00080042 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
[WILDING ADDRPSS: ITRXIH NO,
GWNER'SA ( STENE)HAIZ LA COSMOS ROOFING n AITLICA'I' 'fi•
IONS: 450 SAN ANTONIO RD
�EE SANITAR Poe ,N(i.
440
Mai ARCH[TECIIIiNCINIiIiH: 493-6273 RUILDING PFRIM'IINFO
lu O O_ 19.DG IiLECI' PLUMB MACH
NL�I
uNI.ICENSFDCON'IRACIOR S DFCLARATION Job Description
I heathy.Rimm mw
limit[leaned under,ors our..of Chapel'9 ootion ing
=� wiln Seclion]gglol nirisinnJoohe Bu>inec,and i'rf=vision.Calc..od my he...c
ais in full font and Q
y1
z�6a Liccnw Clu, _ ✓� Lic.M_ _
o nate_/,,�9_ .6_q_ cnnnnelnr_ —_—_ — RE—ROOF
3 a v ARC]II'11:CrS DECIARA'rIUN
ih O 5 I nndenand my plans shall woad.s public records
au eO
a Licen.W as 1p
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ac pC (O/
OWNER-IIDILIER DECLARATION
1 M1crtbY mRnn that 11. comet from me Cession, r',License Law cin the
F2< followingureas ices a[Stenon 7031.3, t,ainn.and Ihnfe,sinn,Cole Anycity or county �`•.i
—F C wh eM1 y permit t construct, her,' 1 I .liah reform,'Irvuurc
C poem t' .. 'len y 'Ili ppliCa 111. II -pill II 'y d:Wlc ncnl
dam
that be licensed E .a: t to for provi,ions of theCnt ion's Licedc,Use chaptcr9 Sy. Ft. Floor Area altcyIn
(enmmencing with Section 70fif of Disision 1 of the Hu,mns and profession.Cale) O
or that he i..saner therefrom action ba,is for the alleged exemption.Any violation
of Sind 1911115 by any npplicert far a In'Inu Subic[,the appGaant In a civil Pen:dry
of not marc than Eve hundred doll,.tssan. - APN Number Occ T pe
[11,as owner of the propji or my employees with wages.,their wile rompcnvtion.
will do the work,and the l ulliou is nut Intended or offmcd for nine(Sec.]1141 t.
unpin...and Prom"initx Code',The Conuvaora I.icemn L.w does not apply In an `a • eClalred IIISPCCtl ons
r cf p,,,,"y Who build,fir improves thereon,and who don such work himself
o ihmu,h his own employees......ded that such imp romnt
vee .am not intended or
m .:dH
end fore. ,Is 0",,the bidding or improvement is sold within one year of 305 — FRAME
iliinleooll,lireoiitdcr wd Ilove fire harden A Pooling thrll lie did not htdld or 307 — INSULRTION
improve for F."ve of pu1cJ.
OLas owner of the pro,si act exclusively contracting with licensed contractor,to 601 — ROOF TEAR OFF _
nxmle the project(S.e.](14.Ilo.in.ss oral Paden.a u Codc.)The Contractor's
`License Law duce it(),apply to an owner ofpo,p=rty whoihi or hnprovc. mrsor. 602 — ROOF PLYWOOD NAIL
and who contracts for such projects with a coutmaorlpl licenn.•d pursuant to the
ContmwLgr
G lam exempt miler sec. B xr p C for this mason 604 — ROOF IN—PROGRESS
Uwncr Date
W'ORKER'S COMI'IiNSA'I'ION OIiCLARATION
I Lanny afGrn o.de penalty of perjury o re of the following declarations:
7 1 M1ave rand will nwintain a Ce"ificam of Consort to self-insure for Worker's
CnI pa-aI inn, ms provided for by Section 37M of the Labor Cale. for the
"'Imuran.9f @c work mr wIiich this permit i.Isvmd.
1 M1me and will our main Worker's Conipenra
aation Imun.e,a.squired by Section
3700 of the Luba Cale,for the performance of the work for which this permit is
ioued.Sly Worker',C en�pensunouJfI mance unnicc,anndd policy�n ndi ore:
Carrier: �""'1_iNn.:✓/ ,/_!—I12�
CERTIFICAI ION OF EXEMPTION FROM WORKIiRS'
COMPENSATION LNSURANCE
P 116,anion need nut he complcaA it the permit ip to one hundred dollars t
151 W)fir lass.)
I certify that in the performance of the work for which this permit is issued.I
Jwll art employ Iury pa any r r m.o In heroic.object m he Worsen'
nnnpensmine I.Itw,or Culitomiu.Dae ice
Applicant
NOTICH*10 APPLICANT:If,aper making this Cenifca¢of Exemption,you should
Isi+ubjc,,It the Worker's Cm..co,ation provisimd nl the Laxer Cotte.You ma,,
Q O forthwith comply with wet envision.or this permit shall ba decors revoked.
F J1 CONSTRUCTION LFNIIING AGENCY
I hereby aflinn that there is it construction lending agency for the performance
of the work he which tits permit i,Issued(S,,.3097,Civ.C.)
6. Q Lender's Name
7 Z I,endm i Address
U 0n 1 c"I,ty that I hove rtud thio application and state her the above information i.
V. correct.1.gree to co up y with ill city and.away ordimmces Ind pate 11,11 minting
Q U to wdd' g construction.andhe by th p m tae..of 1 . 't it,enter u,qu
'he Otha,criewenfirrosed propect,koms,jection vamp.. Qf
fr„s a
(We) g t I dPo Jkeep 1, .. the Cty fC pen i.gains
Zi Cityi jud TY any 'Y 'E in4 smiJ
C„) Z City in comeyuence of the gaming of this permit
APPLICANTUN ' ,NDS AND 'LL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCEREG A ONS— a
signutun of Applica2
nl/C nrac,or Dat= Re-roofs
I IATARDOUS MATERIALS DISCLOSURE
Will the applicant or future wilding occupant source or haalla Inscriptions materia Type of Roof
ns[.tined by the Copemmil Milliieipml Cod=.Chapter 9.12,and the H.Ith and Safety
Cuda Section 2553200!
O Ye, Pte' All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or l care holding occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
[nil h'.rnndaus air eonamimmil,as ddinal by the Hry Arca Air Q,rhty Management
D"micl^ all new materials for inspection. Applicant understands and will comply with
Cl Yes all non-point source regulations.
• I have read the haemunus mmcriak reyuircnmm.under Chapter 6.95 of the
C.hfomia With a Safny Cods.Smtion.25505,25533 and 25594.I and v,land
if the building Jncs nm cunenlly nave amnmnt,that it is my rcsrynuibilib u.notify the
«cuPam
fm myui I which mea be met prior to issuance of o Cenifam of ((( (((
Signature of Ap licant Date
All roof coverings to be Class`•B" or better
Ox net or authaireJ gem I m