02100184 (2) CITY
LIEN UPER'ONNO PERMIT *to NTRACT,OR,INFORM�ATI 0N
BUl@)@2ADRR+ E,NT AV MORAZAN ROOFING INC PERMIT NO 2100184
0`019 AMIE:HARK C AND KOK MIEW Y 740 SHAWNEE LN APPLICATIITIO`1"Td 2002
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orZONE: (408) 224-5785 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
_OO LICENSED CONTRACTOR'S DECLARATION
it-P 1 hereby afr that 1 am licensed under pnwiamn,of chap,,,9(commencing REROOF Job Description
.yzw with section 9NNnnf Division 3"f the Bmincxyu,W p fessinmcoduandmIccmais
<e, in full on, n 1'c,; ✓Xi 5
Dz~�= C'lns' Iic.p
F, ��Contractor 811 n
�5. ARCIIITRCFS D TION
21
1 undefsond my plans shall he used as c records
K�dV
y LL o g Licensed Professional DEC 1. 0 2002
OWNER-BUILDER DECLARATION
x0 Y 1 hereby reaso .Ser thin 1 am exempt from the Contractor's Co License Law co the $8100
y 00 fallowing reason.(emotion 7031.5.Buxlnaae and improve.
demob Code:Any my or county
w which requires a permit to c"nslruct,alk,,improve,dcmnlisM1,or repair any s(ruaure
Fzy plinr In its issuance.also requires the applicant l urxuch permit to life a signed slatement
< that he is licensed pursuant tome provisions of the Convannrs License law chapory de®A@0 Valuation
ca (commencing with Section 7000)of Division 3 of the B,viress and Professions Cade)or
i 3$ mat he is exempt thelefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects to applicant to a civil penalty of
not more man five bundled dollars(5500). PIS N99W Occupancy Type
307 - INSULATION
❑Las r .the pmpeny, employees wimwages as their(Sce.compensation,
will Pr Newark,and
h:the Too Curers mots License
Lawoffered do Tama apply town704L Business {��y� �n�f,ffO
and Professions Curie:mpo Conuaelnd.License Law docs or apply m an owner of 602 - ROOF IN,
W V _Wl Ln5
property who s.provi improves thereon,and whiteners such work himffemdthrough his
hOwn owemployces,ding or not oroneresu for setae- 603 — ROOF BATTENS
however.the building or improvement is cold a within one year of completion,to owrcr-
buoaerwalhave mcoli,,enorproving that neaianot Wild orimpmvefor parpnaenr 604 — ROOF IN—PROGRESS
sale.).
I,as owner of the property,am exclusively contracting with licensed cnnmi Ito
,,sect the project(Sea 7044,Business and Professions Code:)no Contractor's Li.
achu,Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contracumbd licensed pursuant to Inc Contractor's
License taw.
❑I and exempt under Sm. ,B&PC for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby a0im(under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to sd6imum for WurkersCompen-
sation,as provided for by Section TRIO of the labor Code,for the performance of the
work for which this porn(,is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the tabor Code,for me performance of the work for which this permit is issued.
My
CamWao:r✓p wC�^o(y't/y'�1A nln price carrier and Policy er e
olicYNR
UD
CCRTIµAM�
COMPENSATION INSURANCE
(This section need not be completed if the permit is for(Inc hundred dollars(SI00)
r lcxa)
1 amity that in the performance of the work for which this permit is imuc 1,[,shell not
employ any person in any manner sit as In become subject to the Worker(Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the UNIT Code,you must
Q z forthwith comply with such prnskionaorthi,permit shall low deemed evoked.
z O CONSTRUCTION LENDING AGENCY
(-+ I hereby ulBrm mat there is a construction landing agency for the perlimnancc of
ai the work lin which this permit is accord(Scc.3197,Civ.C)
W Q Lander'a Name
O. Lander',Address
z
V Q 1 certify that I ban read this application and statto that me above information is
w F' cmitcl.1 agree to comply with all city and county ordinances and nate laws relating to
QV building construction.and hereby authyva representatives of this ci ty to enter upon the
above-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
y Imbililieajud lists and expenses which may in any way accme against said City
U Z inconsequeneeoft granting this permit.
APPLICANT U I. A 'D WILL COMPLY WITH ALL NON-POINT Issued by: 61 Date
URCE RE
�G Z Re-roofs
t m Apprc on main, Doc
II Z DOUS M ' IALS DISCLOSURE Type of Roof
Will the applican g(occupant store or handle haraNnus material
defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
.Scctiun 25532(x)'!
❑Year nNo 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
m it haeardour air contaminants as defined by the Bay Arca Air Qual ity Management all new materials for inspection.
Dat"c"
E]Yes is No
I have Mad me kvzNnus materials requirements under Chapter 695 of the Cahtnr-
niallcalm&Smil �c.Sormax,25305,25533 and 255YI.lundersundthat itdte landing /p 267
does not cu y h it knam,mat is my Mspunsihility to notify the occupant of of the
require hic Oat
ante dacertificateof Ueu ancg [lire Of Ap 'cant Dale
U'�8
Owner hori.edagemt Date f coverings to be Class "B"or better