03030114 (2) CITY OF CUPERTINO
BUILDING DIVISION - PERMIT CONTE CTO A'TNPOAI'AYl�T"
' PERMIT NO.
BUILDING ADDRESS: KEITH ROOFING CO INC
PEm'T LSU."D610 3 0114
OWNER'S NAME: _ 920 LINCOLN AVE ,CgN;gpy
P SANITARY NO. 0 3 21
(408) 29578616
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: - BO ELECT' PLUOMB MOFLN'
jp LICENSED CONIKA iUn'S DECLARATION lob Description_
+� 1 hcrcM1y eHirm then I am licertad under provisions of Chepor 9(commencing _
whb Secdon7= of DlvmItm3ofdw B..hM, a Pfofculunn CNI ndroylica all FINALED
in full forte
to
'z LlcenseCt l- Lie.0,
"ROOF REPAIR
p Dem Comosm -
££7W =NrMCrSD�D MAR' 2 1 2003
C 1 understand my plan..lull he used u pu li cords
i
G1 Licensed professional
OW NEno clemOER DECLARATION BUILDING
0 2 I herebykso.(hero Nn 1 1. exempt s an the CommWo mm'sCN Licence law for the '
00 followingpermit
(Section7 construct.
Business end are.detlnns Ca de:Any cin Of county
$ which its i su a pmm0 re cores the elms Improve,h ICImitt or repair any awment
cture
primmitatensedpalantto IN the Applicant for of the sucContractor's
LicensMe I e
iLsw(chmmem Sq.Ft. Floor Area Valuation
ecthat tectacing wit pursuant 70th)provisions3thehe usines'tLttnalaw(CNIC)9
t$ (commencing exewilherdn basis for
of theeged exa and PrnfcuinnsCak)or B,�jQ
a.. then he Is campynyjptherefrom and IN bur fm the alleged eampdnn.Any it penalty
of PN Number - Occupancy Type
Section 7031.5 a mydred dolt for a permit subjecss the applicant to s civil pentlty of 1635009 . 00
not more Nen Ow hundred dollen(5500). � � ,
❑1,u owner of the property.or my employees with wage.u their ale campeme0on,
will do the work.and 01 tomoe1.not Intended of offered for sle(SM.7°11,Bualneu .3.Q 5' — FRAMLtcquired Inspections .
and Profeselou Cade:The Commasmes License Law does sol apply to an owner of - ,
property who bulldsorimprows thercon.endwho does such work himself or through his 307 — INSULATION' .
own amploycu.provided that such Improvements are notinumded oroffemd for Asle.If. _
however.the building of improvement Is sold within one year of comPledon.the owner. 601 — ROOF TEAR" OFF
builder will have the burden of proving Chat W did net Wild or Improv for purpose of 602 — ROOF PLYWOOD NAIL
Asia.).
1.as Owner of to property.am eaclunwly contracting with licensed contrcton to 603 — ROOF BATTENS -
Construct the project(Sec.us no7011,Business and Profusions Code)The Computer's U-
'Cas
ms Law doct apply to an owner of property who build,or lmpomes therean
on, d, 604 — ROOF IN—PROGRESS
who Mnumu for such projects with a coommu(s)licensed Pufsusn to the CorVanors
License Law. ,BB:PC far Nr mate.
I am exempt mules Sea
Ownu Dam
WORKER'S COMPENSATION DECLARATION -,
1 heroby affbm under penalty of perjury ON of IN following declarations:
wand will maintain.Cenifhcam of Consent to ACIf4mum for WorkersCompo-
u provided for by Sinton 3700 of fine Labor Code,for Ne performance of the ..
oI which this permit is issued. - ..
I eve and will maintain Worker's Compensation Insurance.as myuimd by Section -
C33 of the labor Code,for the p ommorceof do,work far which this permit Is Issued.
My WofCe,c.mp union sum a eamtcrand PC]MynurolaMr�m� ���
Ce f Icy No.: —7
CERTIFICATE OF EXEM ON FROM WORKERS'
COMPENSATL NINSURANCE
(Mi,actin.need not hecamplemd lithe permit is for one hundred dollars($100)
or len.)
1 aNfy that In to pednmmom of IN work IN which this permit is issued,I shell not
employ anypec on In my macer an as m Weemcsubjecuo the Worker'Compenpdon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this CertlRcam of Eaempllon,you should "
become suhjael to the Worker's Compensation pavilion'Of fie labor Code-you must _
Z forthwith comply with such provisions or this permiuhall IN deemed ranked:
T 0 CONSTRUCTION LEN DING AGENCY
1 hereby affirm that them r a construction lending agency for the performance of
F.
7 the work for which this permit Is issued(Sec.3097,Civ.C.)
W Qlenders Name
91, Lender',Addrsu
t)z I ceni(y than 1 haw mad this application and stain that the show infarmauur Is '
W comes.I Agree to comply with all city and County oNtnames and sWe lam mailing to
D V building COmMctlan,and hereby auNoriu Mrsmamusto s of this city to eros Upon the
N U above-mentioned propony for inspection Pon--
F LL (we)agree to As indemnify and kap harmless the City of Cupertino against s�
h lisbillliu,jud .cos adexpensunw whiehmayinanymysceme against mid City
V,'�Z in COn CILIA soling of this permit. Date
APP ANTU RSTANOS D COMPLY WITH ALL NON- 01 Issued by:
S RCE R LATIONS.
ZI Re-roofs
of antConl ec ane a of Roof
NAZAR S IALS DISCLOSURE j]P
Will the applies.[or Tum uthing oocupsutnom or handle haAsrdous material
As defined by the Cu;,M1mO Municipal Code.Chapter 9.13.and the Health and Safely
Me Section --- All roofs shall be inspected prior to any roofing material being installed.
OYu
Will the applicant of future building oceupem Asa equipmrml or dcvlas which
If a roof is installed without first obtaining an inspection,I agree to remove
it humolous air conmluns u defilwd by the Bay Ara Air Quality Management all new materials for inspection.
sutct7
❑Yes No
a haw mad five huaNlws mamftalsmqum mems under Chaorfi.95 of the clan.
jdacm
r Hulth&S 'ao23505.25533med25534.1unMmm�dumifdm building
no Only a temni,that is my msponsiMliny hwufy to accu t Asa
menu mush el aissuehmeof fm oflk Signature of Applicant Date
All roof coverings to be Class"B"or better
red agent Dom