00110054 (2) CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS CROWN ROOFING INC PeRMH`Ak-11. 10054.
1.0525 JOHN WY
OWNER'S NAME'. APPLICA'I 3 D 11_ 7
VAN EPPS JOE_ F AND SAMANTH A 21,4 CRISTICH I_N 9,I vu]1 2021 I
PHONE: SANITARY NO. CONTROL.NO.
(408) 365-7444
❑ Z ARCHITECT/HNGINEER: BUILDING PERMIT INFO
�00 EC1'
1, PLUMB MI 11
NI,UO Ii
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LICENSE])CON'rRALTOR'S DECLARATION ]Ob Description
" 1 n 070 alllmt Lha an cOlue d under pmvtemn,oCChupr e9lannmeve... '
F�^J whnstth,tn00on,mmi,innamtnolwane tlnaPrnrw,ninnncant,I,namrlimn,e REROOF OVER 1 LAYER OF EXISTING SHAKE WI '
¢y is in lull l'nac anA cffin,
as
w O¢of LiccLic.b
SHAKE
xoa Date to
ARC]IICS DECLION
1 J :I 1 YPI' Illb' o eJ Pblicurd:
�wr
1
u�p ' t hoc
X ac
p h, OWNER-BUILDER N BUIL UI R UI CI 1RAI'ION A/
ny Liffinin rhan I a., bar, he Contractor l r r the
HZM rrich g .(S t 9oU.5 li dP f..- hco e y city ray
z eT o nth y issuance, I I I I .11 p d net,, P. t 'rete - •�
❑3g pr,redhsedpecsoayu the O)vise1.1I n lar Wrhpennr uodvam Os(CnfCmeTl V
than he coccng itparte mnme pre t, nr me enNmnnes unarm—ion, OIL) Sq. FL Floor Area aluation
(enact,11,1,a with Saran]Iron,of Div~bion 3 of the Busman and on Ali ore Crdc):
nr mal Ile�.31.5 by
mnarrnm and or nasi,let ase no,tIf6 astmpnon.Inv Iphamn
orsecrnn 7011sby anydiest dollar,
IX)). subjaw me eppLcnnl n,acivil pctwlry
Irl,at,nnrtthou 0vehanareaanllam(aslnl. APN Number Occupancy Type
°I,as Owner of the property,ar lay emp3oyee.,with wages as their sole compensation.
will do IM1e work,mW IM1e structure Is sot imanded or ulferel for sale(See.7094 Ga
Rnaneas moa Prole—ton,Cod,The Contractors License Law does tint apply to un ��. _ egUlred Inspections
w of property Who huildu or impmvcs thereon.and who does such work hmuell
or thr ugh his own ea,yoye- provided that ILIel,tnopree nal,are nnf mtny ea or 305 — FRAME .
uRefed for sine.It.M1ow c the buildin•f can is sold within are car of r
'con"Isli the owncrhaildcr will Live(M1e buNen of holin,,hal he dud nor hard or ,.
improve R,pnrowe of alt.). 507 — INSULATION
IOC<I _
°3.a nnhe prnpal!. .eln.,ely c„nnacra,will,licensed anmmemr.,to 601. — ROOF TEAR OFF
Lsash,,ihcrpn�Jml(sea.7044.Rush...and Profennion.e Core.)TIN Cmnrannr, 602 '— ROOF PLYWOOD hIA 7.1_
lmnxe Law noes,tor apply to an owner of pmpery who brokk,,imprnva,tharcon.
call who contracts car such lnnicc will, a conn anon'/ uannta prlr,tmm rh
to e 603 — ROOF BATTENS
Cnnlmco"Lian„e Lay.
01an, . hc,h .r See. B&11Cmrfhi,coo — ROOF IN—PROGRESS,
64?4
owner Dane
WORKIJZ'S COMPENSATION DECLARATION
I hereby ulEnn undo Iwnally of battery one al tile following declnnrriom: -
❑ 1 have Iu,J will n ainain n Certificate of Con,enl to ,el6lmnm for Worker',
Cmnpwuaioo, m provided for by Station 3700 of the Lubar Cndc, for The -
penor Loc of the work for which Ihi-c,nor,is.,,.ad.
°I have and will mnimain Worker's C( cn'slion Insma e's.as required by section
3700 of the Labor Coda,for the perfommnce of the work for which mid Itcrinit Is '
sued.My Worker's Congmnsnnon Insurance carrier and Policy number arc
Carrier Policy Ni
CERTIFICATION OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE _
('lois011m recd ret be..... lerial if IM1e pct nit ,fur enc harried doll-
6 or Icns.l '
I comity that in the perfuri tance al the work for which this per nil,s issued,I
,hall nal enryloy any par any n eas toim
biome sublact to the Workers' -
Comptn,ntio I Law,of California.Ilacannern
Applicant
NDncE TO APPLICAN'C If,aIle,nation,this Cenidcare of Escngelon,you should
Z be,oun—hlca n,he Workers Cnmpcla,,nion pmsim nnf he Labor Cndc you nue
Q Q forthwith comply with such provisions or this pemtit,hall he Accred revoked.
z ,
fn
CONSTRUCTION LENDING AGENCY
5 I hrk for nhinn that mcrc iv a mn>W Sec. 3097,0,a,mmy trot he perli,rmm�a _
Lia of the work far x'hich this prnnil in I„nel(Sec.3097,Civ,C.)
B. Lender's Nana
� z
Z I,endcr's Andres
V C) Iceniry that) co,'ead this nppllcatinn and sue that rhe above infurnalinn i,
[�. ..act.I a,u la conryly with all city It I manly adinunm,and saa law,mlarn,
i, ,,houlthn,conawainn.and herchyarLie orim reprecnmrivu—I ILL,city ,,,Lear
mupon
hoahnva. emion,J Pro,cy for inspection porprous.
F y Ova)agree u,won,Indmnniry ad keep M1arna ss the City of Cupertino against _
ata (n liunilia annu reance i cthe anJ r,of to w,,h'nay In any way:theme a,ninM,aid
U z C,lyin r,,od hren.nl'the,realm,nr Ihi,ptnnh.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Jss d Wby: DBIeSOURCE REGULATIONS.
Signa mm of App3icanl/Cuntraatnr Data e-roo 5
HAZARDOUS MAI ERIAIS DISCLOSURE
Will theapplicant or Seam nodding occupant store or i haeam„t.hill Type of Roof
a dcfimpe
tf w,me Canian Manidppt
al Code.Chapter 9.12,and flue Ileahh I Safety
Gnaw Sui a h 2553xtala Cl No h
°
SW
ll be rasp coed fort any roofing material being installed.
Will lheappht:IntOrWork budduh,ux,u,amusu u,nnanOrdcvice,wloVhstalled tho [first terata r an inspection, 1 agree[o remove
to coat nw.ardnns air eI broinam,rodulinal hythc Hay Are.Air Quality Manquican
Distdce tats to ins ection. A-i a understands and will comply with
0Ye °N sour re ulation,
II 'J lhch 't til. ry til and Ch'pl " oI IM1e /J
Calil Health&Safety Code.Sections 25505 25533 425514 1 I undmat
if,he I I I y l Fly L 'truant,that y responsibility t oruly the - .
cupan of the reyul mans which Inmr be reel prior to'Inaance ora Canlecae ur
Occa"nncr pplicant - Date `
owner or aahnhf.cd a,aa Dara All rp6f coverings to be Class "B" or better
OFFICE