02030103 (2) CITYBBILDI,C DIIVIISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20253 CARTWRIGHT WY OLD COUNTRY ROOFING 02030103
OWNER'S NAME: APPLICATION SUB DATE
BLASSER WILLIAM H AND JEAN C 387 UMBARGER RD #B 03/ 20/2002
'e PHONE: SANITARY NO. CONTROL NO.
' (408) 362-1111
❑s Z ARCHITECT/ENGINEER:
M O O BUILDING PERMIT INFO
U BLDG ELECT PLUMB MECH
5 N= LICENSED CONTRACTOR'S DECLARATION ]Ob Description
I herebapty offitm that I am licensed under provisions of Chapter 9(commencing P
with Sation]I100)of D;vision3of the Bus�rca}'naexs dmy Rance REROOF.
:O W U ua�o0i d ° L;e/M1` "c an REMOVE 1 LAYER OF SHAKE, INSTALL
+atec. D1 C°"" 30 YR 422 " FELT & GLASS B HEAVY SHAKES .
�y O ARCHITECT'S D RA ON
g 1 understand my plans shall be used as public records
r�af
S o O L¢cnsed Professional
Oat I am exempt
from
DECLARATION
I hereby affirm thin 11, exempt from the Contev,mr,Cor e:An,c Law for the
?a following pares Permit
]031.5, r.alter.arta Professions Cade:Any city s cony
E`O V,which requires a permit to construct,applicant
improve,demolish.artor repair any swnum
3 poor to a e s La q the ppm cam for such permit to file a Low(Chapteem
V,
he . dp _uann th v Division
the Conanines License Low(Chapter S F[:,Floor Area- 2ftle
(commencing with Sect ]000) fD ion3artheijidwand Professions Codc) i�i'� 5'r:ruq.tl+:k t.v t' f�!\'1�:1a (; �•.i $ atlon -
or that hers 31.5 b thcmfmm anJ the burs for the cis the adman to Any violation
of Section]031:5 by any applicant for a permit subjmx the applicant to a civil pcnalty-
:ofnal mare than File hundred aorta..18500), 31 N`MG`!P UUo : rC Occupancy Type
❑1,as owner the progeny.or my employees with doges ef sale compensation,
-will do the'wmorkf and swd
the is not immnded'orb(fared BJ
for sole(Sec.74," - - -
'Bnslnesa and Pm(esrmn Cade:The Cmitaulars License Law does net apply in an 305 - FRAME Required Inspections;::`ii I ; r
owner of property Who builds or improves thereon,and who dins such work himself
tor throat hh ow ply p dee Nat n p ma t ma�agr 307 - INSULATION
offer d f,r salt.If.h -< the bold, - -"' - -- -- --'- -- --- .. — _._._ -g P em-: Ia 'tadn yeldar 601 - ROOF TEAR OFF ,.':*,;•:' .. _. —c."
completion,N cr bmlder will have theburden of prosin6 that he did not build or
improve forputpaseorsala). 602 - ROOF PLYWOOD NAIL
❑Laathire pmjcc y gwi _ ..----- - -60.3._.-...ROOF- BATTENS----`_--- -`-...---- -- - -
:: Property,am exclusive cnn«aain lh lianud con"aclors to
I:
_ onswat the project(Set.appl]Oa4,Business and Professions Cotler)The Contractor'cporl t
and-wiWwaasnot .sucmanowneroracommmps)ibtsusead . va,R,th, 604 - ROOF IN-PROGRESSr ''
Can' Livens-fors... Projec¢.wiN a commuorts).licenwf Pursmm to the. - ._..__._..__.__..
Commcmr's License Ww... - __..._.......__.._....
❑l am exempt undeISO Q„ ;B&P C for Nis reason
.. Owner' . . ; Date '.. c. .
WORKER'S COMPENSATION DECLARATION
' Ihereby affirm under penalty,of perjury;one of the following declarations:- —1ow
ALE
O 1 have and will mainatin a Cenificuvr of Consent to self-insure for Worker's
Compensation, as Provided for by Section 3700 of the Wbor Code; for the APR 0 2 2002
perfomunce'of the work for which this permit is issued.
❑I nave inn will maintain No lmr's Compensation Insurance;as mquireA by,Section -
3700 of the Labor Code,forthe performance of the k'f which this perm t
issued M W rkei's CC pe bol pane cameo and Plliicyy number
.. .. Po1;cr NaJ
ly CERTIFICATION F F EMPTI FROM WORKERS
'CO
COMPENSATION INSURAN '
'1oa" (Thua
- ionticcd not be completed if the Permit is for one hundred dollars �� .. .�
1E100)o less
s.) -
-ff
I con lay at any,Ne p in rt e of&rner rk fo hien u ct t s r lied,l
man ..._ I":•
Coca at employ wi pe y mannc to bceomdsublea m @e Workers' "•
.,.'AAprils so an win '
pplicant .: .. ., - .. - .: .
NOTICETOAPPto It Ailk if aflrmk or, CnRt fEe pi° h IJ ---
subject
Z becomener,ly It No k C ge roto p cions11 the bar Coate you must
z � fonhw th comply cairn such prove ons onhn pcpm t shall be nee cd revoked. ,
. .-.. .. . . . . . .. -.._... ... ...._... . .. ._ ._...... .. .._ _.._.
I.: 1
F'^ "CONSTRUCTIONisaLENDING AGENCY '
a I h by affirm that thems construction 309O
C agency for the performance'
gL,:c 'Under','Nam p iv C.) :..
Isntl Address d 1s 309] C
of the k for which this t 's tic
11
Z
. U O I certify that 1 have mad this application and state that the about inficienation is '
(L,;(✓ v.el.1 agree to comply with all city and county ordinances and stere laws palming )
D..0 to building conctime,on:and hereby ml haanammprcsenrnms ofthis city to enter upon
} W the abo t ed property f inspection purpose _
[� Cs (We)agreet ate dmn'fy dkeep harmle the City bf Cbperi agent
(A liabill< I ad yL,c sin tl ex s which may n any way cc .,.a.,,said
U,z City i co cyuF c,fR Ne grant f tM1ii perm t
SAT ICA U "STA YD WILL COMPLY WfT13 LNO(POINT' 1 t//r-'�
so c 1 ns d Issued by: Date
stgnawre orapPI n or _..:.. '•.,..•.:;:.,' Dais, Re-roofs '
adef e4l theC CLOSURE 'i
Will
avpuH�n MuniciMdAgle..Apsmswiornith Health ad -.. .Type.ofRoof_._ ..,.,,�._--.., ..
Cupertino Municipal c pal Code Chap¢r 912 d the He hh and Safety ---
Code.s❑Y,25532()" p r(N
- t e tt ' All roofs shall be inspected poo;to an roofing material being Installed.
:
Will the - r bulang cup atee9mv to a i«s which If a roof is installed without first obtaining an ins ecticiDE Pagiee.toremove
e pct dcontaminantsat defined by. Bty AmorAirQuality Management. g p
District?,
ia'n t { all new materials for inspection._ Applicant understands and will comply,with
all",orip'oint source regulation§ t I _ ;,-_,,I
r 1 hal,e rLd the hatialt- menaB qanchicas under Chapter'695 cif the -
Califem a Health Code Sections 2550-5i25533 and 25534 1 understand that'
'ifthebuildinsnort mend have 'nt.that it is my responsibility to notify the
Occup t ¢qui n6 whi st bemiet mm,m izsuria of a Cfnificam of - - - - - - --
Occu71,
.
" - - Signature of Applicant Date
" 'ow""ar,°tri°^= t ": ;. Dine .. . All roof coverings to be Class "B"or better' '
- OFFICE- -