01090108 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19784 WINTERGREEN WESTERN REGION ROOFING 01090108
OWNER'S NAME: APPLICATION SUB DATE
CITY OF CUPERTINO 231 N 12TH ST 09/24/2001
PHONE: (408) 360-9111 SANITARY NO. CONTROL NO.
ARCHITECTS GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
So
LICENSED CONTRACTOR'S DECLARATION
Z y I hereby (firm that 1 am homwd undo fCha nu 9 lcommcncin Job Description
i Z—p Y a provisions o p g
i3 I, wnnsullfan7uw)erect,iaron3enneeadnmaand prmesaian>codaanantybewae REROOF.
2",,n iammn ter«and erceet.
:W LicenseCura Luc.« NO FEES FOR THIS PERMIT.
a O Dae Contractor
3 3 a V RCHITE TSS DDE]rARATION
p G I un .liana ,s,IsI V s
i�
i d p o Licensee 1 r
OWNER-BUILDER DECLARATION
='a 1 hereby affirm hot 1 e crept from the Contmcmi s Liters.Low for rhe
C?< following reawn.(Section 7031.5.9 i.,Imos and Professions Codc:Any city or county
sF O which rep a permit t wctalter,improve demolish Or repair arty stinum
III m prior t 't. ssunnce.inti residues the pplicmt for such pcnrm,to file a signed mountains _ __ _ _ _
man 1 nwd pursuam m the p-vi o x er me eendamerx ucenm inti(Chager 9 n T Sq.-Ft:
- Floor Area a , , Valuation
(nam g with Sec/ 7(IfXll f D inion 3 of the Bui ness55 and Rprusmna coa<) T":,,I•« j }_..� . ', !., %y C)
or that he is eacmpt meiefrom and the basis far rhe alleged clen.puon.Any violation -
no
of of a...,he.Seven nareedea ficur APN Number Occupancy Type
❑Las owncr of the pe,eiry,or my employees with wages m their sole compensation. 1
will the work,limitations the ode:n is not intended or's or License Lredaw rot xde(sec. to 4.
an 3 0 7 — INSULATISd0ired Inspections'
Business end Professions Code: im Com chance s law docs not apply m an "
owner of property em Bum o<i vide tat such iam tine encs such work nded or 6 01 — ROOF TEAR OFF
ofehwugh his own emvase, .provided Nat such improvements is of are not inn ear or
completion,ifaron tile.If.however,the Wildinghave
the im en of Prov is whin within One year of 602 —. ROOF PLYWOOD NAIL "
completion,the owncr-buildv will hove the buMen of proving that he did not build or
improve rte pdrPme of role.). 603 - ROOF BATTENS
Oh re aer'af the p.mperty,somcui .ively eonvaeting with licensed eootrxcurs to 604 — ROOF IN-PROGRESS
nmsuvn the project(See 10x4.Business and Professions Cade:)The Cnmracon"s ( �
License Lew d«s not apply w an owncr of a corm who milds seimproves thereon,
and who contracts for such prolecm with a comm�wfs)licensed Wrsuent m doe ._ FI�p /� B C®i
C 1 am exempt
Inti. a V'r /l"4 Yrs G
❑Lem exempt under Sec. ,B&PC for this rtawn OCTd ' ft'•i
Owmr Date
WORKER'S COMPENSATION DECLARATION C 0 + 2001
I hereby affirm under pcvlry of perjury one of,the,following declarations:
q p 1 have and will maintain a Certificateof Constar to self-insure Ter Workers BUILDING
1� Compensation, as Provided for by Section 3700 of me Labor Code, for the
pi tfonnance of Ute work far which this Permit is issued.
A, El hav and villoainmiri Warkcri Compensaeiurilnsurance,as required by Section
3700 of thc Inbar Cade,for he pmirfo rmantt of the work for which this pcmm is
issued.My Worker's Compensation In..carriu and Policy number eu:
n,.e Policy
kNo ^( �1N'
CERTIFICATION OF EXEMPTION FROM WORKERS'r - t f l..Y t ). .Y a h °•;
COMPENSATION INSURANCE -
(This waion need am be completed if the permit is for me hundred dollar t � �'f•` ry` ''
(k100)or lcse.) .
I certify that in the m in myna of the work for which this cttpermit e issued.I
snail not employ mi)'fC.1i many manner,w m m become subject w me Workers' ' 't
Comies.' on Inws of Cdifomia.Dina
.Applicant _
NOTICE TO APP LICANra's Compensation
ruts Cision, con Exemption ,y unmulst
ZQ Obecamesubjectcouua the Workers Comps orchis permit shall tlalnbur Code.you must
forthwith comply with such provisions or this permit shall be dcemW revoked.
In CONSTRUCTION LENDING AGENCY
_a > 1 hereby affirm that thea is a construction lending agcaey for thc Performance
Wof the work far which this permit is iswed(Sec.3097,Civ.C.)
Y A Lcne<r•e Name
a, Lender's Address ,0 ;1
U 0 1 certify mat 1 have read this application and state that the above information is
Loa F.. correct.l ague to comply with all city and county occurrences end sum laws relining
C.fJ to building construction,and hereby aunhoree rcpreumaivm of this city to enter upon
The above-mentioned property for impection porpoises.
r}. L
(We)i ccc to mi, ,indemnify and keep hamhem the City of Cupertino against
L Vi liabilities,judgments,costs coal expenses which may in any way accme egaimt said
U City in comequence of the griming of this peomir.
'APPLICANT UNDERSTANDS,AND WILL COMPLY WITH ALL NON-POINT Issuedby:
Date
SOURCE REGULATIONS.
Signature of ApplicamlComrenor "" "' Dau + Re-roofs
" HAZARDOUS MATERIALS DISCLOSURE'
wn me apnlmam nr home wading occupaa store or handle ha enc ods maarid Type of Roof
as defined by the Cupertino Municipal,Code.Chapter 9.13,creditor health and Safety J
Cade Seniors 25532(a)?,
uvea ❑Na;. _All roofs shall-be inspected prior.to,any.roofing material being.installed...
W 111h phcwtormturebuildingoccapaatuse quiprsamordevice,which If a roof is insialle'd without first obtaining an inspection, I ilgree't61remove
emit haIDrdnus am cnmeminants as defined by the Bay Arte Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
�I ova ON. all non-point source regulations:
I have read ane haznMous mauials mgmmmnns under Chapter 695.of the
California Hedth&Surety Cud,.Sectionsbroad.05at it
y e 2!5534.mr,ibi dy w i and that
I
me Wilding does not currtn0y have a tenwn,that it rs my rnponsibiliry eo notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
occupancy. Signature of Applicant Date
eT„ar or amnnia�e agent Dart
All roof coverings to be Class "B"or better
r. ': - ( OFFICE