02030079 (2) r CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: PERMIT NO.
822 MILLER AV RESPONSIBLE ROOFING INC 02030079
OWNER'S NAME: APPLICATION SUB DATE
PEARSON ELEANOR J TRUSTEE 2882 SPRING ST 03/15/2002
IPHONE: (650) 969-6151 SANITARY NO, CONTROL NO.
y O O ARCHITEC(ENGINEER: BUILDING PERMIT INFO
E sal❑ BLDG ELECT PLUMB MECH
O U IJ IJ I--1 L_7
ni LICENSED CONTRACTOR'S DECLARATION Job Description
i Z_G 1 herebytion70 ufnrm that I am ofthe J under pod Profe of ns Code.
(commencing P
:ar; with smion7000)ofDivision3ofineBusinssondProfessionsCoJe.andnryliccnse REROOF.
s in ruI1f( elf«t.me en
.owe 4«nslLass 4 c,p r A T/O & DISPOSE OF EXISTING ROOF,
i3 Dte cammw" APPLY NEW TAR/GRAVEL ROOF
u.O t' ARCHITECTS DEC TI
S I undcrsmnd m,plans shat]W used av pu tic mcoMs
i e O Licensed Professional
a." OWNER-BUILDER DECLARATION
DECLARATION
u� to
1 hereby affirm that 1 am exempt from the Contractor's License Use for the
C?4 following reason(Section 7131.5,Business and Professions Code:Any city or county
which requires a permit in construct.alter,improve,demolish,or mind any stmclum
Poon t also req __the Applicant for.auch person rile aigned statement - -- -
of the Commcmrs License Law Chapter 9 ---� _- - -
nnam r aid pursuant n '" provisions;. ( P S . Ft:Floor Area- , $ !.�Ilgation
(can, exempt Shthe om an The iamnoonheland Pen.Any ns Code) , i L�j�}:._L"q k .JVs .sY k'Vt.."I� 'i i , " �'t'. 6d'Y�
or Shut he 731.5 bthemfrom and me basis for the subjects
thalleged exemption.Any l Penalty -
of Section 9031.5 iv any hundred
um for o permit xubj«ter me applicem m a civil prnahy
.or not more than rive nanama aonars($slw). 37Mf2'd;Y8tb`U0 t .. Occupancy Type
111.as owner of nhc pmtixrt,or my empleyces with wages as their role compensation.
will do the work,and She structure is not intended or offered for sme Sic.](W, - - --- -
Nesmesn and Professions Carle:The Comment,a License Law does not apply to an 305 - FRAME Required Inspections'
nwre
r of corm,Who builds Lir in:pinves mereon,Lind who does sacs w,,,k himtdr
ar tpmagn his own however.employees.the
Wildid that such improvements are not intended or 307 - INSULATION
:ortemd rt],vle:u,nawevei,me bddein t:,oma wimin one .. or — - _ -. _._-- _ _ _ -' _ - . -.....- --
gorumen ofpch Year ..._. - I _ _ -. ..
ca:npler:,n.menwner-baJaerwiuhave menareenafpra.mgthat nedid not wimar 601 ROOF TEAR OFF .." . ..
improve to,palpa.e eferale.). 602 - ROOF PLYWOOD NAIL
�
.. °I,as owner nnneprnperty,amexclusively contra6mgwith licenaccontractorstn _. - 603 ROOF BATTENS. ..
- - construct the project See 704,1,Business and Pofea.amrs Code:)The Contractor s 6 0 4 - ROOF IN-PROGRESS, :' ,
License Low does not apply to an owner of property who builds rt]improves merean,
' and who comrai s.for such.projms with,a eomractor(s)Iicetsed.pursueal to be, .__--_-_ -
CommctorsLieenseLaw. .,
-. ❑l am exempt under Sec. .B&PC far reason �B��Nts�®
_ Owner' - Data
WORKER'S COMPENSATION DECLARATION
I hereby AM.code pcnah,of pe�I r,one f,he fallowing declarations: APR 19 2002
i•° I have and will maintain a Certificate of Consent to self-h ure for Worker's
Compenandon, us provided for by Section 3700 of the Labor Code, for the
Performance of the work for which this permit is issued
BUILDING
°1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for She performance ofthe work for which this permit is
issued.My Worker's Compensation Insurance lamer std Policy number are:
QaIpI r I O 4 (icy N /7 �.c� fZ/7o// r f• k P� ;..-rr:� v ^j .
+' CPR IPICAEXEMPT'ION F OM.x'OR/gER�
:;:COMPENSATION INSURANCE-"•
" (This section need nm Ive completed if She permit is for one hundred dollars s "� .t :'
t($100)or less.)
1 certify that in the performancenn the work for which subject permit a issues.I
.hall not employ any person in any ate' ,xo as m become nvbjea to the Workers'
Compensation Laws of Culil'o. .. Doc"
;
NOTICE TOctto APPLICANT,Worker
L after Compensation
this Ccnins of of Labor Con.de,you
ticcomeh comply
the Worker's Colons or
p.honer of ed Labor Code,ydu must
0 Q forthwith comply wim such provisions or Shier pertain stall be deemed revoked. '
-
'� CONSTRUCTION LENDING AGENCY '
a", thereby affirm firm mere is it consomelom lending agency for the perfomArAe - '-
ef,ne work for which miap mtit is issued(Sec.3097,Civ.C.)
QLender's Name.:...._ ,.. ... L.:.. . .._._: .. . .. r..... :.
;D,z Lender's Address
- ..1 .. .
U � t
1 certify mot I have read be application end store mm the above information is
cotrcn.1 agree m comply with all city and county ordinances And state laws relating
to buildin6 eonslniction;:rad hereby:imhoiim representatives ofthis city to enter upon
the a.vc%o,'m1oned Procan,for inspection purposes. .
r0. (we)agemlo save.indemnify and keep harmlessme City ofCuperdona agaimt
Vi liabilities,judgments.cosier and expenses which may in any way accrue against,said
U z City in consequence of me granting of this perhin. B .
PPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT. y:Issued by: r Dale
_ tk'RCE CATIONS... . '
- 'Stgnu urc orAppl cant/ amntenr r . '. ,' Dane. ' Re-roofs
HAZARDOUS MATERIALS DISCLOSURE "
x n me a Coon f tam Wilding lCo a.Chapter
Wore or natal n salt materia Type of Roof
as def d b the 3 t] M Cad Ch pt] 9 12 and m Health tl Snfcry
Code S i an 25532(el i� P � n l 1 :.' � t�� ' . •,
0y. •• ❑N ' I t. '�i 3^ •• ' 1 All roof§_shall be inspected prior to any roofing.material.being.installed. -
wt]meappl c..,t a.mw en la g txcupam Liu equip t a <er which If a roof is installed without first obtaining an inspection, I agree to remove
emit hoaardous tar tom naris As defined by the Bay Arca A!,Quality Management
Dismicl7 all new materials for inspection. Applicant understands and will comply with
°Ye °N all non- oint'source-regulations.
P g
1 have'cad'he h x rdoui'marcnals q it ems under ChapleAgi of She
Califomie Health S Safety Code.Sections 25505,25533 and 25534.1 understand that
ifnhcb, ildiag does not currently have,tenant,that it is my responsibility to notify the - ' "
occupant of the requi,emenrs which must be met print W issuance of a Certificate of
Ciocepancy. - Signature of Applicant Date
All roof coverings to be Class "B"or better
Wirer uthor¢ed ag n
OFFICE