01100094 (2) CITY OF CUPERTINO
' BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10696 JOHANSEN DR. JNSJ ROOFING INC 01100094
ALOWNER'S NAME: APPLICATION SUB DATE
SIMON YEOUNG 299 D BASSETT ST 10/15/2001
ImPHONE: 4082796171 SANITARY NO. CONTROL NO.
tea ARCHITECT/ENGINEER: BUILDING PERMIT INFO
y G ELECT PLUMB MECH
N: LICENSED CONTRACr0R'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Descripti n
„N with Section 7")ofDlai.irn3aftheBnvdas,rndgafassdn.Cndnand mybeenx REROOF.
f—se is in fan force and arc
ig6j LittnxClgss X39 tic.. _20T/O & INSTALL TAR/GRAVEL.
Date ID ISS Cont
ITECT'S D CLARAT ppN
,ej 1 understand lar plan.shall be used as p tied.
i r
g O ucemcd Pmressinnal
OWNER-BUILDER DECLARATION
6 R 1 hereby aRnn that I am exempt from the C....'s license Law far me
L 3 a following amoo.(Section 7031.5.Branner and Professions Code:Any city of canary
E F O which requires a From to construct. Iter.improve demolish,or repen any swemm
C _ ._ _ ._-..______. _........_. .._.._ -..-.
e 3 m ' pia t t issuance,d q t._ aFP aunt wmc pun�sm t°•nig saamem- - - .. - - -
(co h 's1 sedp rs a ttom Provisions / y Sq.-FC Floor•Area, , ll YY 1 ration
or
(commencing a,ehSeolofirmnad thebasisor t to alluspetradPmfAnyvi Code) l ( *a�� 1 �,_ L )A 4.si4 E1.1.k Ll�o '
or mat he is exempt mcrtfrom end the basis far the e116the k licam ,Any violation
of Section than v any applicant rs a permit subjesa me eppliunt m e civil penilry
of not mere man ave hundred aanars(SSW). Occupancy Type
❑h as owner of me pmpe ty,or my employees with wages as their sale compensation,
will do he work,and the structure is not intended or oIerad for sale(Saw.70 .
'Business and Professions Code:The Contractor's License Low does not apply to an 307 - INSULAT I14Wired Inspections'
owner of property WW Wilds or improves merman,and who dine such work himself 6 O 1 — ROOF TEAR OFF
or through his own employees.provided that such improvements arc not intended or - - - -_
offered for sola If,howevea the Wilding or improvement is sold within mr,year of 602 - ROOF PLYWOOD NAIL
completion,me owner-W ildcr will have the burden of proving that he did not Wild or
imvro,e roe purpose ar tial°')' 603 — ROOF BATTENS f _
o1,as owner Witte pmpeny,'e,aa.ask,sly c.mocan,with licensed camacmra m - 604 - ROOF IN-PROGRESS
construct the projen(Sec.7014,Business and Professions Code:)The Conttawar s 1
. License Law does not apply to an owner of property who Wilds or improve thereon,
and who contracts.for such projects with a cminaramKs)licensed Pursuant to the
Cont _ �� LE C 1 -Contractors License Law, ®�
- ❑lam airstrip,order See. B&PCforthismosan 2 t ....
Dana Date - ` OCT 2 3 2001
WORKER'S COMPENSATION DECLARATION t
1 hereby aRrm under penalty of perjury one of the following dechrookar: pI�1�/'�
❑ 1 have and will maintain a Certificate of Can.,In al6fmure for Workers �u'LD''s�G'
Compensation, as provided for by Senien 37W of me Labor Code, for me
_ performan«of me work for which this permit is issued. ., '
Whave and will mainmin Worker's Compenmtlon Insurance,as required by Section
of the Labor Cade,for me performance of the work far which this permit is
issued.My Workers Compensedon Insurance carrier and Policy number are:
CaQ1hWn2l4tt.:Tmt.,Ca par,-yNo.: WC249199627
CERTIFICATION OF EXEMPTION FROM WORKERS', '- '�}v` ] s`r-'t' n p:'s _•. " ', s l •t-J-
COMPENSATION INSURANCE;' .-..-.__- ...._ ..-. .. _-.. :
_._ _ ..... .
.. I ( :
(Tho xnidn neednot be uomplcted if the Permit is for one hundred dollen - c
(E1W)or lcssJ 1
1 certify that in the performance of me work for which this penNt is issued,1 j .• et(•n..
shall am employ any parson in any manner s,as m become subjat m me Workers
Compensation Laws of California.Dam
NOTICE TOAPPLICANT.
Worker'.Com. -
Applicant
O APPLICANk:r,after making this Ciikaas ,0 Latoo Tonle.Youshould
Z Wchme subject pematton Permit shall
or o o tsWr codrevoked. mast
zO forthwith complywith such provisions or mice permit shall W deemed revoked.
Hto '6 CONSTRUCTION LENDING AGENCY ) "'
a 1 hereby affiim that them is a construction lending agency for the performance
fel of me work far which this permit is issued IS,c:3097.Civ.C.)
Q' Lender's Name
O.Z Lender's Address
I canary Nat I have mad this application end sou thin the aWve information is '
Izcerreet 1 agree or comply with all city and di
county onancar and state laws relining
1.Wilding smostoraflin,and hereby authorize reprexnadves ofthis city to enter upon
ythe above-mentioned property for mspechim Imfose,
(We)agree to save.indemnify and keep harmless the City of Cupertino against.
Fa V] liebiliti s,judgments,costs end expenses which may in any way mama against sai0
C.7 Z City in rnsegt nee'0 tae gaming of mak permit -
APDL NLATIO, NDSAND WILLCOMPLY WITH ALL NON-POINT Issued by: Date l/ �01
D 1 ao.
igna ofAppli amiC HAZVRmn r ' m Re-roofs
HAZARI3 5 MATERIALS DISCLOSURE -
Tai up int t t Wilding pa tstore whandle hvudous thermalType of Roof - - --'
is d f nano Municipal Code Chapter 9.12.and the Health and Safety _ '
Code Sates 255326) /. �. r0, y _D'. :. 'lilt: 40,,
❑Y : '' C°f"° �':: 'I s ,_All roofs shall be inspected prior to any.roofing material being installed... -
Will the applicant 0rfuture Wilding acupantuse at,ipmentwdevices which If a roof is ihsfalled•without first obtaining an inspection;d'agree-to`remove
emit M1emdous air cminum mrs�ed by the Bay Area Air Quality Management
�` y District? " all n w materials for inspection. Applicant understands and will comply with
A-
� O0Yaa ON. all n n- i regulations..
'arJ 1 nave tend fire heraadous marshals mquiamems under Chapter 6.95 of me
Califomia Health&Safety Code.Seamans 25505.25533 and 25534.1 uadersterd that a _
if the Wilding does not currently have a anent,that it is myresponsibility to notify the
IX[apd which most he mel poor to imamate of.Ceniol .Of
Si re of pplicant Date
Io IS 01
DI to mired a trade 11 roof coverings to be Class"B" or better
OFFICE