00060126 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HIIILUING ADDRESS: PHItMI'INO.
-10027 SCENIC BLVD JNSJ ROOFING INC 00060126
OWlh;R'S NAME: APPLICATION SUR DATE
HEAFNER ROBERT L AND SYLV A W 299 D BASSETT ST 06/19/2000
Ig)NE: SANI'I'AItYNO. CON]ROIL NO,
4082796171
ppp
-,,-5 ANCHI"fECpENGINIi13Ro BUILDING PERMIT IsmBLDG ELECT' PLUMB MECH
w
ay
H= LICENSED CONTsedundrp DECLARATION RAl4)N Job DCSCrlpt1011
- _ 1 hereby affirm the,1 am lacers,"under Prod Pm a it Chapter 9(commencing
��t,w with Section 700(h)of DivisinnJof the Bmincs and Profa•„inn<Code.and my license
— isiafhnrmcmulcae'h RE—ROOF
e4 -
Y 6 Lie. ,e Ela, Lie.q
Date Cmllrimm
5 a vii dRChall be use UECLARA I'IoN
f LLu O; 1 undcrsmnJ my plans be u>cA as public rce,N,
ne 6 = Licensed Professional
apo
OWNER-I)UILDIiN DECLARATION C TION
=m I ne,lo a(Sen mat I tun cBusin I'mm Zhu C ma,Professions
n's :Any
Law Ibr the
C% following rereon. eeninn 711.115,Business and I'mdu%slut,(],dc:Any many stoutere r
2O wM1ico rcgniresae.alsoem,lncon.aheapplicnt for such per iitt are rep
air
gnedany
sonccmrc -
6pat he isS issuance.pursuant
in therexims the room,o for Con permit License L w(shmemem
(commehee.ud pSeumnmme Pmesionson of the Business
Law(ChapterCor9 Sq. Ft. Floor Area Valuation
or that
with,theten..... 1)ofDivision J of Ilii Business mp ion.An, i Code)
o,mat ha is exempt,he,ehmn and me basis fm me alleged exemption.Aly yilordly $5000
of So,,!.... lain five
wryuprd dollfor alutnit wthlcns the hmPlicmn..aciJil penult'
Brno,mmmoienuanfiylnantbeJamm,%1s5(x1y APN Number Occupancy Type
01,aS nwne,of the pmper,or my cmph,i cs with wage.,as their vole cou'rosatlon. 3971219055
will do the work.and,he,Imemre,is not intended or offered for sale(Sec 701
Husince,and Profession Codc:The Contractor s License Law does not apply to an _ Required Inspections
r it popery Who hoi Lis or inhP,aves thereon,me who docs Such work himself
o�nnough his own em,plorccs.provided her such m,prnvcmcros are not amended or 305 — FRAME
offered for sale IL however,the building or improvement is wild within Inc year of
unipinine,the owner-hullder will have he hand,.of proving that he did not hand it, 307 — INSULATION
"rpari
fsul" 601 — ROOF TEAR OFF
❑La,own„of me prolms'rty,in,escwsivel.co.lac.ins w int licensed,o"ttnctor.m 602 — ROOF PLYWOOD NAIL
L,neunet the P,,,j,,f(See.7(44.Broin,,and Profcxionx Cala:)no Comranor's
.,cnsu Law docs Bol apply to un owner of popery won builds or Improves themon,
and who contmch for such projects with a contracrons)licensed pursuant to the 60 3 r —
ROOF BATTENS
Coatelcor
01 am exempt under Sec. .H&P C for this reason
Owner Dme
WORKIER'S COMPISNSATION DECLARATION /
1 hereby affirm under Penalty of N jury one of the following dedurmions.
s I have and will maintain a Certificate of Consent to,elf-Insure for Worker's 6/
compenvaliim, as provided for by Section 3700 of the Cefna Code. lot the ^v
md;....a v of the work for which,hi,permit Is iounL s O
❑1 have and will nmintain Wicker's Comlcnahlon Insurance,as required by Section -
370d,at the Labor Core,fir the pnronnaace of the work for which this permit is
issued.My Worker's Compensation Inwm.Set�carrier and Policy number arc:
c;irie:�7lontcNnMvll"d° ''NIL: Nw 117US6
CERI'IFICA'I'ION OF ENI71011I'ION IBOM WORKERS'
CONPENSAIION INSURANCE
1'phis section need not he completed if the permit is or one hundred dollars
isIbut nr lett.)
I cerlly that in the PO,fomi;mcu of tic work for which this Penni,is I...Od.1
,hull nil"a"I"y any person in mry numnct nn n m I auhject to Ili,Worker"
Compen.wlion le Cplilnmiu. e 4 11c _
'Appati
NO'1'ICon A', N-11 IL uflar making,Imis cnificvte ofExnnpuon,you,haul)
become subject to he Workers Compensation p...kinn,of the Labor Cud,,you mus,
OO forthwithconmply waw inch Provisions or this permit shut I he dcemN.ocmced.
t� CONS'I RUCTION 1.1 EN DING AGENCY
I hemby ofifnat that there is a cun>tmction lead ng ngeney far the"Ifo mOnce
of the work for which this permit is issued(Sec.3097.Civ.C.)
Q Isnder'%Name
5 z Lender's Address
V O 1211111'that I havc,ead this apphcmion and suite that the above iullnnmation 1,
t++ P cormva 1 risme to ennply with Ill city and unatty ordinances and stale laws relating
Q V ,o building consauc,ion.and hereby amhmim reprexmahises of this city m,enter upon'
,he%Mom-num lo.ed Pullmor imilli o'PurPo,nx
tt}„ y (We)agree us save,indemnify and trim,hornless the City of Caper in,finunr
rn Iimbi litre%,judgments,costs and cO,emves which may in any way accrue ageing said ,
U z City in coilecyaena of rime gramir,ofmi,Pclau.
APPLICANT UNDERST DSAN W COMPLY WITH ALL NON-PAINT kwo:z
1n
SOUR�ILEGULATIO fk `'IG Ij 00 Issued by: Date
Signamrc of Apphcam/Comr¢tom Dale Re-DOONS
HA9SRDOUS MATERIALS DISCLOSURE
Wit She applicant nr rutem buildingociaPam scare nr handle hrnomm,material Type of Roof
as ddned by the Cr,nlnn Manieipal Cale,Chapter 9.12,mud the Health trod Safety
Cn It,Salon 2553200"
G Yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future lahilmngoerprintusecquipmentorde,'im%w'hich If a roof is installed without first obtaining an inspection, I agree to remove
mit hreandnu,air moratorium,as defined by me Bay Arca Air Quality Managenen,
',,,torr I all new materials for inspection. Applicant understands and will comply with
0Y, �ti` all non-point source regulations.
I have read the ha...di materials rc'mmaunu under Chapter 6.95 of the
California Health&Safety Code.SLirion,25505.25533 and 25534.1 understand that
if the building does not currently have a mount,that it i,Dry'oc,,ar vibdity to notify me
muslin,of the rfl which nand he me,prior to issuance of a Certificate of
o„"rian,y Signature of Applicant � Date
�'gWO All roof coverings to be Class "B" or better
Owner or suthotbed agenr )ate re
OFFICE