01090009a
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`Y
CITYIoFNG
DIVISIONPERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO,
20627 SUNRISE DR
SAN JOSE ROOFING CO
01090009
OWNER'S NAME:
APPLICATION SUB DATE
LAWSON SAMUEL H AND MARILYN
350 SENTER RD
09/04/2001
PHONE:
SANITARY NO, CONTROL NO.
(408)227-4931
zp ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
�
ELECT PLUMB MECH
I IJ I_J IJ
a
i LICENSED CONTRACTOR'S DECLARATION
Job Descri IIOn
O 1 hcrchy u( mm 1 am licenxd under provisions a(Chaprer!,1, ncing
with Salo )of Division3al the Business and Profe"i G,te. and mylironse
RE -ROOF
- is in fu orci nd effect,
u�Lle,k '2`
T/O & INSTALL COMP.
re'_ Contractor �'jr
ARCHITECT'S DECLARATION
I unacrsmnd my plans shall be used as public records
Licensed Pmfasioml
i OWNER BUILDER DECLARATION
1 hcrchy alarm tom I am exempt from the Conn.,.,', License law for the
a following reason. Iseniou 7031.5. Bminess and Professions Cods: Any cit, or county
O which requires permit to c .wet alter. improve demolish o poi y swcwrc
.priori i 4 n ppleum forsuchpi on ride.. d atemem..
__ _ _______ -- ----
'.t'„ S Ft,Floor.Area�• -
a uauon
- that he slce sedpunu.wtotfi pro n softheContractoraLi La (ChapterY
s
(commencing ithSection 7000)of Division 3ofthe Business and prfezosCuJe)
ar that he it exempt lhercUom and the basis for the alleied exemption. Any violation
..q' „tl,,
2 29
-mf Section 7031:5 by any applicant for a Permit subjects the applicant to a civil penalty
A
Occupancy Type
of not more than rive hundred dollars (SSW).
umber
.:.
O 1, as owner of the property, or my employees with wages as their axle cnmpensatinn,
r
wiH do the work: and the structure isnotintended toofered for rale $Sec: 7111,"
' eaanesx oda Prnfen,ims Cade: The Contractor's License Low, discs nm apply to an
307 - INSULAT Mpired Inspections "' ... .
awn r property Who Wild, or mpmves th on 0 Ira d such rk himself
601 - ROOF TEAR OFF.
nrthroughhi ployersprnsdedthat . mr improvements tintended _or
o ewr,
_
. - - -- -- -W -- - - - ----
Impend! If ho the building itemeni is sole withinone year of
6-62 - ROOF PLYWOOD NAIL'' -`
spli then rl un the burden fp proving did otb�ldor
r f p ma f 1)
603 - ROOF BATTENS
of ones pens excluumlyly contracting thlicensed< t-clr.to
cj
604-- ROOF IN -PROGRESS
m project (ti ]Baa B d Profession, Cod ) Th C
them.ms
;,C
terconstruct
e
1 ice a pply t of Property wlta wua. p m can.
and . 'hcontracts-f such projects.wnh a contracmtiq licensed. pursuant. to the.o
7. Contractors License Lep,.
❑lameaerrutnder Sec; .. (il&PC for this main
l,"i'. r•. 4" :';o,
Owner " Date' ..
' ,
WORKER'S COMPENSATION DECLARATION
hereby affirm under, penally of perjury one at the following dcclanuionc
.
❑ 1 have and will'mainmi. a C,mrcdtd of Consent to seff hurt for Worker's
Compensation; ®-provided for by Section 37M of the Labor Cade. for the
performansx of the'work for which this permit miscued
❑ I hove anJ will'timinivin Worker's Comperiation Insurance, as inquired by Section
37M of'1y I rr'Code. for, the performance of the work for which this Permit is
„ ,pa. rW kr Co pe f Insurance carver and PolcYnumberarty„r.
,.
_c
S-� Lam. ..
/ yt a” - _Policy
_ _...
r, 7,
arem No
-'CERTIFICA'I
.
j :. r '
ION OF EXEMPTION FROM,WORKERS't-
x"'
. - . I.,— COMPENSATION INSURANCE • -t . `_ ,
-___ ..._.. . _ ..____ .__ . _ __.
' • tic completed f the serious For one hundred dollars
(TM1 i sect on need oat
t'' •, - I '1
III W)orless) _
I c n fydhm in the srrfo nil c f the o k'f Which p t sued. 1
1. -
one o
m any ma . s as to became mbjar to the workers'
shall not employ any u
fCalid
Jon Lows of CuIlGimly. Dvte
pen.,.
...
Alies..
'NOTICE TO APPLICANT: It, nfbc u,aking lhi, Ceniricmc of Exemprion, you should
`
nanme subi to the workers Compcnimion provisions of the Labor Code, you must
,
fonhwitb comply with such provisions m this permit shall he deemed revoked.
`CONSTRUCTION LENDING AGENCY
1 t
`
1 hereby n(fnn that thele s a consrun on lending agency for me pedommucc
, t
'nf the work for which this permit is issued ISee 3097, Civ. C.)
] - Lenders Name•it .'. _ _
_. .. _._... __
Lender's Address..
-I certify thio I have read This and anile that the above information n
relating
to coon.iandira all city and county Ordinances and Slam laws rdmmg
cityand co
"recd. I agreeng
Wilding hebyaurhoriu representatives of this city to enter upon
Con
d the
abo Purposes.
propcndemot ify
a] the nba(We)agree
to and keep .leis the of vino a, nit
y (We) agree to save. Indemnify and Aa
aCop
way
and expenses which mny loony way acerae vgainst said
O liabilities. 'u runts, costsre
City i saq ace of the granting o his permir.
(Z�by:
AT .ICANr NDERSTANDs'A' 'ILL COMPLY WIT NONPOINIT
-ATIONSI
Issued Y' Date
S - ,1;
�,•
Sfgnatureaf ApprcanVcomraetar: ': '• .. ate'.
HAZARDOUS MATERIALS DISCLOSURE �.
Re -roofs
- - ; '. Will the applicant oen " Wilding pari tars or handl haiallous matcdal
-
Type Of Roo .. ... _: - ..... .. .
- or defined by the Cupertn Mu pal Cod Chapter 9.13, and the N lth and Safcry
s -
Code Section 25532(x1 EF 1
ore! ' -'' ono:,. ;J:'. ` ': :y
„_- All roofs shall be inspected prior to.any_roofing,material being. installed. _
• Will the applica torfut <h ildingoccupantuseequpmem e, ices which
-'
If a roof is installed' without first obtaining an'irispection;'I'agree`to'remove
emir hoz fdo Ciarmo r as iter ed by the B y A A Qul ry Management
Dat r
all new or inspection.,Apphcant understands and will comply with ..
or ❑No, t
all no omI source regulatlo
d the ha 2 dor. m t dal q t ruderChapter6.45 of IS,
Calf a Safety Code Sethi... 25505 25533 nd Z553a I ode turd that
Iflh b ngd note dyh to t rh t t nyrcp a' liryt rfy rhe
i
/C/�/
. .
oix p t IF - q remem b st be n pn to vas f u Certificate of
main u
e , t
Si nature of Applicant Date
Al] roof coverings to be Class "B” or better
Us.
ow a arm dzea.g r a.
., ;..,t ... OFFICE
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