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CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDINGA91l WOODLARK WY
LOS GATOS ROOFING
PERMIT NO.
O mw@005@17-^
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OWNER'S N94TAy AMINA
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1771 SMITH AVE
APPLICATION SOB DATE -40
7�//.. /
PHONE:
SANITARYIARYNOO CC(�Jft
ARCHI'rEC'EIENGINEER:
(408)358-1233
BUILDING PERMIT INFO
BLDG ELECT' PLUMB Mlicu
IJ 1=1 1=1 1=J
LICENSED CONTRACTOR'S DECLARA'I'WN
Job Description
I hereby arum Thal I am licensed made, provi,ions of Chapter 9 ancomeming
withS.1ion 7(XX))'It 1)iv 1 the Ratio... and Prol'egin I, Code, and., licence
is in full force a
Licensejjjjjy��- Lir.«_{ 03
�
Date �t
ARCHTIIiCf'S DIJECECLARA )
1 unJersmnJ my plant shall M uvea as puhlie rca+Ns
WOOD SHAKES TO TILE ICBO#2969
Licensed Prufcoinoal
OWNER-BUILDIiR DECI kRATION
'
1 heaby air. Zi I am encmpl from the Contractor's License Law lin the
following ,etls"n. (Section ]Bi L5, Business and Plufessimrs Cale: Any city or county
which require, a permit it, construct. vlmr. improve. detntd'0c or clear any still
prior it) it%issuance also tequilas the applicant for such period to rile a agnea statement
Sq. Ft. Floor Area
Valuation,
dour he is liam,edpmsuom,, IN prossia+s of the Conu'nand, l.icrme Law (Chapter v
(commencing with Section 7000) of Division J of the Business and Prom,ions Crate))
D 1 4JIT Qt
r , for the u11c,11 csmllninn. Any violation
or at he is camau fifilltall taut
N
of Section 7031.5 by any applicant fora permit subject, the applicant to a civil penahy
of m+i (norm than live IF...ri , dollar. ($5110).
A ' (39. 00
Occupancy Type
0I.asownerof the property,, my employee.,itch wages as TheireNe I.... cromilan.
Required Inspections
will Jo the work, end the stmcme, i, not intended or n0'cmd lin .,ale (Sec. ](N4,
Business and Promsorms Cale: The Contractor'. License Law Jars not apply to an
veil property Who build, or fit ,prnve, Ihrrrnn, and hodoe, such walk hlnt¢If
or through his own employees provided that such improvements an not inmnded or
offered for sole. It, howcna, the building In impnwcmenl is sold within one ,at ill
mpletion.the owner -builder s;it have the burden ofprovmgthat hedid no, build or
anpnwr
305 - FRAME
lin' pu,,,e of sale.).
307 - INSULATION
0 a,avoeaof,ja, opec,ameada,wely..utudia,with rar,eda+Imaelo,
the project (Sec. nw, Business and Pmfe„ion, C,Ac:)'rne C"mce,ol-
601 - ROOF TEAR OFF
Iaaracl
:acnw Law all not apply u+an owner of progeny wan build, or improve, Ihaam,
and who convects for such pnjmis with a carni s7 licensed por,aam to car
602 — ROOF PLYWOOD NAIL
Cnnuwme, License Law.
O l am comfit and,, Sec. .B&PC for this ma ... a
603 — ROOF BATTENS
Owner Date
604 — ROOF IN—PROGRESS
WORK17R'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
0 1 have and will mainmin a Certificate of Corwin to self-inwre lin Worker's
Co,n,,,ao,r, as providel fur by Section 3700 of the Labor Code, for the
per have lac of the work Inc which this itis issued.
as by Seaton
have end will mainmin Wythe
ICompensationlove'f' a work f which this
-c of the work for winch thio permit is
i XI of the Labor Com far II I list
issued. May WorAcr s Comp tion Inst cCurr{ierQand�Put icy numhcr arm:
comic r?
/
O
EicY IONF7���
CIiRTIIRCACOMPJFP_ ONIISURANC WORKIiRs
CUMI'IiNSA'I'ION INSURANCE
-
�
f1'Li, minion need nal he....limed if the Penni, is for one hundred dollars
($100) or lac,.)
1 certify that ithe refformance, of the k ]or which this retain is issued. 1
Iliad nor employ any person Y , an : t became Subject I Ili W'o ke,i
Qat
MAY
Compensation i Ip n D. m
Cu
A, t
2 2 ?000
'
NO[ CE 1OAIILICANI If. ftr 'kiy0':Crtl mtlF ,a yIhuIII
Wennesubject it) the Workers C rope ,at pro% sict oftM1 Labor Code you must
p
By�
forthwith comply with ,wed m celspermit be drumed invoked,
CONS ON LENDING
CONSTRUCTION
ageAGENCY
em is a lending00. agency vn the perhmwnce
I hereby aRrta Nat them is v issued
ser.
of the wok fur which Thi, Irmtit is InwIW lSrr. )IVP. Civ. C.1
Landers Name
Loader's AJJrf.Y,
'
1 ernlfy that I have rend tnk, apphe n ter sad smm that the able mferandimt is
mea. 1 c m comply with all city and emmy ordinances and pate law, relating
1 m Niilding construction, and hereby sidearm mpresenmtives ofthis city to enter upon
p the ab sae -us cloned property fa nalle ran purpose,,
(We) agree In save. indemnify vol keep locales, the City of Cupertino against
1 liabilities, judgnrenta, cn,l. and capnwe, wbmh may in any waY accrue against said
City in .,.sequence of the groming ofthis permit.
s APPLICANT UND17RS'LANDS AND WILL COMPLY WITH ALL NDN-POINTIsSUed
b r Date I —
Y'
SOURC12 REGULATIONS.
Re -roofs
Signam,anlnppucanveomraaor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding trcurout once or handle hmmdaus nonevent
Type of Roof
as Jelincd by the Cupertino Municipal Cale, Chipa r9.12. andthc Health and Safety
Calc, Seecliwo 25532m)7 O No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicntnor room Wildmgmc"rynt use cyuipnmm nr device, which
If a roof is installed without first obtaining an inspection, 1 agree to remove
n, WmNom air contaminant., a, delinN by Nu Buy Arco Air Quality Managentent
nihaiae
all new materials s ection. Applicant understands and will comply with
Ott, 11 No
allnon-point sou' e e latio
I have read the hamrdom, anterial, rwuimincnts ander Chapter 695 of the
California Health & Safety Code. Sections 25585.25533 and 25534. 1 undcamnJ That
_
17-4
if the building dims not earranly nave a Rmaff mat it is my ro 'I'thility,+notify the
cupam of me rcyuircnunls worn must Fe me prig u+ issuance ill' a CmEcam of
DS
eco
p'"`Y'
Signature ofpp 'cant Da[
All roof coverings to be Class `B" or better
Owner orand horiced agent Dole
OFFICE