03020110 (2) CITY OF CUPERTINO ? '�
BUILDING DIVISION PERMIT iCONTRA.CTUR�IN1?ORMATION
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BUILDING ADORES$: E ROOFING PERMIT NO.
21421 MILFORD DR 03020110
M'S NAME: - 925 W 17TH ST PERMTTISSUEDATR
MURAI TOM AND ROBERTA 02/26/2003
NE: — SANITARY NO. CONTROL NO,
ARCHITECT ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
30o
0oLICENSEDCONTRACORSDECLARATION Job Description
it M
1 rtby affirm that I em licensed under provisions of Chapter 9(commencing
Z� with Section 70(11)afDlvision 3 of Me Bissirpis and Preload"..code,and my nceuo to REROOF
:^ In full fortuapykf(e -, "
b04LD�c�nto Clavl� `f COnvecmr ZS T/0 WOOD SHAKES, INSTALL OSB & 50 'YR.
3
A cxrfacrs RATION PRESIDENTIAL SHINGLES
all
unM d my p andl W wed u public recortle
Pmfeadome wo /� LECC
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OWNER-BUILDER DECLARATION - FI,tl/ D
I I hcmby in.that 1 am exempt from the Camrsnmrs Lismse Law for the
p o fallowing neasno.(Section NO 1.5,Business and Professions Code:Any city or county
$ which requires a permit to construct,actor,improve,demolish,ee repair my someone
f S^ prior N its issuance,also requires the applicant for such permit to file a signed comment MAR I
€< IMI he is icensed interaction to the provisions of mc Conuectariluense Law(Chapte,9 Sq.Ft.Floor Area Valuation
Fag (commencing with Secdon 7000)of Division 3 of die Business end Profwions Cade)or
�" 3 N.I he Is exempt therefrom and the basis for tic alleged eacmption.Any v)oluien of RI W
Section 7031.5 by arty applicant for a permit ubjero die applicant to a civil Mostly of APN Number yType
not mom than five hundred dollen($500),
❑[,as owner of Ne property,or my employees with wages u their auto compensation.
94
will do Mowers.and disarmers.is runimededaroffeced forsalc(Sec.7041,Business Required Inspections
and Prefasalane Code:The Commeme.License Law does not apply In an owner of q P
property who buildsor improves thereon,andwho dassuch work hlmulforthrough his 305 — FRAME .•
awn employes,provided that ah improvements are not Intended mortared feesala if.
however,the building or Improvement is sold within one)eu ofcompletion.the owner- 307 — INSULATION
Wilder will lave One burden of proving,that on did not build or Improve for purpose of
sale.). 601 - ROOF TEAR OFF
❑1,as owner of the property,am exclusively contracting with licensed conracton N 602 - ROOF PLYWOOD NAIL .
consumer Ne pri(Sec.7044,Business and Profession Code:)The Conmcm's I.I. "
cense Law does not apply.an owner of property who Wilds or improves thereon,and 603 ROOF BATTENS ,
who contracts forsuch projects with a contractor(s)licensed pursuant to the Commences '604 — ROOF IN-PROGRESS
LI law.
[=exempt der ,BkPCfor Nr moon -
t v2 2pD
WOR 'S COMPENSATION DECLAiWOON "
I hereby afllm under penalty of prijury oneof the following declareloor
V I haw and will maintain a CeniOmu of Consent to sel6insuto for Week&&Compen-
Compen-
sation.u provided for by Section 3700 of the labor Code,for the pedormenee of the
work for which use permit h lured. ,•
❑1 haw end will maintain Worker's Compensation Inum mM.u required by Section
3]OD of Ne Ube,Code.for the prdorm.nce,of Ne week for which Na permit 1.issad.
yW rkers Compensation lnacnnto carrier ted Pollc numheran:
PoI'
CERTIFICATEOPEKEMPROF WORKERS'
COMPENSATION INSUJIANCE
flits aection need nothecomplemd Erie permit Is future hundred dollen($100
or less.)
I certify Net In nh rfo encti of the work for which thio pttmlr b issued,l Nell nmI
emP1oyanyprrsen in u s bemm 51ijecuo No Worken'Comimmiuon
laws f Cti font a u /TD
NCrrIc
NGI'IC� A PLICANT.If,after mlaking Nis Ceninnto of Exemption,you should .
become subject.the Workete Compensation provisions of the Lahr Code,you muss
0 foMwilh comply with each previsions of Nis permit Nall be deemed mucked. -
.~y. - CONSTRUCTION LENDING AGENCY
fv Ihereby atRrm Nn Nen itis construction lending agency for the Performanceof
6i the work fur which this permit Is issued(Sec.3097.Civ,C.) -
W�Q Leedch Name
=z Lender's Address
V Q I certify than 1 hew read this appllnstim and tub that the above Information Is
it, F correct.1 agtoe to comply with all city and county oNinutts and sur laws totaling m -
D V building construction,and hereby authorize representatives or this city to coed upon de
W aWvemeri miW peopeny for Wpecllon purposes.
I0. (s ju gme m saw,indemnify and kap harmless Nc y. of Cupertino against
In Ileblll0ex,Oagrento.emu udexprn whish may inseyw City
Cupertino
ag City '
U 7 in consequence of de granting of Ih rmlh S -
r7 APPLICAN UNDE TANDS D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CE CUL NS. ' I
JU/g�'/�// La'o Re-roofs
Sig"naturt of Applianl/Conrnnor Dam
HAZARDOUS MATERIALS DISCLOSU�tE i Type of Roof .
.Will Ne applicant or future Wilding occupul isom orhandle huudom materiel
definedby die Cupertino Municipa ode.Chapter 9.13,and Om Health ted Safmy -
e,Section 35533(07 All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
Will the applicant or mw.mildiry occupant use equipment or dmias which If a roof is installed without first obtaining an inspection,I agree to remove
I
t hueMous sir anmminenu u dented by Ne Bey Arca Air Quality Management al;n:ew:materials for in CtlOn. '
tha /t]Yes .[�N.Ihew.ad Or Msardor��\meur5.2353in 2553.1.., epmr thuir Ne Gldin / � ZOHuINBSaferyCode.Secuo 33505,35533 eed355N.l undrnund thuiflhc Wilding
o not cumntly hew.¢rte that h Is my responsibility an auly Iles Occupant of the
ul men wnkh esus Ipriorrststuanceafeccnl0ca¢ofOccul, cy. i nature of Applicant ate
ner oraumorircd seem / Dale - All roof coverings to be Class"B"or better