01080106 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
11091 SANTA TERESA DR EXTERIOR SOLUTIONS 01080106
OWNER'S NAME: APPLICATION SUB DATE
COLEMAN EUGENE M AND FRANCES S 1771 SMITH AVE 08/21/2001
t PHONE: (408) 358-1233 SANITARY NO. CONTROL NO.
O s Z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
K O O BLDG ELECT PLUMB MECH
y Z LICENSED CONTRACTOR'S DECLARATION Job Description
1 hemby arnt thver
a 1 ,licensed under provisions of Chapter 9 he mmaating
hF.y fGwiihScction]W`01ofDiokmn3ofthcBusines.andPmfcssacmCmc.undmylicense REROOF .
is mail form ender ❑e.n� T/O SHAKE, INSTALL 30 LB . FELT,
z m 6 Licen Cha.
Date / ' a4 Cosnme"r 7/16 "OSB & 40 YR. ELK
i 3 c vt-iARCHIIF(-F'SDECLARMON
hg I understand my plans,bull he used as public¢cords
3r_
dp O LI[[Omd Pmfcssional
X. OWNER-BUILDER DECLARATION
1 honey affirm that I.S.exempt from the Contractor's .License law fur the
F Z Y which
ulna a permit
t ]03 ommBusiness and Profusions Cede.Any city or county
-< whirl requires n permit do construct,alms improve,demolish,or repair any
structure
Sp
i3m -prod t eolvs istriondr.uppic,cm( ace pesmitwBleasigMA mmemend..
dcdocrgjmapm,mudhe pr nn Co we lis Lsense lawlCM1apmr9 5q'F[-F7opr'Qrea anon
fmm- enswmserdronaulB3orD.tai 3armeBnpne.aatdl><areaadonacedm t'C!s a k • . ares •l.1C_'T' ; $1151'
or that he is caemprdheiefmm and the basis for the alleged exemleimi Any violation
-of Section]blain v anydireddandforapermit subjttds the apPlicam macivilpenvlry-
afnmmomdhahftvehvndmJJollam(S500). 35A%1619nl36r0 i- : • Occupancy Type
❑I,aownerofthend the s, amyemployeeswidedogesastheirsokcomec.704t. I
-
-will do he work:and Uc ode:T e Contractor not s ld eor mc Lad for motlt,(Sec.]044,'
rBuilds.endertyWhom Code:Theowei License Law does notapply mm 305 - FRAME Required Inspections •' ^" `�
t
owner of propene Who buyers or improves thereon.and who does such work himself
or mraagn his own employer'.provided the,such imrrovemenrs are nm mtenem ar 30 7 — INSULATION
:offered for sale.If,however.rhe Wilding - d is within ane of TEAR
__ ._. .. ._ .. - ._ .. _......_ _ _ ..
reyrdeno` "" 601 - ROOF TEAR OFF "• ' l.' r". "'
icompletion,dM1e owner-builder will have the burden of proving that he did not build or
mprove ver pumosc or sale.)' 602 - ROOF PLYWOOD NAIL
_. _ ..:- --- - - - - -
commucing 603 ROOF BATTENS !
anmmeaw the does
Istt.HaanBadnessandemfwhobC�denThevestheo.a 604 — ROOF IN—PROGRESS "'
License Ido d«s nod apply man owner Lh n her halide wire thereon,
pP Y pmpe Y w proves
.. _and wbo contracts for sn<h Projects widh.a comracdonsl licensed parsaand to the
nLaw.
01am exempt under
,
Sm. - � ' ;li'�PC for anis reason
Owner P ENS FINA L E D
WORKER'S COMPENSATION DECLARATION
I hereby af(o under perelry,of perjury one of the following decearmions:
❑ I have and will maintain'e Cenificatc of Comxcm to self-insure for Worker's OCT 1 5 2001
Compensation. as Provided for by Section 3]00 of the labor C"dc, for dM
performance of the work for which this permit,is iss Tal-,
- ❑I have and will rrCode,n Worker eCompensation a wink f as rtjuiml by Semien BUILDING
- - ]]00 of the Labor Cale,for the performance of the wink for which this pebbly is
I....&My Workers C t pe e d 1 : —
tlumne} dr
if- rw ..U,v.0... oddy Nn (t r 41:
f . d, n
t. CERI CATtION+OoiEXEMPTION FROM.WORKERS'A x
-_.._....__.
s,...,.... .: COMPENSATION INSURANCE;,,,,-
m on`sked her he mmplc¢d i/the Permit is for one hundred dollars I"
15100t or
I mo fY thin mthe pert Tin ac ofah ork to; hch this promit is issued,I ��� •• ..-. •�• .. ,-}l;11^''_v! :.Y 1`J^i•C'_ i� ... , '-""
shall not employ any pc,,(in m any neenners.it,to bacone'subjee,to heWorkers
Cninpenwdion Law,of CalJorhm.Date
Alicant ..
NOTICE TO APPLICANT:It,after making his Cendcme of Eaempdion.you should
become subjecto the Workers Compensation provisions of the Labor Cade,you must
Q O
Rmlwidh mivply widhw_ ch pmvisiona be or this permit shall deemed revoked.
F s� '•�1' " '` 1 CONSTRUCTION LENDING AGENCY
C.> 1 her
of on mad them is a mosmommi bending agency Rothe pedorntSxe
of the work'for xhich anis penult is issued ISec.'J09],Civ.C.j _ ... .. ..._ ... _ . . ..
Lender's Nmnc=P• u,...
Q.Z linter'.AdJmed' '
V�Q I verify that I have mad this.,icvtiun and swm that the above informmion is
0-U tovicevngagme con to comply with all armhor enemy ordinances and bite mos minding
Q_rJ the Wildingconstruction.propand ncm6yvutctiob urposes. fives 6fthis city mcnmr upon
dhc abovementioneo pmpcndem ify and keep
purposes. _ _
I ;1 (s judlicem.cost indemnifyand which
may in the City of Cup ninn".amid
z City inco waluendns,cons and expenses which may in any way xcme against wit
Viz APPLIC nxqucnce of the gmmingD WILL COMPLY
.,.ib.,
'••' dl•RI_IG NDCRSTANDg AND WILL COMPLY WITH ALL NON:POINTo
: so+ R uLAnoN "� � �:� •" r-�, Issued by: Dale
Ar�� �
o.Applica drum .: .: .. }Date. Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
N dl ane afiplirant m future W W ag ctompon,m trade hazed malt" Type of Roof -,_. -_ .. _....•, ...--'_--_ _'_
as defined by the Caliendo.Municipal
�Y Mu ' p l cd Chapter 91nd ItM1 Health d Safety
, It,Cod Section T5Q32WI f j , t {' _ 1 l;'. r. : inns•_• .f,•. •i 7 f'4i:
l ', �•,r .
r ." „ •.;_ ' {; ,-,_• _„All roofs.shall.be inspected prior-to.any roofing material being.installed.-
Will he
nstalled._wume arnica d or r to ndaieg ceecu,umthe ce.Ai t d ..cumin If a roof is installed without first obtaining an`inspec[ion'I'agree tolremove
sit hazardous art containment, .defined by the Bay Arta A Quality Managemcm
oiataa^ . . all_new materials for inspection. Applicant understands and will comply,with _
r oY< Nn' all non-.Elul sourceFegulauoris
t� r
1 ha a rcad�Ne harmd ui mamriel mq 'me.Uonder Ch.pm 695 of the
Culifomin Health'&S t ey Code.Sections 25505.35533 and 8534.1 understand that -
fth bold gd inn ire dl'h veum vin dhoti" ryrc p ilbiloymnotify1he
umupa d art 'mi rtmrndi which mum be recd prior to iauantt of 6 C ri Gc m of
OmoP _- Signature of Applicant _ Date
Owner ornot�end - . D ro /.— All roof coverings to be Class "B" or better
r , t OFFICE