01100040 (2) CITY OF CUPERTINO
BUILDING DINSION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10750 BROOKWELL DR CAL-PAC ROOFING 01100040
OWNER'S NAME: APPLICATION SUB DATE
VAN DIJK RICHARD AND VIVIAN E 36 RAILWAY AVE 10/08/2001
' PHONE:
(408) 369-7444 SANITARY NO. CONTROL NO.
GOO ARCHITECF)ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Zee a LJ I"_- CJ L:.I
LICENSED CONTRACTOR'S DECLARATION
•5 ? Job Description
z t2—0 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
tots wini,hSeaion]q0)ofDivisionJoflheBusinessendProfessionsCodeandmylicenx SHAKE TO DUNLAST FLA
Ss ren roree and erne,.
c w 6 Licenx Class Lic ,x
O a O Dale Contractor
In ARCHITECT'S DECLARATION
gI undersmM my plans shall be used as public r«orris
Sp O Licensed Professional
nOWNER-BUILDER DECLARATION
t� 1 hereby.(Seed that 11. uempt from rise Comrams Co e:Any Law for the
C?< following rcass n.(Section]03L5.Business and Professions Curie:Any city orcounty
$9991
I F O which requires a Permit to consomat.aper improve,demolish,or repair any swain
u°13 Po .Pno ... ..alsarequires Jx ppRanm
zfarsuch part"a fa
les,gnd eswmmem.
e.
(cothamencin i Sectiouotepronno aofto11Busines mile Low(Chepter9 ,t`.jr��C' a Valuation
(commencing g t,its 2000) fD basis
a thc.Bjed Business An vi Chile) (•{,)*s,'1•{3�9'Z ,V,,y(y,,r'1Yd�1{t'L rzT{{;y .
or Jut he,s Bumpy any applicant
and the bass(or the alleged eaerepnibn Any violation
-of S«don 20713 by any applicant for a permit subjects to applicant m a civil penalty •
rof not marc than five hundred dollars n5Jo). 3 0 gSPN*RkQM {' - ' Occupancy Type
❑I,as owner of the property,or my nnployecs with ,as as ncicir sole compensation,
will do the work,and the stra Lure is not intended or offered for sale(Sec.2064,
Business and Prokssfons Code:The Contractors License law does not apply to an 601 - ROOF TEARquID'EOnspections 3,
cr of property Who builds ar improves pves iWoom.and who does such whimxlf
ork
or trough his own employeesprovided that such improvements are not inmMed or 602 - ROOF PLYWOOD NAIL
.Offered for sale.If,howeva.,he Wilding or improvement is aold within one year of 603 ROOF BATTENS t _
- --' -' - -
completion,the owner Wilder will have the human of proving that he did not Wild or , "
improve far Pugnse ar.ale.)' 604 - ROOF IN-PROGRESS
.. ❑L as owner of the pmpeny,am exdusivdY contracting with licensed cormorant to
_ conswd the project(5«.9044,Business and Professions Cade:)The Comnemr's
Li.law docs not apply ro as owns Of property who Wilds or ind"ovu thercon,
and who contracts for such projects with a conuactorts)licensed pursuant m rhe- _ . ..
Contractors License Law. -
❑lamtriennia underSoc. '•,B&PCfor Nis rcawn
Owner ES '' 'd Q
' WORKER'S COMPENSATION DECLAMATION ( ^ /
I hereby aRrm under Penalty of perjury one of the following declamations: -(/
❑ I have and willnuhad.a C<nifica¢of Consent to self-insurt far Workers
compensation, as provided for by Section 37M of the IaWr Code, for to
tsmOrmonce of the work for which this permit is issued.
❑1 have and will maintain Worker's Cm.KnOttion Insurance,ai required by Section
37W of the Labor Code,for the performance of to work for which this permit,s
issued.My Worker'.Compensation Insurance carrierend Policy number i m:
Policy Nis:.... -
- CERTTFICATION OF EXEMPTION FROM WORKERS t.-{• °.1 "'c !I'. c. .':Irl.. °:' yd•.:,:
COMPENSATIONINSURANCE„ 7, ' ... ... .-.... .._.. --_. ._.-I
ca le non o,he m
need nmplereJ if trm
o peit is forone hundred dollars
($100) IcssJ
1 certify That in to performance of the work for which tis ptorm,is issued,1 - -- - '
thrill nor employ,any person in any manner so as ro'become subject,to the Worken' t„l •1'=s 1
Compensation laws of California:Dam -
Applicant
NOTICE TO APPLICANT.If.after making this CcniOure of Lampu oric.y yshould
ou
Z b.h.iihummlly rh Imchcre Compensatmn provisionseribeof ed Labor Cade,you must i
� 0 fonhwilE comply with such provisions or his permit shall be dttmed revoked.
CONSTRUCTION LENDING AGENCY '
a->a-Q o1 herby ffirm tar to'_is a ,Ier-.Wing.a..g.ency forme prtonace
ftFwwkfarwhichtispmitisimued(SW,302,CivCJ
Lender's Name i
.. ,.
v._.- ..-..t.. ...
UCZ Lender's Address,
1 certify that 1 have read this applicmion and smte ihauhe above inf srmmion is '
I54'Fr Correct.I agree to comply with all city and county ordinances and state laws relating
to Wilding construction,and hereby authorize representatives of this city to anter upon
rhe above-mentioned property for impcnion puryoxs.
(We)agree to save,indemnify and keep harmi the City of CLperium against J^V/
Vi liabilities,judgments,costs and experts which may in any way accrue aain g said /� ✓' f
(,7 Z City in consrquenc'e of d o gaming of tis permit: / e
g
APPLICANT UNDERSTANDS AND WILL COMPLY WrfHALL NON-POINT'
SOURCE REGULATIONS . Issued by: Date
Signamrcof ApplmanUConvactm,' Re-roofs
` :'-.Dam
HAZARDOUS MATERIALS DISCLOSURE
ng pant wort pr handle haramous mat t
•',and toappspant r nae Wdai « - 'm Type of Roof
as de,Sed io to Cupcn M' pal Cod 11. 9 12 a d IM Healy and Safely -
Code ❑Ys25532(a) tONo ° A. 1{ .-st ff� '. tll.t: lu'fYy i\p. It ztr ? li4.J.i2
-, ,All roofs shall be.Inspected prior to.any roofing material being installed.
WIIt so
turf bailinedding by the otom
yAse ea Air Qu litsor which If a roof is installed without fust obtaining an ins ectidrl;13 agree IO remove
emit hazam ra i.s, ail find byte Bay Ares i r equipment
Quality Management g p g
Damumdo Ya ❑rya '” all new materials for inspection. Applicant understands and will comply with
all non-point source regulations;
1 have read Ne hazardous trmcnals requirements under'Chagcr 6.95 of the
Califomla Healy&Safety Codc.Scptions 25505.25533 aM 25534..1 undersand that
if to building does not currently have a xoom,tat it is my asponsibility m notify the
«caupapon m
of the requirements which must ba' et poor to issuance of a Cenif,Ce¢of -
..� P'. Occncy.
Signature of Applicant Date
= -�L Owner orsummarized agent _ Date All roof coverings to be Class"B"or better
- - r ... "• ' OFFICE