo file a signed mnemem• - -- -- —
mallteisEn.caRuR°�tmdevro•,swmnrmec°mraeto:suan�eWwfcnamer9 S FCFloorArea;r, . Tjr,,, auation
Icommeoming with Sectiun,7000)of Division 3 of the Bu3 cess mal Professions Code) S} j2 9'. i ,
or that he is exempt therefrom-and the basis for the alleged uemoiori.Any violation
-of Seemin 70314 by any applicant fora permit subjems Ne applicant m a civil petwlry
'ofno,mmethanriisehandleddollars(S5IX0. A um er '_T•.'+a.r' Occupancy Type
01,as owner of the progeny,or my employees with wages as their sok compensation, 3 05 - FRAME
will do the'wurk,and the shunure is not intended or offered for'sale'scc:71W4; t __lt„
'Business and Profe son.Code:The Contractor's License Law eros not apply m an 307 — INSULATTIMired Inspections
owncr of pmpeny Who builds or irepruvcs thereon.and ss'h°does such work himself
°r thr°y h his own employees.Pmmded that such improvements are not intended or 6 O l — ROOF TEAR OFF
offered for mile.If.howemr,the Wilma t is sola within one f ---- - -'-------
Wilding hmproof pro rqa° 602 — ROOF PLYWOOD NAIli'r'"'' "' -
�ohrpiniov,the ose cif under will have the WNen of proving that M1c did not Wild or
mprone for proposecif sak.l. 603 -_ ROOF BATTENS I
- - t � - - ' -. - - -
❑rim Deme:la jec progemy,or.e.nusiveydPrllmsinilntisanese Contractor to 604 - ROOF -IN-' R=
License the does
(Sm.7044.ownons.er
andiony who
Code:)The Ces toor ,or,
T oil.. ca ones not apply man mis.of propcny who W lids or improve n, ..,e
and who slice s for such protects with.a.contmctm1a11iamN Wrsuam mane. .-
Cnmmernman License ., ,,.,OC•T..,:],, 7.:2001 -
❑Ivmexemptund�Sec.� ` - 's .e&PCforms,mason t) .
0�nrll at.
WORKER'S COMPENSATION DECLARATION BUILDING
1 herehy affirm under penally of perjury one of the following dalarmi°ns:
E) I have and will maintain a Canifcam'of Consent to self-insure for Workers
Compensation, as provided for bySection 37M of me labor core, for the
_ psommu se of the work for which this peomit is usucd..
01 have and will maintain Wooer's Comp mm ionlniumraa.as m luim i by Section
_ - J7 f the WWr Coste,for the performance of me wall,for which this permit o
is
e/ M W rk YsC pe�m�l/'Insurance nand
7 Policy /'ben urea: -
une�r/i'"' 'PolicyN J0:ro� N0/Yj/ _f.... f•. `hs t1" t '{i,^..,.._. . ..._. %•a u,l ',li._.. -
's� ......_...�... .. .. ..._.
i ERTIflCAT10N OF EXEMPTION FROM WORKERS, i- -'t p �. . t
- COMPENSATION INSURANCE t -----_--------
dentition
_ ._....__.. . .
+ TIT s secunnnecd na he rontplM d if the permit is for one hundred dollars '
($104nrlessJ -
flnotempltharypereeeinary'm rierso subject
te WmrM' j} :,pti:••i l`I•pP:f l'it�il"° N' 3Y'
shall vet anon Law
wv f aliform.:
it any manner so as io'become subject to the Workeri
ComApppensation irm Wws of California.Dale'
NOTICE TO APPLICANT:If,after making this Cerrism,of Exemption.you should
nate.subject the Workefs Compensation provisions of the Tabor Coce,you mum
O O forthwith comply with such provisions or this permit shall be dimmed revoked,
^ Vi F' q_ i' 'CONSTRUCTION LENDING AGENCY
I hem
by B Ih I the v ns ct ou 1 ading Lgemy f th perfodrearace T ''
of the k f which thispc t ,, ,sued IS 7097 CGr6iv.C 7
fslr , ....
Udder',
N m
Q'Z Wnier Address... .. Oil LIli
V � 1 mnify that I have read this application and mate that the above information is
CireF correct.1'agree m comply with all city and coun,,,ordinances ordinate lows riming
QJT, to Wilding construction.and nimbi authorize repreunmtives ofthis city to enter upon
the aWve-mentioned property for impection purposes.,_, . . .
I Will 6grm ib save:indemnify and keep harmless mi Ciry'of Cupcnino against
U.y liabilities,judgments.costs and eapenses which may in any way accrue against said
'Z Ci conriquencg
e of the' mno
ting of this pen°) ?
TTH NONPOINi ly/
PLICANTGUDERST SNDS AND WILL COMPLYN ALL Issued by: Date
, /
Si- DPA HA].ARDOUS'MATERLS DISCLOSURE
Contractor T'
Re-roofs
a'Iih pphcu t r m W IA1LIng pail'r ern dl n'ani 6 maenad Type of Roof,-
as
dr, dby.the Cupcn on tpal CtNe Chapter 912.and the Health and Safe,,
's
Code.Scmivn 255320.. I i ,+f,l STA' P' i<i';ia
Duel" ': �dNp;. , ,IN:., :. `,sat t All roofs shall.be.inspected.prior to.any-roofing.material being.installed..._.
wu heapphcamorfuture Wilding«cuparo
ntomegamentorpevm.•awlnch If a roof is installed'without first obtaining an inspection;') agree'tom
'reove
emit I.W2,I ssmecmaminanlsas defined by the Be,Area Air Quality Mavgcment
niatdee. all new materials for inspection..Applicant understands and will comply with.
7Yea Q" all non- Dint source re Mations,:,
I
in ,.nI,,
P g `..;:.U.-,cs
teasen' 'the hazvdous'nm¢rials'requiremcms under Chapter 6.95 ofthea Hcaih&Safety Code.Sections 25505.25533 and 25533:I undemutd metlding does mol curtcndy husevmnant.mat niq my msponsibili,,mnoof th rectmo on which mum he I p or to is. a a of a Cendi ofy re of pplica Date
w r a s I G/ All roof coverings to be Class"B" or betterre I
"
OFFICE ..