02050159 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
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BM"1A'1UkKSHIRE DR OLD COUNTRY ROOFING PERMIT NO 02050159
OPX'- CfUD SHANNON 125-B GROBRIC CT AU5°/T'V4"?J(Y2
PHONE: (707) 864-5557 SANITARY NO. CONTROL NO.
O m Z ARCHITECTIENGINEER: BUILDING PERMIT INFO
m O BLDG ELECT PLUMB MECH
C--3 L,
8 c LICENSED CONTRACTOR'S DECLARATION
5" I hereb rfinn mall nm arenxd under rcna ler 9 anmmenem Job Description
iz"-
tic ra pre1pPo, p c RE-ROOF
,n u� with Senior] for Division Jaf me eusineas arm sion>Code,and my licen.x
in full fore d epa
z�S License Ch Lic. Z 3
O a u Dalg/ C"nnarmr
u O •JV If ARCHITECT'S DEC 10
Pr-iii
1 undcmana Illy plans shall be,used as p is awed,
E,,,00
1 d O O Licensed Professional
i OWNER-exempt RDEthe Commerce's
ON
L_^ 1 mass .Section
ct on 1 tiro exempt from the Convns Co License Law for the
t-z a following mason panni ,]on S. t.sinus and Professions Code:Any city or county lure 4000
adO whichits iisanpermit also reclaims
the
for sudcnudlch t t errrepairany structure
a3s prior to'I asuadprsuantt 'm ..ilium for Contractors unfilLow nommem - - - - --- - -- _
(cia ommencing
iltt velpSectio mthe p- vision ma the Bmines Licvna Wwons Code)
or
F d�. ; Valuation
or comma Section a) fDl III
{{and Pro(Anyvi Code) al `�i I'..iL \,; vi .. lv.. . .^ {\•
or Seth he is exempt therefrom unJ the hugs fns the allege)eVemphoo Any l Penalty
-of Section 7031.5 v allyaped loll fora SW). subj<nsthe applicant toacivilpenalty-
�rrdetmom m,d five hundred dollars(SSW). 3 U bAPN ,. , ..• Occupancy Type
❑1,asownerofmeproperty.ormyemployeeswithwagesastheiraolcempenation, 307 - INSULATION
will do the'work,'and the stroclare is not intended or offered for sale(Sec:]OSx,to an p,
IBusi`ei`tind Professions
lds or me Contractor's o eve who icense «��cn work
lhimxlf 602 - ROOF 'I (� 1� dons' "
owner
o prvpe y proses
or through his own employees.provided that such improsements are not Intended or --6 0 3' ROOF BATTENS, .
-'uffcred far sale:If.however,the building - is sold within orae-ear of .. _....__. ..___
oruren of
y
iempmaoof me awn o-n aria er.viu have the burden tar prtwing that he did nm halm or 604 - ROOF IN-PROGRESS
mprove purpose
-. _._..__...e _.. ___._ _ . _um _ . .-
co h us owner of the p(Seeny,nm Business a d Proving will Aenwd our it �o .
cmuwci Inc oesproject Isco.]OSL ownersa add eny%tions Glc:)nx Co thereo's
License Lawdoes not apply loan owner of a mmay who bullas to improves thereon,
...and who s Lacers for euch.pmluts with a commnorts)licensed Pursuant m me
' Conua<mr's Liccnsc Low.. - -- -- -� - - -- --- --
❑lameve III under Suc.' ,9&PC for this mnaoa FINALEnaDJ .
cr ,.. ..,
Own "Date r �Y
WORKER'S COMPENSATION DECLARATION JUN 18 20OsL
I hereby affmr tinder me,nahy of perjury one(If the following declamJon
O I have and will maintain n Certificate of Consam to self-immm Tor Worker's
J Compensation, as provided four by Section 37W of the Labor Cade, for the BUILDING
perfurmanae of the work for which this permit is issued,
Ell have and will mainmin Worker's Compensation Insurance,s required by Section
0]00 of the Labor Code,for the perfonrmnec of the work for which this permit is
issued,MY Workers�� ku. cy cart cr an Pql Rimer firer' �' '...,_.i.. _! y 'f F :
,..CERTIFICATION OFFEEXPEMPn FROM W30RK SCl,�C .Y. t •t .r.! -_ -
COMPENSATIO SURANCE
1'ITis section died not be completed if the permit is for one hundred dollars t
I5100)or les.) ,
i fy ihot in thee'f rtn ce of he work for which his .it is issued.I t,,y
shall not employ any person In any manner so as to become subject to the Workers
ComPensnlion laws of Caliromia.Dare'."
APPlicant . . .. .. ._. _ __ .. ._ . .. . . ._..
NOTICETO APPLICANT.IL after making terse Cenificti¢of Exemption,you shruld
become suhjen In the N'nrkets Compensation provisions of the Llmor C«Ie,ybu mot
Z
Q forthwith comply with such previsions or this pcmrit ahvll be tlttmcd revoked.
CONSTRUCTION LENDINGAGENCY '-
1 hereby ufrnn Thal there s a const I n lending bgency for the perfnrmance'
r of the work for which this permit is Issued(sec.309];Civ.C.1
6. Q -Lender a Name.. :_ -._.. . ..
ID Z Lender's Address'•
I ccnify mall nave mud Ihia applieminn and store tem the alwve inforuadon is '
fsa'E., comer.I agree to comply with all city and county ordinances and state laws relating
C.V to Building o musedern.and hcrcby authorize'reyaumidives ofthis city to enter upon
ri] the lit,ovcmemioncd property forenion purposes.,l
L~ G IWe)
it sI'eove.ind it and whi hamayinthe ways Cupertiainst said Vl liabilities,jun Is,costs a J s whin may in any way accrue against said
ra,z Cary in Sue a of the g of in"permit.
AOPIC .T� DERST f AND WILL COMPLY H'ITHALE'N'ONT Issued by: r Date
�. e
. signaturee-I a Ac RDner. /Dole Re-roofs
HAZARDOUS'MATERIALS DISCLOSURE ' "
"• ,Wll y he Caper!ant m fmaai,i,ure l Co e,Chapter
r ore 9.12.handle Health us and a¢nal Type of Roof .. .... _ .� -
: : $s de,S p o m c pen Mu 'p' Code,cn m 9 Iz and me Health and safety P P Y g .. ginstalled.._. . ..
Cdde Sen on 255]Nel r l u.; 7 ( t • ' 1 '
El Yen toNr - i f t _ All roofs shall.be los ectad rior to,an _roofin materia] train .,.
- W II IM1 Ppfitart f I c holding'o,a,mm use cpu p e I or devices which If a roof is installed Withoutyst o airing an inspection', I agree to remove
son th rdous airs nm moo s defined by the Bay Am.Air Quality M....arem
District. all new material inspection Applicant understands and will comply with
❑Y I.. .oN :: all non-poin arc iegulatI ,
1 read the h d e, tori I. q '25533a'under Chapter 695 of the
Cal fou t He a I CWe Sectio 5s05 2x533 end 2553) I understand mel
ifthN gd snow tlyh
tenant,that tis my responsibility to notify,the
n(mc rcprfrtmcn¢ ust be met prior io issuance of a Certificate of
°eta " _ Signet r_eofAp ca Da(e
0,act a,nam a aged D D All roof coverings to be Class"B"or better
OFFICE
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