01110017 cl BUILDING DIPERTONNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21852 WOODBURY DR BECKS ROOFING 01110017
OWN R'S NAME APPLIC TIONS BDATE
MC�ARTHUR BARBARA L 6191 OCHO RLOS DR 11f05 2001
nHONE (408) 365-8979 SANITARY NO. CONTROL NO.
.Z reO ARCHITECT/ENGINEER: BUILDING PERMIT INFO
0
CC BLDG ELECT PLUMB MF-CH
L7
F N_ LICENSED CONTRACTOR'S DECLARATION
Oz_ 1 hereby affirm that 1 am licensed under Provisions of chapter 9(commencing Job Description
=t withSection7(giorDivision3ofIn,Businessand Professions C am hcenre REROOF.
,a j i.imm�rwaaCve t. e j T/0 SHAKES INSTALL 1/2" PLY &
e re c se Linnu mss .c.a
:od, Date 30 LB. 40 YR. COMP.
1 u u.y 3-8 AR ITE DECLARATIO Its
] O 1 understood any plans shall be.sad as public one s
Y
W
c O Licensed Professional
OWNER-BUILDER DECLARATION
o
W= 1 hereby arf n that I am exempt from the Commular's License Law for the
f- a following.,an.(Section 7031.5,Business and Professions Cade:Any city orcoamy
8 O which requires a permit to construct.alter,improve,demolish,or repair any swctwe
.a3�._ptto its isonnce.also requires the ayplicant for such prrmiuo file a sighed antiment. - -.—. - _- _ _.__.- __- .- _ _ _ _
thdbtzislioms1 pahuim w the pievor.tons ofthe Commnoh License Law(Chapter 9 ..�. r._.res tSQv_h''t,.Floor/�[ea!l: R t ••' 75giduation. .
(commenemg with Seetianagq)of Division 3 of the Business and Profession Code) (_tINT!.��k_ t1.•fr. :.A1'4.rf\_11.'sl iE..`. $
or that he is eaempi therefrom end the basis for the alleged drimptioe.Any violation
-of Section 71331.5 by any apptcam fara vormt,abjews the applicant to a civil penalty
Iofnotm «Nnfehundcdllrs(S5(q. 3 2 6�1Rb$�h40 Occupancy Type
t71.as owner of the pmpeny.n my employees with wages as their sole corepenwtion.
-win do the work:and the structure is not intended or offered for sale(See.704a. 305 - FRAME
Bummax'and Professions Code:The Contractor's License Law does not apply to an Required Inspections' •'
owner of propcoy Who builds or improves themon,and who does such work himself 307 - INSULATION '
or through his own employees.provided that such improvements are net intended or _ _ -
"offeredfoFsole.ILhowever.-the taildins ar improvement is within a he year or - .. 601--- ROOF TEAR OFF" -r
commence,f then,e ofbuilder will have he Women or purring that he aid not hand or
mprove b:r pamnre arsile.). 602 - ROOF PLYWOOD NAIL
__ .,-- - .- ------ ... - __ ---t - —- ---603'—= - ROOF BATTENS-..-- ......
❑L as owner of the progeny,am exclusively contracting with licensed contractors to - - _._._
- ammuua the goc ex,see.7(j1,1.Business and Pmmsaans Code:)The Contractor. 604 - ROOF IN-PROGRESS -
License Low does not apply to an owner of progeny who builds or improves thereon,
and who contractsfor.such projects with a.contrommr(s)licensed-pursuant to.the
Contracwls License law.
❑I am exempt under Sec. .B'&P C fort his..,on
Owner Date
WORKER'S COMPENSATION DECLARATION FINALE®
I hereby ufErm on der penalty of perjury one ofithe following declarations:
H I have and will maintain a Certificate of Concent to self-mouse for Worked DEC 0 3 2001
tl`l Compensation, us provided for by Section 37W of the Labor Code, for the
performance of the work for which this permit is issued. 1 p 1G/1
❑1 hanotnotve toad will Worker's Compensation Insurance,as required by Section BUILDING
37W of the Labor Chile,far-the Painformation of the work far whol thisgamut's
c:
its i ivy ker.Cwnp i 1 sur c ca 'er and Pd cy number in •--`- -- ----- a
-- - �•
�.5 x Fohcy .�..t.tY-rP s. v i„lsrt[ sl�t� )[ { ,'t17� • .. .
CERTIPICATIGM1 OF EXEMPTION FROM DRKERS'AI
„_,' COMPENSATION INSURANCE'': ”
i7hii section need not be completed it the permit is for one hundred dollars _______
I canny that in thc,pcAonnance'of th�'work for which this permit is issued,I �..I, ,,I'• :: t I'.: ,1'`t' `
moll not employ any person in any mmmu,'so as to becameobject to the Worker'
cian'snsadon Law,of Califomta.Date
Applicant.-
NOTICE TO APPLICANT If.after making this Ceoificate of Exemption.you should
subject to the Wel els Compensation provisions of the labor Code,you st
mu
Q 'L funhw th comply with such provisions or this permit shall be deemed revoked.
' - CONSTRUCTION LENDING AGENCY
, '
,1 he eny'offrm that there is a counteraction lending agency for the performance'
mf,he k for which th pc' t s issued IS 3097 Civ.C)
L0 Lend N. a .s.,..: ........ -
=-,Z Lenderx Add¢ . . 't > .
V 0 1 certify that 1 have«ad this application and 11.1,that the above inrorromen is _
W'so coned.,l agree toexmply with all city.and county ordinanesand.sus laws relating
�.V m building mnstralflkin:and herehy authmrixt represenitivei of Imicitym enta,.,o
W the above-parod and pro,amy for inspection purposes. _
(we)agree to save:indemnify and keep haimlem,the City bf Cupertino against
L tq abilities,judgments,costs and expenses which may in any way,ac a against said
V'Z City in consequence of rhe granting of thi.permit. "�
r`PPLI=UNDERSTA' IND LCOMPLY H' ALL NO'-POINT Issued by: DBIo
SOURCE REGUEATIO' . Y'
Sig_t of Appecarc m .. - ,Date. _ ; -Re-roofs--
), ' HAZARDOUS MATERIALS DISCLOSURE
WOltna pplicantwfumiebuilding leo tmoreorhandlehaum axmatenm. Type of Roof�l Cv. ..• --:-(�.:. .:- - I
as d f ed by the Corrado.M ucpal Cade Chaplin 912.andfl Headdi and Safety
C
rideSecton255321 )'' .., r,„,i, . k - 1t
f;tt
❑Yes '.'(' .ONm ,:v.: v ,._v:” n'. +
_-All roofs.shall be inspected.prior-to.any-.roofing.material.being installed._. . - .._.
r.
Wnn the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection;I agree to remove
i m t hesuardims air maimimmon,as defined by the Bay Area Air Quality Management ,
D t' n •--,all new materials for Inspection. Applicant understands and-will comply with
.oN all-non point ssoourrcce(fir/reeg I'ati
'o
1 ha ad the hY d u:
materials requirementsand dcrt Ch pt 695 nthe
CSafe,, - W ✓' / / r— D�
1 f Health&Sef t Cade m Son 25505 255]333d 25514 i rs
1 d rnd that ♦ _
cath biltling down cna hwe t.sifin my issuance of. to notify the \ �, -
1f hu bot « meats whic t be ton prior m issuance of a Cen notify
he
_ aeoP ey j;l_ Si nature of Applicant _ ., _ „ - Date
/!
Owner or anmori:m agent� - „ , Date.. � All roof coverings to be Class "B"or better
" ._.t n•.. ..._ ,:: ._ _, ._ +°. . . . .. OFFICE