03040023 (2) FOW
TY OF CUPERTINO
yp� ���yyy�1t s
BUILDING DIVISION p�l'RMIT O r �ORlltlF� °AN:
s zn4'R qv.$^
01�180UsCRESTLINE DR JIM KRAUSE ROOFING PERMITNo.03040023
e 's E: PERMIT ISSUE DATE
�� MODINE 2310 DIANA AVE 04/03/2003
E; SANITARY NO. CONTROL NO.
(408) 779-0704
ARCHITEC IENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
lam'
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
1 herby arRrm Net I am licensed under provisions or charm,9(commun=ing p
with Sccdm7OM)oft)ivldon3offt Buri anend PTofeWoN ,andmyliw h
'+ lefullforeeende@pro -ate uc g —S CY3
LI=ennC C.%Is v / REROOF
J......
RC.... gOECWRAT'ON T/0 COMP. SHINGLE , ADD 30 3 FELT & 30 YR.
I understand my plane Mall W used u public meords COMP. SHINGLES . °
Licensed Professional kms+
OWNER-BUILDER DECLARATION [� ']
Z 1 hereby affirm Nu "
I am umpt from the Contra Ton's License law for ds JUN O 9 2003
p o following moon.(Section 703 1.5,Business and Proresdun Cade:Any city or erumy
which requires a permit to common,alar.Improve,demolish,m repair any swctue,
gNu, prior m lis tsmmce,also requires the applicant forsuch Permit rile signed moment
gyy''< that he Is licensed pursuant m the provision of the Connector's License Law(Chapter 9 Sq.Ft.Floor Area VI�D'� Valuation
pa (commencing with Section 7000)of0ivulo,3 ofthe Budnuuand ProfeWnns Castle, B G
B that he B e¢mpl i emfnm and Or buts for the alleged exemption.My violation of vp
nowt a.Mona comer°aupiw•(15m).anbjteu the.pplinntmemvll penalty of ApN Number Jricbt�6y Type
❑I,u matter the property,a my employees with wages as thehanle eorepenu0on.
ando th "�' de utIntended wesipall.ca �e romfe. acodcow comncLicense Laesamapr u36224042 . 0 0 Required Inspections
propray who builds m Improves Wharton,and who doeunh work himmi r or through hal
ownemployers,provided U l mhimpmwmmumnotinwxlcdmofiured forme.If,
heweveethe buildingmimprowmeal iswld wlthinanyeat orcompledm,meowrcr. 305 - FRAME
builder will have the burden of proving that he did but build or improve for purpose ser 307 - INSULATION
"to.).
❑1,as owner of the property,am"elusively consenting with licensed ronvutms in 601 - ROOF TEAR OFF
convect the project(Ser.7044,Business and Proresalen code:)The Ommictm's U. 602 - ROOF PLYWOOD NAIL
cense law don not apply to an owner of property who builds or improves therein,and,
who contrast for such projeeu with a=onlnetor(s)licensed pursuant to the Ceremonies 603 - ROOF BATTENS '
License Law.
❑lunea=mmundn Seo .08PCfmihtsmason 604 - ROOF IN-PROGRESS
OwnerDau
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury,ore of the following dechroula e
hew and will maintain•Cenifnm of Cone.to self•Inum for Woreces Compen.
an,as provided for by Section 3700 or the labor Code,for the performance or the
work fm which this permit Is imwd
haw and will maintain Wmkefs Compewdon Iwnnce,as required by Section
is of the labor Cade,for the parcone ecof the work for which this permit is issued.
My, mlwY C�Ssmmmttro l n Imemoce carrier and Policy number m:
Caller: ;.7—A_,Polley No.:28.$-owip go
r• CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thusecdon need naMc cmnpleedlfthe permit Isfmomhundrtddr im(SIM)
or leu)
I terrify that in the performance of the work for which this permit Is Issued•I Mall Will
employ any pence in any summer an u m become subject to the Workerf Compensation `
Laws or California.Dae
Applicant
NOTICE TO APPLICANT.If,ager making this Cadfinte of Exemption,you Mould
become subject be the Worker's Compensation provision of tie Labor Code,you mus,
0 O forthwith comply with such provimn or this Purnell Mall be dcemed ewl d.
CONSTRUCTION LENDING AGENCY
(-t ti 1Wmby affirm Nal them is smnuunion lending agency far the Performance or
the work for which this permit ts issued(Sec.3097,Civ,C.)
W�Q Lender's Name
."J Z Lender's Address t
U Q I comfy that 1 haw read this application and mm that the show InfarmMun is
V, correct.I agree to comply with all city and county ordinances and mu laws misting in
Q building mnuuction,and hereby authorize representatives of this city in enter upon the
{id abew"mentiondpopeny for lnpection pu0usea
(We)agree m ants indemnify and keep harmless the City of =gamins agdns, Z
ry IlaNllti(We)g r e in core and mpensos which mayinany my City
of Cupertino
&&Clay /)
U Inn
woman,c of the Bolting of this permit.
APPLICANT UNDERSTANDS ANqXIjL COMPLY WITH ALLN N OTNT Issued by:S4"&0 Date
SOURCE REGULATIONS• r dt331�
7 // Re-roofs
Slmsture a(Appllesrancom
r D
HA7A
HAZARDOUS MATERIALS DISCLOSURE Type of Roof .
WIII y t applicant or from building e,Chapter
sore mmul thandle huallous metrial
es defined by the CupeNw Municipal Code.CTapmr 9.11,and the He.lth and Sealy
Cods,Section 25532(a)7 _ All roofs shall be inspected prior to any roofing material being installed.
❑Yrs
Will the applicant or future building occupant use equipment or devisees which If a roof is installed without first obtaining an inspection,I agree to remove
t hmudom air comminns as defined by out Bay Amo Air Quality Management all new materials for inspection.
met?
Yes *K
l haw mad the hmmdousmaerim requirements under .Chaper0.95of the Califor. -
it=nllhgrentlyhawaSertimu15505,13533mtl2553i.londcnand thetlfthe building .. 03
dm not currently hew a mnmt,that it h my responsibility to notify IM a upanl or tire
mgmremen.1�k Tomb tpriarmivyyter sera caure.ear Opry .�j Signature Applicantf� Dale
Owner or suthrecd a est
All roof coverings to be Class"B"or better