01050062CITY OF CUPERTINO
CONTRACTOR INFORMATION:
nmLmlNc DIVISION PERMIT
BUILDINCAD[Za931 Lip AV
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SANITARY NO. CONTROLNO,
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BUILDING PERMITINFO
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ar n,...700mrmtnmin3olheeJnnderpn,vi.inn.nlL7,CoLI amrmeming
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REROOF WOd�n l F'�iALT.
1
.rei whb falian)(IBlll of Did. 3nl Inc i3usinep and Pedes„ioncCee. and my licen„e
"n full b+se and arc Qg
c las. 3/ Los .
u Licen'-4L
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I undcrmmrJ if, plain shall Is, used us public record..
OLepammd Prore'domal
OWNER BUILDER DECLARATION
I hereby dlirnt ,h;+t I :1111 exempt from the Cotmanr's Licennc I.e. for the
following learn. (Salton 9031.5, Bmincss and 1'mfe..tam C+xl,: Airy city err sroumy
o which requires a factor n) comimc,, dins, improve, demolish, or repair any saamure
prio to its issuance, also squires the applicant far such fecanino file a signed statement
— Lone 9
Valu i
,hat he is licensed pumaam to the povi.ion. of Canaannes lJoeme (Chapter
Sq. Ft. Floor Area
(commencing wnh Section 90110) of Divivion 3 of the Busimesa:md Pmfessinnn Cale)
nr,lout he is exempt thcrefrunl and the husis lire the allege ,cii E. Any violation
of Section 7031.5 by any applicant I'm a permit subjects the upplicunt n+a civil penalty
APN.iY011p8002.00
Occupancy Type
,if natitcthan live handieddtdmm(S50n),
❑ 1, as owner of the prapery, of my Employer with wages as their sole compenvtion,
05 — FRAMFuired Inspections
will do the work, tint the smsole i, tie, intended nr summit for salt, (Staro”.
iia. and Prof 'n v Cajr:'ILe Car,ralnrx Licmna Law titles not apply n+u
;,+r O+ it+n n
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Ownerand who
r f
road
307 — INSl.11_ATTON
cansarmnwincebimslr
that mer vementmn Or
hisOwWhobuildsnrividedtatsuch
his awn arc not incone
that within nuc year of
howevercrupopt ended sol
fo whe.whoweverthel
601 — ROOF TEAR OFF
havetorhmpmvcmentis
nmplerion, the awnerbuilJer will have the M1uNcn of proving that he did not Wild or
completion,
..tpmve for pEgmm„r
602 — ROOF PLYWOOD NATL
❑1.;is owner nfthe prtlpLant mclu.welycontracting wimlicensed coca memmm
6002 ROOF BATTENS -
consumer the pmjal (Sec. OWA. Business and Professions Codi The Contractor
License Law does not apply to an Owner n(pmpery, who Wild, or improves themom
604' — ROOF TN—PROGRESS
and who contracts for such projects with it commercials) licensed pursuant In the
Co braaturs Liccnw Imw.
❑ 1 Lou awn,p, antler Seo , if k Is C for ,hie reason
Owner Date
WORKER'S COMI'ENSA'f10ls DIiCLARATION
I larch, affirm a aide, proa i, al'p✓jury ane of the fi+llowing dedum,inm:
fir Workers
FI NALED
I have and will n ainuin a Cerificsm of Consent to sclGinsum
Gmpenntinn, as provided rot by Sectio, 39w of the Lader, Cod, for the
performance of the work fur ahicn this permit is issue.
MAY 15 2001
1 have and will midmain Wodcl',, Contpcmation Iasi as rcquircrl by Section
3700 of the Lm or Coda for the he ltarranco EI'the work or which ,his Lot is
i... puf My work Cu cion I...m�ace 'mnr POLICY,mmhe, am:
0/
Currier �
fII+ICA
BUILDING
CIiHVi
N Op E%BMPf]ONr(
COMPENSATION INSURANCE
(This,,eation need not h..... quod i1'the permit is for nuc handled dollars
($ 100) or less.)
I ccriry that in ,ht, perfnmlarace of the work fr owhich do% peri l i. Iwotl. I
shall nal Employ any pc mon In tiny manor ,,,, u,, , re, cam.a npb r,r ,, the WErkmd
Cunpe, vatian Law,, al California. Doc
Applicant
NOTLCIi TO APPLICANT. If, after making this Cerificate of Exemption. you ,,hold
baE...c subject,, I lie Worker's Compnnrmion provininnv of the labor Cee, you nmst
Loch, lip comply vello such ppovkin I, nr this permit shill be Jccn ad mac kad.
/] CONST BULL [ON LENDING AGENCY
L hereby affirm that them in a cnnnmetion lending agency for the perfom,ame
of the work for which this ILL in Noted (Sec. 3099. Civ, C.)
Lcndcr',. El
z I.,oul sAcidic,,..
I ramfy that I have mad this ufplicainn and zla c that the aMwe information is
E. coral. I agree m campy with all city and county communes and .tate laws reloling
V m hadding communion, and hereby nomadic reprcwmativcs of this city to enter upon
ILL Ih ,' l mo,ayl inspection loopola,
C (We) i,, p ' le if, and We, hI atheCity I C.1wrlino agidnct
VI liablibij Jg Is. voo, Lord es,peril, whiEh y-n any wee) acme tga,:r said
Ay
Z City in consequence of the granting of this permit.
WILL CONI PLY WITH ALL NON-POINT
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APPLICANT UNDERSLWUS AND
Issued by: \ Oa I
rnlurcMh';1/,'fide an,r"On. Eine
Rc-roofs
HALARUOUS MABtB1A1S DISCLOSUBIi
Will the applicant or forum leading ocupanr store or handle lowart nuterial
Type of Roof
as defined by the Cupertino Municipal Cade. Chapter 9. L2, and the Health and Safely
COLE.crYuv 255321a1' ❑Nor
El
All root's shall be inspected prior to any rooting material being installed.
will the applicant or furore building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, 1 agree to remove
emit haardous air contaminants as defiod by the Bay Arca Air quality Managemem
Die,ricre
all new materials for inspection. Applicant understands and will comply with
❑Yes 0N
all non point source regulations.
I have read the havardona materials regaimnamte undo Chapter 6.95 of the
California Health k Safe, Code. Sections 25505, 25533 and 25531 1 understand char
it me Wilding does not currently have a team, that it is my ne smsibiliry to minify the
ccuwnl of the requirements which must Be mel prior to issuance ora Certificate of
Signa re of A licant Datta
11NI f
All roof coverings to be Class tB” or better
Owmeraraam++era agent Dare
OFFICE