02040046 CITY OF CUPERTINO
L BUILDING DMSION PERMIT CONTRACTOR INFORMATION:
BUILD W'G ADDRESS: PERMIT NO.
10550 WHITNEY WY R E ROOFING & CONSTRUCTI N INC 02040046
hT OWNER'S NAME: AP LICAryTION Syy D T
all STEVE & SHEILA DOLEZAL 108 OAKLAND PL (�4/ 10/�25�2
PHONE: (408) 925-9995 SANITARY NO. CONTROL NO.
Q60 zo ARCHITECTIENGINEER: BUILDING PERMIT INFO
s u- BLDG ELECT PLUMB MECH
S i, U C_I L 3 t_J
m•ea
LICENSED CONTRACfOR•S DECLARATION
iv Ihemny.ffimthat Iamlicensed under previsions of Chaptervfxammrnang Job Description
wt wimSation]000)or n3ofineBusincss dProfcuiomCode.vn m license REROOF.
smran rn.ex �,e cert r. �a 12�(��
ae' uernaecl n n urs✓ T/O EXISTING 2 LY. OF ROOF, INSTALL
3°a. D Cmuri �— NEW 1/211CDX, 30 # ASTM FELT & PRESIDENTIA
a. ARCHITECT OD
O 5 1 undmund my plant shall be M as public re
Y
E p O Licensed Professional
z OWNER-BUILDER DECLARATION
I he..by M.but 1 am exempt from the C..(mswr's License Law for the
h z< follow ing season.(Section 70313,Businessmid Professions Cade:Any eny m county
i E O which requires o permit m construct,alter,improve,demolish,or repair any s0uaum
6C3$ prion t a also req s the applicant for such Permit fl signed sum
tcrnt
mI
he s xnscd pisu m m the pto' tons o/the Conuacmn L Law lCnapa 9a S FI F1oorArea,'.
(commencing wish Section]000)pf Division' p
3of the Bunessand Professions Codc) is ,kCl': f � 't? i F 'l $111N1A67atm
On
or mm fie is exempt therefrom and the basis for me alleged c4crimion.Any violation a
-
of Section 7071.5 by any applicant for a Permit subjects the applicant o a civil fertile,
mrnm dn;e m;n Btt nnwrta aalma asoB). 36g�, d)Iitgnbq'0 •I bF:`.a. :'3 Occupancy Type
❑1,os ox ter afore progeny.nr my emr�oyas won rages m rev sole compcn.tim,
-w;n'do-m�gark:and me sweture is not intended or'bffered'for sae(See.7M,e 3 O S - FRAME Required Inspections -^�r-
f Budneis and Professions Codc:The Contractor's License Law does not apply to an
owner of progeny who builds or improves thcrtan.aid who does such xork himxlt
307 - INSULATION
or through h s own empl y p o ided ilial such improvements m not intended or _ _
,offered for tele.If.however,the Wilding or improvement is sold thione year
f ........
eotnpfedon the owner-Wilder will have me burden of prong that he did not bund or 601 -"ROOF TEAR�OFF -'
improve for puryose of sale) 602 - ROOF PLYWOOD NAIL
p -❑Caerafore procexclusvelyroiwitnlienudeommctorsm
construct the project(Sec.7044.Business and Professions
cnae:)Troe carwmorY 604 - ROOF IN-PROGRESS';Lon mL.IZT pl.l:%•,t e'il
License Law docs not apply to an oxner of property who builds or improves thereon,
a.' .mdwhocontncu.fw_suchropursuant-tome. _ ------- .._.-___ _ ___-__._
Commctors License Low_.,
Law,
__. .....
❑lam exempt undo Scc." B&PCfm this rcmon
Owner :.r: -� ;t D,•, ,...,Date'.,.,. i'-
WORKER'S COMPENSATION DECLARATION
-1 hemby affirm under penalty of perjury one of the following dcchmtions:' INALF-13
'1 0 1 ht1sa mo''Will maintein3e CcniOcgm of Cunam w self-insurefor worker's
Compcvztion:m-providd-for by-Section-37W of theLabor'Code. for the APR 2 3 2002
performance of me work for which this permit is issued
01 have and w II mains Warks -C.inpensati6rimiumance,as required by Section
�/\t< ode for me perf tt of me h'ror wh¢h this psora, s
ism ed M W k t Com nmtlon lnsumnce tune a Polieypvmber me U
7700 fth Labor itd�1 �iI V
IFlCATION EXEMRION FROM:WORI(ERS'�', 1-. -: f •s
r
?L l .its semn' neednotbe compleied if the permit is faro.a hundred dollen ` ts` .'li?": rat .li ' •. 1IC'CC 'E.^.;`; ^v,i;:
' ' 1 ttni I Nat in drc lira nett of the work f which tet
6,` Y R R It stssued-I s ,y.•:I. YC::, - an. f
hall Dat eihplay,ony'pershn m any monnee so as to become sub)ed to the Workers '
Compim'r Laws of Celifomia.Drd '
Ap I t .. '..
pp .. _..... .. .. _ _. ._. ..___.._.
:NOTICETOAPPLICANT If after making this Cenincan ofExemption.you should . n - .. . .t .
r'ZQQ� forthwith'ecM1om mub)ecomply
ltyo with et-h wT'oacdh_eptros.C.v_om onosathis
his pp cnvnia
oshall
-fbtehed tubad CrtodoekeYd
:In til%tC6NSTRUCr10NLENDINGAOENCY
u__most
_.-_.___.._. ._ _. _.__. ._.__.. ..... ... .......... 1 ._ .__ ..
-thereby. not that m - ommm d {- gncy for me performance f a1 te.l
ofd workf whichm pe i issued(See.3097 CJC) ...p v.a._:.i..-va
y;0 -LeMerkNamF ' "c..,_.. .a._. ,..•.._.::.. ., . .__._ .._. ..._ .... .------_ . __ ..._ -__
P,Z lirders Address - -
U 0 ,.ri Testify agree
m t 1 h d alcity
and
applicationmy stat thates W information is III /s
W [-n correct 1 agrc t ply m 11 tydnd county ordinances and state laws mining /U/yl•-�/
Q.0 mora ld gm wet on eMn rtbS' thonae rcprcs nut acs of hits ity toenter upon
g>a the W t cd p perty for to rte do p rpou _ ..
ly (W<)agrtt to mve,'indemmfy and keep harmless th!Cny of Cupertino agunst
h Iia)Ilnmyppdgments,emu M asperses which may any ay accrue against mid
U .Zr ny , si ue'a�0 that, i gofmis permt '
SAPP'Ic_ , iTT,]�i SA 4 OSIpLyWrrHALL'NON-Po O sued by: r Date
definedbythe cam M cpWCod Chapter 9.12.n�hei i M1]��� Re-roofs
PF an o DOLS MATERIALS DISCLOSURE
'
Will y he I cant m future bu(din e,C t ty pe Of Roof -
. solar �. � -y` � ''_ __��....._.. i U•I-. _- �'--" - '
Ce Semon
-n ❑Yesl t - tyirt
6� N� ..,,,..,,. . . ... . .; . .All roofs shall be inspected prior to.any roofing material being.installed.,._—__.
emit hawdouimmntammaniaaa de0neo b orern 'AreeA Quality
which If a roof is irisEalled�without first obtaining aniinspectio'n;`d-agree:td.reinove
< II me a I tent ti urns b Ida occu em use e m t o d
9 Q Y Managemain
oistna `ems all n aterials for ins ection. A _],cant understands.and will tom 1 with
L ❑vex ,;.." t (unWd
non-p in urs egs PYa cad�me Was s materials .....m....under Chaptere[ SefetyCode.Secdom25505 255]3and 25574 I idtc nemly rn het usmYrespo ubthryt• t,prim, en.M•Cture of 'cant_ Date _
ar Inn u o 0�)� All roof coverings to be Class B or better
,
.... OFFICE--._.... ...... . . .-