04070128 I CITY OF CUPERTINO r �' "' r ,
BUILDING DIVISION PERMIT , iag","oR I
BUILDINGADDRESS: KEVIN SULLIVAN ROOFING PERMIT NO 04070128
PERMIT ISSUE DATE
OWNER'S NAME:
V I CKY - SANITARY OL N0.
ONE:
BUILDING PERMIT INFO
OWNERS
BLDG ELECT PLUMB MECH
Le
LICENSED CONTRACTOR'S DECLARATION C tlOn
w I hereby affirm deal am licensed under provisions nr Chapmr 9(commencing
with Suction )of Division3ofthc Business an
Ions Codc,andmyliccnmis
U
�'� area, dU ca — REROOF
Z Licence Classa�Lic.g 'JUL 30 2004
Dam Canuactor
n o-u� ARCHITECTS DECLAR
a 1 undersand my plans shell W used ss public re Ns BUILDING D I
yU
G Licensed Preform...I
OWNER-BUILDER DECLARATION
iMI hereby affirmo that I am exempt from d Commcmr's License Law for the
i p yo following mason.(Section 7031.5,Business and Professions Code:Any city or county
y a y, which acquires a permit In construct,alu r,improve,demtlllsh,or mpaif any slrvamm
prior In ire issuance.alw requires the applicant forsuch pennio to f le axigncd ammmem ValUat 00
I"�< IWthe ulicensed pursuant mthe proved....rthe Coutwo 's Liccnae law(Chapter 9 Sq.Ft. Floor Area
s�$ (commencing with Section 7000)of Division 3 of the Business and PmfessionsCode)or
that he is exempt tMmfrom and the beau far Ne alleged exemption.Any violation of - ma.wn.�.i. _
Section 7031.5 by any applicant for a permit subjects the appbeent to a civil penalty af. 3�y,"Idfuft(ar0 0 Occupancy Type
non more to five hundred data.LOW). r
0 1,as owner of the pmpeny,m my employees with wages as their sole compensation,
will do the work,and the structure is not intended or o@cod far$Me(Scc.7014,Business Required Inspections
and Pmfessioos Code:The Conmdor'a Lim.Law it.MI apply to an owner of q P
preperlywho builds mimpmurs thereon,and whodaessuchwmk himself.,through his
own employees,provided d nsuch improvements tie not intended aroffined for sate.If.
however,the building or improvement is sold within one yew of completion,the tweet
builder will have tic burden of proving that he did not Wild or improve for purpose of
uleJ.
❑1.as no,of the pr-
pen,,am exclusively contracting with licensed contractors to
..,met the project(Sec.70404 Business entl Pnopmams Cade:)The Contractor's Li.
cera law does not apply to an owner of property who Wilds or improves dmmon,end
who contracts for such projects with a commiloo(s)licensed pimento to tic Contractor's
License Law.
0 1 am exempt under Sec. .B&P C for this,coon
11C11,11
ner Data
WORKERS COMPENSATION DECLARATION
rt hereby of man under penalty of perjury one of the following decimations:
I hew end will maintain a Co tiRam or Cement be self-imuse far Wmka'sCompen-
ion,as provided for by Secure 3700 of the Labor Code,for the performance of the
W
for which this f ennu is issued. I
I have and will maintain Worker's Campo...ar n Iuxu rance,are required by Section
00 of the Labor Coda.for lee performance arthe work far which this permit is issued.
y Works a Cc.in aeon Innu.nca came,end Policy num herartier. El olicy No.: �' v' -
CE [FICA 0•EX ON Fltj/M WORKERS'
COMPENSATION IN NCE
(This section need not W completed if the permit a forone hundred dollars($1040
or less)
I anify that in the performance of the work for which this permit is issued,I shell not
employ any peon in any mannerm as in become subject to the workers'Odurna sstion
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation previsions of the L ahur Code.you must
,JZ forthwith comply with such provisions or this permf.h.11 W deemed rev.ked.
ZO CONSTRUCTION LENDING AGENCY
ri, I hereby xlTrm that them is a construction lending agcm for the performance of
(Yi 7 the weak for which this permit is Issued(Sec.3097,Civ.C.)
W Q Lender's Name
z Under's Addmas -
U 1 anify that 1 have mad this application and stem that Na above information u
W F emlect.I agree to comply wit all city and county on inwhas and state laws mining to
p V
building construction,and hereby authorim mpresem,iwe of this city to corer upon the
W above-marooned property for inspection p opmem,
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilitiesjudgmentecons andexicrum which may in anyway same againamcd City
U 7 in consequence of the graining of this permit.
G APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S Date
3
50 CE UL
ztc= Re-roofs
Signet nt.cmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle hwudous material
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health end Safety
AWLC.da,Section 25532(.)?tiAll roofs shall be inspected prior to any roofing material being installed.
❑Yea
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7�qmi
is hazardous air conuminents ss JCOncd by the Bay Ama Air Quality Managemcm all new materials TOT inspection.
strict?
0 Yes No _
Ihavc aceJ thehmanlnusmamrialsacquimments unJcr Chepmr6.95 of the Califnr.
a Health&SufalyCodle,Sceumw 25505,25533 and 25534.1 undcrsmnd thatifthe building l/
na not currently hove a mna.a Nm it n my responsibility to notify the occupant of the
rats es prions issuance of Ccntificam of Occupancy. S gnatur - a
taco All roof coverings to be Class "B"or better