03030095 (3) CITY OF CUPERTINO "fit' �
BUILDING DrvlsloN PERMIT �COIVTIt'ACTQI2 TNh'OKMATO .
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aauiLDING ADDRESS: ERNEST DAVIS ROOFING PERMITN.03030095
m7DINA CT
OWNER'S NAME: PERMITISiUEDATB
ONE: - SANITARY C OL NO.
(408) 210-6133
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION lob Description
I herby off.that 1 am limsucd umm,provisions Of Chapin 9(mmmcuing
i with Seviermuf10)of Diviaton SofW Budrtw and Profeaaiuns Cole.aMmylicense is
_ in full forte and crcecc
,ilg Lmenseelts. L .. REROOF
Dam ARCHECTSDECLSRATION T/0 SHAKE, INSTALL PLYWOOD & 50 YR. PRESIDENTIA
�ieD uM slenJmyplanssull umJupuhllertnrJs COLOR SHADOW GREY. CONTRACTOR: ERNEST DAVIS ROO
iLLp Licensed Professional
OW NER-BUILDER DECLARATION
eI hereby affirm that I am exempt from the Contractor's License Law for the
❑O following mason,(Section 7031.3,Business and Professions Cole:Any city or county
$ which re drai a permit to ennslmot,alter,improve,demolish,or repair soy structum
Fly
prior it)itissuance,also mquiresthe applicant fenuch permit to file A signed miscreant
that he is licensed pursuant to the provisions of the Communes Sq.Ft. Floor Area Valuation
¢�$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)lir
y .• Nat he is exempt thmfrom and the bub for the elbecd esempdm.Any violation of 5,14800
Secdon 7031.5 by A"Applkmt for A permit subjects due applicants W A Civil Penalty Of. APN Number Occupancy Type
not mom than raw hundred dmlarm HOOD.
❑I.0 Ownerofthepmpmywr employcuwi0ms uftkmlecmponuum,,
willdo 0ework,andthe.uuctum isnotimanded ororcered for WefsecJOlA,Business; • OO Required Ins actions
and Profusions Coda:The Coreactor's License Law dots not apply m an owner of 9 P
propeny who builds or imymms themon,and whodocuwh work himself orthmugh Ms
.employ=.provided distance improoemenu Am not intended oroRered fwsale.If.
however,the building or Improvement b sold within one you of completion.the owner.
builder will have tM burden of proving that he did not build or Improve for purpose of
salcJ.
❑1,u Owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7W,Business and Profusions Cade:)The Contractor's Lt.
came law dots not apply As an owes of property who Milds or impmw thereon,and,
who convects for such projects;with a eontracmKU licensed pursuant o the ConuxtoYa
License Law.
❑IamuemptunderSac .B&PCf.,Oi,..
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury oro of the following declarations:
1 have and will maintain a Cerdfcate of Consent to self-htaure for Workers Creation.
1031'W
ion,u provided for by Section 3700 of tlm labor Code,for the performance of the
rk for which this Permit is issued.
I bave and will maimtaig Workers Compensation Insurance,u required by Section
of the Labor Code,for the performance of the woh for which this permit is issued.
y Worker's Compensation Insurance caries end Policy number mc:
rtier; Paltry NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(DO;section it notMcomplemd iftie peonh b fesenc hundred dollar(SIW)
nr leu)
1 Crotty that in the performance of the work for which this Permit Is issued,l sad)not
employ any person in Ory Winner an at b become subject to Ne Worlmor COmPanmallan
Laws of Callfomia.Date
Applicant
NOTICE TO APPLICANT.If,.(mr making ON Ccnifrcam of Exemption,you should
become subject to the Worker's Compensation previsions of Ihn tabor Code,you must
�Z forthwith comply with such prnvisinu or this permit Mell he deemed revoked.
zCONSTRUCTION LENDING AGENCY
�••rto)
I hereby aflUm Nat then is a construction lending agency for the Performance of
C'5 the work fur which this permit is issued(Sec.3097,Ci,C.)
WA 1-mikes Name
C Loubrs Address
Z)z
U Q 1 certify that 1 have mad this application and sum Nat Cha.boss infnrn.om is
LL (" Correct.I agree to comply with all city and county oNinantta and state[acts relating to
OU building construction.no hereby authurim representatives of this city mentor upon the
ahow-mentionW property for inspection purposes.
LL (We)agree m save,indemnify and keep harmless the City of Cupertino Against
wcn liabilities,judgments.Cwts and expenses which may in any way seems against mid City
U,'Z in consequence of the granting Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature:of ApplicaHAZA Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will theapplicant Or future Wilding ic.Chanutumor handle Hauth and Safety u dcOncO by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calm,&do.23532(att All roofs shall be inspected prior to an roofing material beim Installed.
1 Y. ONO P P Y g g
Will the applicant or future budding Omupam um egaipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hauNnus air contaminants a defined by the Bay Arta Air Quality Management all new materials for inspection.
D
istrict?
❑Yns ONO
I have mut the hxvardous materials requirements under Chapter 6.95 of the Califor.
Health&Safety Code,sections 8505,25533 and 25539.1 undemmrd Out ifthe building
not currently haw a moans Nat it is my responsibility m notify the occupant Of the
uirements which muss be met prior to issuance Of a Ceniftcam of Occupancy. Signature Of Applicant Date
ncrw au@arisJ agent Dam
All roof coverings to be Class nBn or better