02030055 'CITY OF CUPERTINO '
r�
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: PERMIT NO.
1204 YORKSHIRE DR COSMOS ROOFING 02030055
OWNER'S NAME: I APPLICATION SUB DATE
NICOLE GALEN 1901 OLD MIDDLEFIELD WY 03/13/2002
( PHONC: SANITARY NO. CONTROL.NO.
(415) 493-6373
0 a Z PHONE:
BUILDING PERMIT INFO
W C BLDG ELECT PLUMB MUCH
a tco 1=1 1 1 I_J 1___1
LICENSED CONTRACTOR'S DECLARATION
z 1 nercn flan mat 1.am licensed ander of 9 aommcncin Job Description
iZ—O ya provisioreo per g
:SCS with se<Iran]1%IU)orDivian,n3oan=Ba,me,aand ProfessionsCode.andmyBeen,e RE—ROOF
'n fan fora ana s
i c w I Licemc Cha�o. ti.
a yjCC��aa I
'O u. Ople 1 L SDE Lm�(�
1 a o G ARCHITECT'S DECLARA Lund,/KK/
,g I und=rsland my plans>hall w used as Public rccards
i 6 p se Licensed Professional
o LL OWNER-BUILDER DECLARATION `O
^ I hereby arnnn Inst 1 am exempt frommtheme Contractor's 1..an,e Law u,r the $].4 8 5 0
L z following rens.(S=ermon]031.5,Business and Professions Code:Any lily or county
E cl O which requires a permit to construct.alter,improve.demolish,or repair any structure
ad poor t t.issuance. Iso q Permit the for such Permio file asgnedam
amem
rat's he sfc n. a0 hue u80pmi nsorlhe Cottracmnl cense Ww(CM1apmr9 _ Q,- S�`Q, Dr.�@a �, Valuation
from g 'm Section-7") f D ishm J of the Buimess aM Professions Code) d�;� 1 1,3 g C fib 9,�p.,'ItJ�1V w), .'?x 5 51 ,4
m that he Ii exempi therefrom vad the basis for the alleged exelot Any v:oleuon - -
-ef Section 71131.5 by any applicvm fore permit uubjecu the applicuot to n civil penal',
.ofnamoamanfive Wrdaad.1hrs(s50B). 30�,PNI�i E fir..: Occupancy Type
_❑Las uwn<r orthe prupcny,or my nnployces with wages as their sole compensation.
will do the work'and the structure is'not intended or offered for sale sce.Lw,
Business and Profession,Code:The Contractor's License Law does not apply to an 601 — ROOF TEAF4uWllnspections
or through
r of progeny Who builds or improves thereon.and who does such work himself
or offeredfor
his own employees,t provided that such vermat mgpla are not attended or 602 — ROOF PLYWOOD NAIL
cRcrcdfon rule:gerWilr,i w wiave - lis sthawitdid notbc f .-.._.
g```imvrov=men rWo 603 — ROOF. BATTENS
completion,the own=r-wiener will have me wre=n orrrovins that he aid not baud or .. '
improverorpnm°'°orame) 604 — ROOF IN—PROGRESS
_—.- . . . ion-. . .. . — ---. —
_ ❑Lao owner of the progeny,vin exclusively d Ponf ing with lianad comracma to + I'.:t I.'tsm
Licens a the Project(Sec.](Na,Bioowner a dna eny who Code1)The ventmreon,
License Law docs not apply loan owner of prapeny who Wilds sa i:.pmvcs t to.th,
._dna narm,tracts.for.such Pmlects wim,e comracmr(s)Iicenud.Pvnuam to.me. ._.. .. _...__ .__._. ._ - ..._._.- .-
C 1 m exempt
License Law. ir
- ❑Inco exempt under Sec, � .B&PCfor this reason
t.
Own ''Data .
WORKER'S COMPENSATION DECLARATION
` 1 hereby affirm mtder penalty of Badu ty care of the following declarations: -
0 ❑ 1 have':ind'will maimbin v cenl0<:de of'Cuna•m ro self-insure for Worker's
Cann mamiao, as provided for by Sermon 3700 of the Labor Code, for the
aperformance of the work for which this permit is issued. .
_ Qs.f have and will mainiain Work=r's Cumpensation'Insurance,as requited by Smion
1]110 of the Labor Code,for me performance'ol the work'(or which this permit is
i ' ssocJ My W rkeJ Comp n.m o I lily bcr am
ran c O
1 CERTIFICATION OF EXEMPTION PROM WORKERS') t.s', - f0. r.. \ r( - F..'N.'F rll r.• +.`'• r
ig; COMPENSATION INSURANCE—
c'Thos'lmion-need nm he eumplciea if the permit is for one hundred dollen - "" "'' '• "' '''fI t"` -
ISIUO)orlces.)
Icnlfyth1 tt pc whinanceof Or oak for h'chfl permsiissued'1 --- --
shall not employ any pe n in any mann as to become subject m the Workers
Cosopco mi or Laws of California:Dam " _
_APplicanm ' .. .... ..r... .. .. _
NOTICE TOAPPLICANT.he Wim:IL Co makingmissom.6,of h Labor Code,you auld
to
become sobject m the suchIsCoimr,.,ion provisionsof heLaborCode,you nest
ZQ forthwith comply with such provisionsor this permit that l be dcemW mvok.
7.. ti .., ., .. .N _.... ..
aJ_.
''(CONSTRUCTIONLENDING AGENCY
","
I hereby affirm that(hem is a cnnswnion Icndin6 agcncY for the performdace
s of th k f hi=t rat''perm t sued(Sec 3097:6v C) ,... t. .._.- ... . .. . _.. ------
;D
-__._;D z LendcraAddress,"
I certify that l haverenlffin application and ,all then be above informmma is
eonech-1 agree to comply wilt all lity'and county ordinances and state laws relating
'C) U to Wilding cormsWctibn:rand hereby authorize repreumatives of this city to enter upon
the above-nandonid propeny for inspection purposes.
(We)agree 16 iav=,indemnify and keep hvmkss mho City of Cupertino usainst
W) liabilities,judgments.costs end expenses which may in any way accrue again'said
C) .Z.a City n consequence of th gra t g f oris pc t - "' m" '
APPLICANT UNDERSTANDS AND COMP WrrHALLNO PONT
SOURCE REGl1LAnans 3Issued by: Da O
Signature of ApplmvWC nae<t ,Date Re-roofs /
1 HAZARDOUS MATERIALS DISCLOSURE
ng occupant st handle hauNoiu material Type of Roof
\\911me Cupertino
future
asaef cA by meC pen Mu cpl,CoOe Chapter and the Health dSefcry `
Code [cfi.r 255320) x t mil t}'1 s, ,t s s •, 17 i '�( t v -} t f J r' .
_, - ll roofs shall be inspected prior to atiy roofing material being Installed._.._.__
Will m pllcam f t buildo g oc p t c equip e t J bes which
P If a roof is ifistalled'without first obtaining an inspection;'I'agree'to remove
<mit h Nods onto n t defineA h)m Bvy Area A r o 1 ty Management
Dill m - all new materials for inspection. Applicant understands and will comply with
S, „ �Y' r�"' all non-point source-regulations. -
`L.r . 1 m
LI'hvve read me h card us materials rcqu remenn Linde Chipmr 6.95 of the
:
mia Health&Safety Cone.Sections 25505:2553]and 25534,1 tademand Natilding'as notcurtenmly brae e¢nant.mm it is lay respunsibililymnomiryahedt of th q n h h must,be met pri t .suvn<e f C ni0cvm f`ySignature of Appl' ant Date
63f pm m nae'reg t r D re All roof coverings to be Class "B" or better
:', ' .OFFICE .. .. .. .. ._