02080015 CITY OF CUPERTINO -- ? "a" 1_ °
BUILDING DIVISION PERMIT 'CONTRACTOR INFORMATION .f
BUILDING ADDRESS: PERMIT NO.
1 10574 STERLING BLVD JNSJ ROOFING INC 02080015
OWNER'S NAME: APPLICATION SUB DATE
MIKE DILIAVIN 299 D BASSETT ST 08/05/2002
PHONE: SANITARY NO. CONTROL NO.
4082796171
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
I—I lar IJ I_..I
LICENSED CONTRACTOR'S DECLARATION
z 5'z Job Description
D Z 4 i Phemhy affirm the I am Iicense0 updcWmviaians of Chapter 9lmmmencinl
5wilhsectinnl 1)orDi "ian3afthedui ndPmf ondmylicense REROOF
n fuLit
g
3 a Dam tom r
e as le Q T�n ✓• Isl Zo sed DE RATI
5 1 undentN tomy plans shall be upuhlic records
p Licensed Professional
OWNER-BUILDERexemptDECLARATION
hereby,(tire on 1 am exempt From the C ssions o License Law for the
following recon,permit
t 7onstr Business and Pmfcuiom Cade:Any tiny or county $3790
D which its requires o permit re construct,alter,improve,demolish. file
repair any mu structure,
prior its�ensed .alsoi requires theapplicantfordin Contractors
Permit m m a Loov(wamem
mmheis licensed Sectio tothe orDiiassof oCatrcein.License LawfCheper) L Or ea Valuation
(commercial;he ing wishSectionthereinto
and the basis o d the alleged
temp Preaion,An vi Coca) 3 7 58�' u ,
of dustheis 31.5 b Iany applicant
and the has:,for the cts the esmant to Any l violation mI
of Section 707n five
ydredam furaPermit subjects the applicant toocivilPenalty p y '7p
or not nmrc mon fire naneina down(3500). 3 O 5 APN�i �I' Occupancy Type
01,as owner of site property,or my employees with wages as their.mle compensation,
will do the work,and me structure is not intended or affected for sale(Sec,7004,
Business and Professions Cock:The Connector',License law Lias not apply to an 601 - ROOF TEAgegirpd Inspections
owner at protest Who builds or improves Merton,and who docs such work himself
or through his own employees.provided that such improvements art not intended or 602 - ROOF PLYWOOD NAIL
offered for sole.If,howawer,the building or improve non is said within one year of
completion,she own r-lemider will have the burden of proving that he did not build or 603 - ROOF BATTENS
improve for pn,,,a,crude.). 604 - ROOF IN-PROGRESS
0I,as owner of the pr speny,am exclusively contracting with linen d enntroctam to
anawn the Project(Sec.7044.Business and Protestants CadeO The Contractor,
Limas law does not apply to on owner of p opery who Wilds or improve,thereon.
am who contracts far such majo s with a comacturt)licensed pueuam in the
Convectors License law.
0 i ant exempt under Si ,B A,P C for this nwson
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby mTrm under Penalty of perjury one of the following declarations:
I
Compensation,1 have and will rrovnial a Certificate of Cons37W o m se Labor toe Work the
amneohe provided fm by Section JIW of the Labor Code, for the
performance of the work for which mit permit is innued.
01 have and will nuinmin Worker's Compensation lneence,as required by Section
37M of the Labor Code,for the performance of the wink for which thin Penni[i,
is,ucd.My Wor ex n i 1nxu xnm tort:r o d oliry a
Carrie I��J�=E Miry Nn �f'
CER FICATION EMPTION FROM WO tl ERS'
COMP SATIONINSURANCE
(This sedan need not be completed if[be permit is for one handed dollen
($1 W)or leu.)
I minify the,in star,perfammme of the wark fur which this permit is issued,l
shall amt employ any person in my manner m an to become subject to the Worsen'
Compemation Laws of Culifnmia.Data
Applicant
NOTICE TO APPLICANII If,ahcr making this Cmitims,of Exemption,you should
hme u
ecnsubject the Wmkcr's Compention provisions of the Labor Code.you most
O O. forthwith comply with such provisions nr this permit shall be domed invoked.
LLFFy"i'i' CONSTRUCIION LENDING AGENCY
ae I herby offrm that them is n constmnion lending agency to the performance
LiI of the work for which this pemsit i,issued(Sec.3097,Ci,C.)
Q Lender's Name S—A
Lender's Address
V G 1 certify that 1 have mallthis application nation that Ne above information i,
W �,S const.I gagree con to comply with all city and county ordinances and one laws relating
W tto he Wildingconstruction,paland heshyomhorissposemmivu of this city mercer upon
e, :6 me abo(We)agioned pmpetry for inspersionp purposes.
(s y r Wjudgme m save,indemnify a ify and keep hi hm ay in an Cityay Cupertino against
aid
[Vy VJ liabilities,in sequence costs and expenses which may in any way Dame ogoinu said
APCitPLICANT4UNDERWPSof the ang as thisAND WILP` IMPLY T ALL N P T
Sou neoT _ °p Issued by: Date
y_K29_.�
" wnurc of pplicom/Cam 11 Data Re-roofs
HAZARDOUS ATERIAIS DISCLOSU
Will the applicant or feu mi
mc,cm arum or hndle haead ut material Type of Roof
as retired by the Cupenina Municipal Code,Chapter 9.12,and the H.1011 and Safety
Code,Section 25532(0)4
°Vex All roofs shall be inspected prior to any roofing material being installed.
Will the applicant ortuuin Wilding am,sam use ocimpmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit".,&as it Conumicut,as Jefiad by the Bay Aro,An Quality hlmegeincot
Dialect? all new materials for inspection. Applicant understands and will comply with
°Yea all non-po nt source re ulations.
1 hove rend the h Y or nus Sections
2 requirements 33 a under Chapter occasional
al the
California building
lth class Safer Code,have
ate ant,that
23537 and 25534.l ity to a l the
if the builAing Jas am curcmly here n¢neon the it in my responsibility or ity a n c t th
acupnn of the require ms which mon bl m riot to nuance of Ceniticme of
° � Signature of Applica t Date
net ar amourned gent LieUmc All roof coverings to be Class "B" or better
OFFICE