00060196 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESSi' I PERMIT No.
10760 JOHNSON AVENUE 13 Vc6ing 000601.96
OWNER'S NAME: APPLICAI'111N SUBDAI ii
DAVE ROE — &t/oo � JI I� 06/30' /2000
PHONE: 1 � SANITARY NO, CON'IRol.NO.
w 0 ARCHITECI'IIiNGINI ER: S(AII
0 BUILDING PERMITINFO
BLDG B diel PlAi N11i Ni
tiu�i I� IJ l-1 1=1
<H
y'
LICENSED
LICIh COM1 ' UR'9 DECLARATION
-
Job Description
I hereby that I am licensed underprovisions of Chapter 4 Ro Nog
Its o1M10)ffUv>pppppp3oHheBudos,wnryf6S licensew;in iml CLAR ;up
REROOF
Lnnrnctnr
3 C 1iCUi
=°g I note...millimy plans shall be mad as pubic emits
fir_
ea S p O Licensed Professional
ff
OWNERBUILDERDECLARATION
X o, 1 hereby at ion that 1 am exempt form the Connote, ,License Law for,he
F-Z S polls.in,reason.(Section 703 L5,Bmine,s and Pmfe„ion,Coi Any city or county
fx° which orapire,a evornot, tato,irer.improve,demolish, r repair any.t uurc
pdorto Illit'll loolml,h Ipl t tor suchpound t filwasignedstt tent
dn,hellbecold loolount to Inpmv, ,.III locC„t'leor,L (Chapter 11 Sq. Ft. Floor Area Valuation
(commencing with Sccuon 7100)of Division 3 of the Buones .a W Proess ons Code)
or that he is exempt hereform and the basis for the alleged exemption.Any viol$auu $6000
Lir Section 7031.5 by any applicant for a person.subjects,he applicant It a civil penalty
(if not mom man rive hundred dollars o5«). A PN Number, Occupancy Type
01.a arms,of the property,or my employee,with wages as their sole compemnsme.
will Jo,he work,and,he%trvcwrc is not Intended or offered tor sale(Sec.7044,
Rms;nms and 11 fi,,yott,Core:The Cmnracun'a License Law docs not apply on air Required Inspections
„rpmpeny WI...baBd,,,r Improver metro,and.1111doe,smm work himaelr .
.rvtl rough 1de own employees.pmmdeJ Our,Veen hnpn,eemx a Imenaea 11, 305 — FRAME
uttered fm sale.11,however.,he building or Improvenmmis sold within one year of
,umplhomr.,heownertvimerwill havemc burden of pmvingmn,he did not build lir 307 — INSULATION
impmceforpnri,ws,dnale.). .601 — ROOF TEAR OFF
O L as owner 11f the propery.am eselm;vel'contracting with licensed contractors to 602 — ROOF PLYWOOD NAIL
Li,construct the pmjca bee.7,41 Business and Professions Codc:)'Me Contractor's
ce w Law does not apply to an owner(if property who builds or;mprnees thereon. 603 — ROOF BATTENS
slid who ...tract, for rich purlcom with a r raseo(,)licen,al oromn to the
Com,aero'.^LiaaocLm. 604 ROOF IN—PROGRESS
01 am exempt tinder sec. .0&I'c ronhis rewon
Owner Dare .
WORKFR'S COMPENSAr1ON DECLARATION
I hereby a0irm under Penalty Lir perjury one or the following declarations:
Li 4t h I 'l l p d C I ', I Consent i Worker's
Como t provided r Y S ) f dw L t Oils, lot the
perItire .Is ior which pu ,is
7/
lard.
01have and will maintain Worker's Compensation Insurance. required by Scion /
37M of the Latin CWe.far,he performance or the work for which this pfn,i t is _ 0
.sued.lily Winker1,Compenurion Insurance carrier and Policy number are: - O
Carrier Polity Na:
CiiR' nzicAr1oN OP EXEMPI WN 17ROM WORKERS' _
COMPUNSAIV IN INSURANCE
(This section need no,be amnplemd nine permit is Inr one handled colla,
(SIM)or less.)
1 seedily that in the performance ol'the work for which this permit is issued.1
aha11 not employ any n any manner so a%m become%object to the Workers'
Cnmpcnsatior rCalif..min de a
NUTICETDI .R:AIPI:It.al rmukingl nCct Jinacol'lixengnionI yousho.dd -
beenme subject to the Worker's Con,penwtlon pruvmon,lir,Im[.all,,,Crile,you taus,
Q•O Emhwim comply will,sucl,provision,or Ili,pens i,shall be Jeenmd revoked.
CONSTRUCroN LENDING AGENCY
1 hereby afOnn,ha,here is a canna tion le,d;ng pgenry to, he performance
film work for which mi,permit is issued(See.3097.Civ.C.)
Q Lender's Name -
Q 7 Lender's Addrcv ,
L) O Icmlily that l little lead this apldic..lion und,tatctha,t he above ufm our is
G. t,,, mired.i agree R,eumidy with all city and county ordinance%and now law,relmi„g
Q (� :o Wildogemourrct;on.and hereby uamori,a nyresmnatives lir this city m enter upon ,
rhe aMve rentioned property for inspection purpose,.
F y (Ws)agree to w,c.indemnify and keep harming the Cityot Cupertino samm,
N City in c.judgtnems,foss and expenses lofhflema may in any way untrue again„said ,v^
U 2, city m e.judgments,
g mene onhe s and
pem,it.
t--' APPLICANT UNDER DS WILL COMPLY ?-POI Issued b Date
50 REGULA' OG B�/G y'
sig nn11cat m,nae,m nate Re-roofs
HAZARDOUS MATRRIALSDISCe or handle
Will by
the
or future Municipal
Chapter 9.12.
.had to hareardIInIth us Safety Type of Roof
as ds.Sic li me Cnperrino Municiryl QNc.Chapati 9.12.and the IIcalrh and Safety
Cods. 25512(u)?
.OYes 0 N All roofs shall be inspected prior to any roofing material being installed.
Will hea,limarlo„mamhudd;ng wlto,tre cclolamnnadeviec,wIrih If a roof is installed without first obtaining an inspection, I agree to remove
mit Eamrdons air eonwmdnatns us dclined by the buy Afca Ah,Jrmlity Management
in„der all new materials for inspection. Applicant understands and will comply with
ore, 0 N all non-point source regulations.
1 have read the hmai mumnt rcquimmems under Chapter 6,95 of,he C
California health&Safry Calc.Sections 25505.25533 and 25534.Iundernandmat G ✓ C
if the building dons nm cuncally have a would,that it is my respm%inlity to notify the J
ennt lir the mainirements which muN be mer prior to i�%s^:mce of a Cemticam or
occupancy. Signature of Applicant Date
Owma arifirmucd agent Da,a All roof coverings to be Class`•B” or better
OFFICE