03060197 (2) • CITY OF CUPEWHNO ao-k
BUILDING DIVISION PERMIT ilCONTRACT�ORhNFORMATION
BUILDING ADDRESS: T D ROOFING PERMIT NO 03060197
OWNER'S NAME: 3540 MARGATE AVE . PERMRISSUE DATE
ONE: (408) 892-8872 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+00 LICENSED CONTRACTOR'S DECLARATION
�ro❑ 1 Worthy affirm that 1 am licensed ender provisions of Chapter 9(commencing Job Description
Z with Seclim.70DOWDivision 3olthe Business and Professions Codd.ind in,license is
infull nmd.naerrdcl, -� REROOF
>n? License Cla Lic.X_ F� s�A //a p �pv�
t•o Da¢ GOmf ECL B 419 N'@,Rw. 3e�
ARCHITECTS DECLARATION
I'S.U I undersand my phos shall be used as public records
k JUL 1 0 2003
'.0
S Licensed Professional
OWNER-BUILDER DECLARATION
a0 1 hereby.(firm that 1 am exempt from the Contractor's License Law for the BUILDING
00 whnwing mesoa.Permit
t ]O3 LS,Business and improve,
dri nm Code:Any city m county
<$ which its has a permit m canton,aloe.improve,demolish,or repair c ssmnum
prior is issmncc.also rrquimnw applicant for such Permit Oleasigncit satememsr
E�0 that he is licensed pursuant to the provisions or the Contractor License Law(Chaplet 9 Sq. Fl. Floor Area Valuation
yt-di (cum meneing with Section 7000)O(Division 3 of the Business and Professions Code)or
- that he is exempt therefrom and the bums for the alleged exemption.Any violation of 32630168 . 00
SaboOrLSbyany hundre dollafarapeemiosubKctstheepplinnno.civilpenaltymf APN Number Occupancy Type
not rota Nan five hundred scant forrs a Per.
❑1,as owner of the pmpeny,or my employees with wages as their sole compensation.
will do the work,and the structure is not intended m offered for sale(See 7004,Business
and Professions Code:The Contractors License Law docs not apply to an owner of Reyguired Inspections
property who builds or improvthereon,and whodoes such work himxlfor through his 307 - SM
NSULATI-ON
Own employees,previded that such improwments are not intended or offered for sale,If. 601 — ROOF TEAR OFF
however,site building or improvement is sold within one year of completion,the owner.
builder will have the thodcn of proving that he did not wild or improve for purpose of 602 — ROOF PLYWOOD NAIL
sale).
[11.as owner of dre proNny,am exclusively contracting with licensed contractors to 603 - ROOF BATTENS
convect the proicm(Sec.R344,Business and Professions Cal0no Contractor's Li- 604 - ROOF IN-PROGRESS
deal law does not apply to an owner or progeny who wilds or impmm daemon.and
who contracts for such projects with a contractor(s)licensed p ermilm to the Contractor's
License law. ,
❑I an exempt under Sec. ,B&P C Tor this reason
Owns Dae
WORKER'S COMPENSATION DECLARATION
1 hendby anitm under penalty or perjury and of the following declarations:
1 has and will maintain a Cenificad of Consent to xlf-insum for Wurbir s Comped
anon,as provided for by Section 37M of the labor Code,far the Perfurmame of Ne
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance,u required by Section
3700 of the tabor Code,for site performance of the work for which this Permit is issued.
My Worker's Campewtion Insurance carrier and Policy nvmberan,
Cartier. �{ a -••��a PolicyNo.: 4156
CERTIFICA OFE%EMPnDN FROM OR ERS'
COMPENSATION INSURANCE
(This aemhm need not w completed if tbe permit is for one hundred dollars Di FOR)
or less)
I certify that in the performance of dm work for which this permit is issued.1 shall not
employ any person in any manneru az to become subjnvo the Worlsom Compensation .
Laws pf California.Date
Applicant
NOTICE TO APPLICANT:If,after making Ibis Certificate of Exemption,you should
become Subject to the Workers Compensation provisions or the labor Code,you must
.J ,Z foMwith comply with such provisions.1 this permit Shall be deemed revoked.
Z'O CONSTRUCTION LENDING AGENCY
.4 1 Wmhy arfirm that there is a cormmminn lending agency for the perrom udec or
Qi the work for which this permit is issued(Sec.3M7,Civ,C.)
Under's Name
a .Z lenders Addxaa
V Q 1 ttnify that I have read this application and sac¢that the awrc information is
it. P cored.1 agree 10 comply with all city and county ordinances and sold laws rotating to
0 U building cdnstmdalon,and hereby authumexpmxnwims of this city to corer upon the
rabovomcationrid property for inspection parpoxa.C. (We)agree to save,indemnify and keep harmless the City of Cupertino against
rq liabilities.judgmcnts.costsa"' Orrtses which may in any way accrue against aid Ciq
Uz mconseyuenecoftheg arcingof this permit.
" APPLICANT UNOE STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:% Date
SOURCE RE NS
6 30 o Re-roofs
Signawrc of rcam/Contracmr Date
HAZARDOUS MATER DISCLOSUREType of Roof
Will due applies.,or or building am num or handle havarduua material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
cpde,section 2ss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
Yes
Will thea scant or f m wiwin Occupant axe If a roof is installed without first obtaining an inspection,I agree to remove
PP g p equipment or devices which g
it wrardous air contaminants as&Imcd by Ne Bay Area Air Quality Management all new materials;forTinpection.
s ricR❑Yrs
I have teal the haraNc aterials myuimmcna under Chapter 6.95 of the califnrnixHealtha Safety Code.kiniumus 255(15.25533 and 25514.1 undersandthsiflw wiiJing ` X /c 7j0 �3
does not currently hale a tenant,that it u my respomihility m notify the occupant M the b
mquimments which meat or met prier to issuance or.cemfida praapxey. Signature of Applicant Dale
Owner or authorized agent Gm, All roof coverings to be Class t'B"or better
CITY OF CUPERTINO
awn REROOF
,560 l `1
OF
CUPERTINO PERMIT APPLICATION FORM o3
APN # 3 Z� Date:
Building Address: '�((
x-0$88 GireevAtca � dS-tr &- er a CPc 9 01 ¢
Owner's Name: C-v c,y Ing°`\ Phone#:
Va» � c, la «� e✓ �vo ��vz 13 4o8 9 3 — 951
Contractor: c. e v e.�r Phone#: License#:
T D IZ4o-6 a.4cl to4 ;L— GTG6 as
Contact: Phone#: Cupertino Business License#:
Davt d Noaw yob 5o9 14-19
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles 'A Asphalt Shingles
47 Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings!— ❑ Provide I.C.B.O.Report#
l9� To be Removed ❑ Provide Mfgr.Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: C
ve t,voock 6Ltctl.Ae_ V-e(�Iac� vv/ 30 -i Lr Urn,
Residential Commercial ❑
Fire Zone: No Confirmed with Pla ' g Dept. i
there are anyres ctions: fi
C st of Project: Type of Co
nstruct n: Occupancy gr p:
nstru
Qty..if
A c e 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