04110108 (2) CITY OF CUPERTINO- ..
BUILDING DIVISION PERMIT =CONTRACTOR INFQRMATI0
BUILDING ADDRESS: LINDY ROOFING CO INC PERMIT N%4110108
- 10179 BYERLY CT
OWNER'S NAME: PERMITLSSUEDATE
alk CHARLES SUM 5554 HARVARD DR 11/17/2004
ONE: SANITARY NO. CONTROL NO.
(408) 269-2025
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
n O o LICENSED CONTRACTO 'S DECLARATION lob D�pS,IrI ,,,Ory MA
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w Ile Ya(Rrm�I liz, u rnd mi'm=fC alien my he'.
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i� with�atu)of Divivon]of thcB and PfofcSJom Codc.and myliccascin On� y®ytd(r( Y 'E
^« in mBf ranee@c Lic.IS REROOF
t p Da¢ sea Contractor
�U Iundc dory its RCair cd asEG 1' oils DEC g 2004
H Licensed Profession IIr��� n
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m exempt
D Ce Conor ON 11 II II ®� p fl
<y I hereby,(firm that I em exempt from the Cnnuactar's License Law for the U I'IILy I�IO\u\IJII
pp following moon.(Second 7031.5.Business and Pmfcssions Code:Any city of county
Lm which requires a Permit to consumer,alter,improve,demolish,of midair any structure ,�4 4 5 _
Prior in its UnUm e,Shot requires the applicant forsuch Permit to Glc a signed statement _
bio thatkh6¢mcdP dam? t )ofDiSi mm3of Bu6n rkLlceawl iomC pmry - 'Sq. F[. Floor Area _ Valuation -
¢� (ret In,
ngwith Sectimsandl)ofDivision]oft al,minessandimfA"vi Cnec)of
$
that he u excmpl thucfmm erJ the basis for de Jlcgcd Gumption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
but.0.Nan love hundred dollars(S5Wk - 2 Occupancy Type
I.ss owtiu of the pmperty,amy cmployus with wegessstheir sole wmpensstion,
will do dework,and theawctum is not intended oroRerW fo nih(Sce.7(104,Bum. '
and Profession Code:The Contractors License law dnt nm apply apply to an owner of �. . . _ �, ... Required Inspections -- - - - --
propany who Wildsorimpones theroon.and whodoessuch work himulforthrough his
ten employees,provided that such improvements are not intended oroRercd pursue.If.
however,the building or improvement is sold within one year ofcompletion,the owner. _ _ _ _ —.— —__ -
builder will have the burden of proving that he did not build or improve for ptupose of _ -
Sale.).
0 1,as owner of the pre cri,am eaclmively controlling with licensed Cotmsebers t.
condoner the project(Sec.70x4,Business and Professions Code:)The Contractors Li- .
cease law does not apply in an owner of property who Wilds or improves themon,and
who contracts for such projects with a commctor(s)licensed pursuant to the Contractors
License Law.
0 I am exempt under Sec. ,B&P C IDI Nis ocean
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby Saint under penalty of Perjury one of the following declarations:
1 have and will maintain a Certificate of Commit to self-insure for W.rkereCompen-
wood.as provided for by Saturn 3700 of the IaWr Code,for the pmfmmarace at the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
31 W of the Labor Code,for the performance of the work for which this Permit is issued.
My orkcr's Compensation In nee carticT and Po icy nu kr arc:
C. r Policy N
C I A OF F7:EMMON WORKERS'
COMPENSATION INSURANCE
(This Semon decd not In completed if the Permit is for one hundred dollars(SIM)
or lesaJ
I Mnifv that in the performance of Ne work for which this Permit IS issued.I Shall not
employ any person in Say manner an as to haeme subject to de Workeri Compmeart
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you Should
become subject m the Worker's ComPemadnn provisions of the labor Code,you must
.JZ forthwith comply with Such provisions or his Permit shall k doomed invoked.
z CONSTRUCTION LENDING AGENCY
F' I kreby a1GTm that them is a mmuuctinn lending agmuy for the Performance of
cethe work fur which this permit is issued(Sec.3097.Civ.C.)
W QUnder's Name
0. z Under's Address
U C) 1 certify Nat 1 have lead this application and sum that the above information is
W F correct 1 agree w comply with J1 city and county onfinances and SUM laws relating to
0 U Wilding construction.and hereby authorim representatives of this city to enter upon de
ahwcme umind property for Impaction purposes.
F4. (We)agree to save,indemnify and keep humless the City of Cupertino against
w h liabilities,judgments.costs and expenses which may in any way accmc againsuaid City
f>z
in mmuquence of the graming.(thiS mnil.
PPLICANT UNDERSTANDS AND WI 41, MPLY WITH ALL NON-POINT Issued by: Date
UR ERH�}LATIS. / // / a// �L Re-roofs
SSAnalurc ffv/Applplia�Smmwm f'Y— Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle haudous material
u defined by the Cupertino Municipal Co@.Chapter 9.12,and the HeJN and Safety
see.Section 25532(,)? All roofs shall be inspected prior to any roofing material being installed.
Tes g No
Will the applicant or future building occupant use equipment or dcvicn which If a roof is installed without first obtaining an inspection,I agree to remove
mit hanodom air contaminants as defined by the Bay Arca Ail Quality Management all new materials for inspection.
District?
O Yes I�Ku
I Rave mad the hvafd.us reamrialsrequitements under Chapter 6.95 often Call(np ( /
his Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if tic kilding n 4
s not cunomly hare a mnanl that is¢my mepomibilily w n.tily dm occupant or Nc
r<yu' menus whihcouv •ty' imance Grd&am.(Oec.pvt.y, igna[I3re of Ap a I Date
ownm.r,.med'rcdas
DSM All roof coverings to be Class"B"or better
CITY OF CUPERTINO
( � REROOF �f ( ( � P, ZS
ICUPERTINO PERMIT APPLICATION FORM
APN # 312- ( Z bc�_ Date:
� d
Building Address:
Owner's Name: Phone#:
G
Contractor: t _ Phone#: License#: r
Z, r e.7c a / /
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
Wood Shakes_ -_ - ❑ Wood Shakes
❑ Wood Shingles - - ❑ Wood Shingles 4 ,
❑ Other(Specify) El Other(Specify) /Vyvi I-CA Z1 'A"y�
Number of existing coverings ❑ Provide I.C.B.O.Report#
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
Residential Commercial, F.
Fire Zone: Yes ❑ No r Confirmed with Planning De t. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
Qty. if -
AppliA,16 Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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