04120023 (2) FI-1
ITY OF CUPERTINO '' +'«, +-� �`^ '^' "'�` -at`�e-
BUILDINGDIVISION PERMIT CONTRACT,ORINFOR&sr` '.
MATION L
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a :k`§`. !y'i,
LDING ADDRESS: CROWN ROOFING INC PERMIr
N°04120023
6359 BLACKWOOD DR
OW NER'S NAME: PERMIT ISSUE DATE
YO MISHKAI 3535 KIFER RD 12 /02 /2004
NE: - SANITARY NO. CONTROL NO.
(408) 874-0784
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
EKTI
u00 LICENSED CONTRACTOR'S DJI�CCLARATION Job Description
C 1 herchl/grum Nu I.IicevW urderyr�o4isions of Chapter 9(commencing p -
bb with5 6%3"I of Division 3 or NC BusFLWProfcssium Code.and my licevc is
^�,� in full I and elft b
5qz Lieenrtela:, '39 Lia.n L9842 REROOF _ Hk',1�1
t=p Date 10 - u - 7,m< cmaxacom Lc Vas 'TGT JYaIY. L
aFty ARCHITECT ECLARAT ON _ �N 16 (s y
I updCrsund my plans NJI k used u p orris
BUILDING
C vl-i Licenud Pnucsi 1
:M5
� OWNER-BUILDER DECLARATION
.�a a I hereby.(see that
11. exempt from the Contracmfs License Law for the -
p o following mason.(Scc6on](ALS,Business and Professions Code:Any city or county
(v which retrains a Permit so ennstruct,eller,improve,demolish,Or repair any structure I
888
FZaprior to its Issuance.also myulmsft applicant for such Permit to file a Signed statement
that he is licensed pursuant to the provisions of Nc cnnuacmrs ldc..Law(chapter 9 Sq.FL Floor Area . . Valuation
(commencing wish Sution]of0)of Division 3 or the Business and Professions CaM)or
.-
that k is exempt therefrom and the basis for the alleged exemption.Any violation of
Section]031.5 by arty applicant for a permit subjects Ne applicant to a civil penalty of - -
nor mom than Five buouland dollars($500), car Occupancy Type -
❑Ido ownedg.add mpcny.or i1 maimoycca with wegv u adev ec.Compeniatian,
will do Newodt endo: heConesnots Licend,Law
osnotapply to aa,Business -
pandro Professions Code:The Conmcmrk Liceom law dao not apply la an owner car Required Inspections
Ownertywho Wiprovidmproruschimpr, arrems dousne andedwcokicroselfar though nu
however,
uiprovided that suchimprovementsartne year dedaOBcmd for sale.If.
however,d¢building or improvement is said within one year Ofimpro a for the owns- --
builder will Nse Ike WNcn of proving dist k did amt Wild or improv for purpose of -
salc.).
❑1.as Owner of the property am excluarmly Contracting with licensed contractors to .
construct the Mj a(Sec.70W,Business and Profta ions Code:)The Cmd acmes Li- ...
cove law docs not ePPIY man Owner of property who Wilds car improves Ikmon,and
who contracts fa such projects with a eanuanor(s)licensed pursuant to the,Comrsetoes
Lima.law.
0 1 am exempt under See. .B&P C for this mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations: .
I km and will maintain a Ccnificam of Covert,1.calf-mates,tour WorkersCompen-
suian,az provided for by Section 3700 of Ne Labor Code,fm in,perfarmance.[,he
work for which this permit is issued.
1 bare and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for Ne performance of the work for which this permit is issued.
My WOrkCrs CO Ion Insurance rriu end POlirynumher art:
\ 1
Carper.
T/Yt/(i —u ND poliaob0275L•LeAl -
CERTIFlCATE OF FJf Offyy MWORKERS'
C COMPENSATION SURANCE
(n ois ucsim need nut becomphrad if de permit isfvone hundred dollars(SI00)
or Ices.)
I certify Nal in to performame of the work for which Nis permit is issued.1 shall not
employ any person in any manner u az In become subject to Ne Workers'Compensation
Laws of California.Due
Applicant
NOTICE TO APPLICANT:If,.(to,..king this Certificate of Exemption,you should
become suhjul m On Worker's Compensation provisions of the than Code,you must
.J z forthwith comply with such provisions or this permit shall he deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
F� l kmby affirm that Vert is a covVYClinr lending agent,for the perfurmamm of
C$ she work for which Nis pandit is issued(See.3M.Ci,C.)
B]0 Lenders Name
az Under,Address
V 0 1 certify shat 1 have mad this application and sum that use aWw information is
Ig.PCoeuee 1 agree In comply with all city and county ordinances and sum laws relating to
0[, building Construction.and thereby aulhonce mprescmRdWar Of this city to cola upon the
yakve-mentioned properly for,ivpccuon Purposes
(We)agree to save,indemnify and keep harmless Ike City of Cupertino against
tZ) in coitiu,ju tc of the
cosy and expenses;whim may in any way emus against said City
U z in earsegnencc a(thc guntin (Nis permit.
^ APPLICA������iiiiii''''''UNDERST S A�ID}�LL COMPLY WITH ALL NO7-POINT Issued by: Date
DUR H"REGULATI t fes/ I U N _
// Re-roofs
5i near pyliCxWCOntr CLCr T
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applinm or future building Occupamsmrc or handle ha Cautious material
az deflood by she Cupertino Municipal Cade.Chapter 9.12,and Ike Health and Safety
ak.5eetion 25532(x)]
❑Yes , ' All roofs shall be inspected prior to any roofing material being installed.
Will 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
•nthict? us air counuminanuuudcfincJbyNcBay ArcaAir Quality Management all new materials for inspection.
District? nart,/figr
❑Yes /�
I have reW Ne hvardos materials requirements under Chapter 6.95 of she Cal ifor,
ialicalN&SafmyC c,Scctiov 25NIS.25533 anal 255Ja.lundcrsund Nat i(Nc building n ��
Jars not eurmn un a Nat it is my respovihility u madly Ike arupent of Ne
z
myoid muss ormissumaaraceetifcamaraa Nt,. 8ig'nature ofApplicant Date
ownern tmo vcdegem 'r t d„e All roof coverings to be Class•B”or better