03110128 (3) CITY OF CUPERTINO
BUILDING DIVISION PERMITCOIVTRAGTOR�INFORMATnION
k*m.
BUILDING ADDRESS: R E ROOFING & CONSTRUCTION "Tt4t"003110128
SWR'S NAME: PERMIT ISSUE DATE
WALD FERNANDEZ 152 11 /21 /2003
PHONE: SANITARY NO, CONTROL NO.
(408) 925-9995
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
o t� L t�
j0o LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm the,I am licensed and r provisiue of Chapter 9(commcncing Job Description
i with Rection]080)ofL7I ajqn3 of the Busi and Profcesioe Cede.md Uicense is
infmlra n err / *;g
� REROOF p�w��License Lic. a ll�'0Dau 'e1/1 ARCNITE DL I ts c.tan my Puns eh"I W tau is
a° 9 2003
it j Li nseJPmfcuionel DEC
OWNER-BUILDER DECLARATION
I I hereby affirm that 1 am exempt from Ne Conuactafs License Law for the ��'�'�
00 following mon.(Section 703 1.5,Business and Profasioe m Cade:Any city county o
3 o
S� which mOd.a permit to construct,slue imPmw,demafiah,m repair my nruaure
zy prior In its issuance,also requires theapplieant for such Permit o file a signedstatement
that W is licensed pursuant to the pmvisions of the Cenmctor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
222 (commencing with Section 7800)of Division 3 or the Businw and Professions Cntic)tar
i $ Not he is exempt therefrom and the basis for the alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit subjects the Applicant o acivil penally of 3 a1PN4\QiUer0 0 Occupancy Type
not more than fin hundred della.(SSW).
❑ I.As owner of the propcny,or my cmployea with wages As their sole compensation,
will do the work,and dm structure is not intended or offered far sale(Sec.]6th.Busimas
and prorwioe Code:The Conusctres License Law doe not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements art not intended or offered forssb.If.
however,the building or improvement is sold within one year of completion,the owner.
builder will ban the burden of proving that be did not Wild or improve for purpose of
1,as owner of the pmpcny,am exclusively contracting with licensed contractors to
construct the project(Sec.7064.Beinw and Praressians Code:)The Contractor's Li.
cense Law does not apply to an owner of property who Wilds or improves Nertom,and
who contract,for such projects with a eontrachet licensed pursuant so the Contractor's
License Law.
❑1 am exempt under Sec. .B&P C for this moon
r Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following delusions:
❑I haw and will maintain a CeniOce,c ofConsem to selhinsum for Worker's Compere
talion,As provided for by Section 37W of the Labor Code.for the performance of the
wank for which this Permit is issued.
❑I haw and will maintain Worker's Compensation Insurance,as required by Section
37W of Ne Labor Cade.fm the performance of she cork for which this perm itli\s issued.
and Policy
C r i C CERTIFICCOMUSATION7INSURAN WOcart �ERS_ V .
(Thu shim recd not he completed if the Permit is for one hundred dollua($1 W)
or leas)
1 certify Out in the performanec of the work for which this Permit is issued.I shall not
employ any person in any manner an As b became subject to the WokmW Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after making this CeniOcau of Exemption,you should
become subject to the Worker's Campcwtion provisions of the labor Code,you met
.,z forthwith comply with such Provisions or Nis Moral Shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
I hereby%Roto that Ncrt is a convection lending agency for NC Performance of
(3r'' 7 the work for which this permit is Wood(Ree.3097,Civ.C.)
{[7 Q Lender's Name
= z Lender's Add. _
V 0 I modify that 1 have read this application and sake the,the above ofammlon Is
bandit.1 Agrce to comply with all city and county i mcof and sou laws relating to
0
p building construction,and hereby%ulhomprwewntatie rtwa of this city to enter upon 0t,
%Mve-mentioned property for iePccdon purnmeaL
(We)agree In saw,indemnify and keep liumlw the City or Capetian Against
W Iiabilitieu,judgmeots.eosu and catamount which may in any way accrue against mid City
V jara note
of the g.nung of this Permit.
APPLIC UNDERSTAN ILL COMPLY WITH ALL 0 -POINT Issued by:9 Date
T ONS ^,
l•'�7 Re-roofs
gnaturc pplicenU�Cn&nRDOUSMATERIAfS01RC URE raeW oke Type of Roof
Will du applicant or future Wilding occupant mom at handle haendous material
ss defined by Ne Cupertino Munmi 1 Code,Chapter 9.11,and the Health and Safety
.Section 15531(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
oof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equip=jfft
ich _�--
colt havarO us air conbminans u defined hy�the Bay Arca Ant all rte .fDLLerials spection.
District? I
❑Yes qqgS
IWwreml Cods,SNmemateriasrequimmenu under onT2� 0,TiaHtalth&SafetyCode,ucamnns15505,2mymor11553a.1a ing
Juba not currently haw•unanti N�{.' it my msponuibilitY b dfY Ne oceullant oC !
qm it ohl2DgPton or.CcNhcate Occ Signa re.00Applican(
12 All roof coverings to be Class "B" or better
orizcJ%gen, pam