00110129 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HUB.DINGAIyplf!$.Yi90 ORANGE AV KEITH ROOFING CO INCPERMIT NO.00110129
r IWNER'S NAl PVJV APPLICAl 10 SIIi )Br
I�pNG JIA—TANG AND EMMA J 93=0 LINCOLN AVE /2000
PHONED (408) 295-8616 SANITARY NO. CONTROL NO.
❑mZ ARC(III'EC'17ENf11NIiER: [WILDING PERM11INFO
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y firmthSED tIaCON'CRdunderpUECLARATIONsofChpt Job Description
OO Z�, thereby a1Bnn that I am licensed under provisions of Chapter J Icomn¢ncing
p,n�q with Section70101of Division 3 o the Bwiness and Professions Code.and my license TURN R CAP
6 in in fail force and Telt (� (/�8
C ce I.iccnre Cln/1— —1 I.ic.M
s a S DEC u
AK shall:e l"S I1,mb
C� � 1 nnderatanJ I,Iy pwnr.rnan 1,:assn L,habhe reenm. -
a4 w':.
ca
p 0 hiccnscJ Pndcssinnal
OWNER-BUILDER DECLARATION
I hereby a1Bm,that 1 am exempt fmm the Contractor's License Law for the
C? following reason.(Section 703 L5,Business Part Pmfcssians Cole:Any city or county
Ito
which require jamout inconvenor, It p J r4,or repair any:t cturc
prunrl I alsal maladies(he'III' : II It'cof file P signed'famomnt
iatlse is 1 1au"a the n„,.........lfl 11he Curlrai1 c Law ILhper9 Sq. FC Floor Arca Va111r7�t
nwn1p[�0
(e,n ,g wlham Sl7fNgBar D'v Pt 13 rl live'I3mn . Jlrtle', Code)
j� tl
or that he is exempt Ibemfnen and the hxsis for the alleged exemption.Any violation
of Section 703 1 S by any applicant for it Permit.subjects the applicant In a civil pa ally
PF not mom than five hundred dollarsSgn). A PN Number Occupancy Type
35719063. 00
❑1,d un'ncr of the and
the ,m my employees sPro with wages as(heir soli le(See,
7044.
will do live work,ani the odeIh is not intended vl or c Law for vole(Sec loan
Rus ,nnJ crl,WIP,m Cale: ... mW,,hcr n,lcenm Law doer h w..pply m an Required Inspections
anf pmperty build sIa such andwin)
..us are wadhlnumr 305 — FRAME
ffirre filo hi,own cll,pinyva,.pmvideJ Ibnl such ilnpmv cow a not ine year
n
offered1'ars;Je.II:hnweva, be will
avete hnenofprtvinsoldliedidoneuildor 307 — INSULATION
�m,repletion,the ar-ofsaildp will have the burden n[pmving that he did mit build lir
pmve rte Pamse lir attest. 601 — ROOF TEAR OFF
01.a%owner(if the pm,city.am exclusively contracting with licensed carearcums Ill 602 — ROOF PLYWOOD NAIL
sumer the podw(Sea 704.1,Business and P-essionx Colb,)The Contractor's
ud who coutfats forapplysuch
In ran owner thpc,Pnywho balltN iceorllnpmmaii, t the 603 — ROOF INATTENS
—PROGRESS IId won a,ntmntn for.Pel,Prnjxty with I.�,Plmmnnnl Peel,nen pPmuam In the 604 — ROOF I N—PROGRESS
CoIlan,cl, Liacnvclaw.
❑1 nm excn,pt ander sec. .B Nr P C for This reuse
Owner nam
WORKER I'ENSA'rION DECLARATION j
Ih hy'0 J ,speu'alylly fpc3 y fth f II gJ I i s:
❑ I M1 ' I will itin a C YI 't C all"Iono,na for Worker', l/
Conuperocatiwu. P, idea ill, by Scat 1 1701) Af'he I-abc, Code, for the
,rianusucculll k l h' h mi 1 1 J.
❑1 have and will maintain Worker s Canlpcmal on hourcurce.loaquinedbYSection
3700 of the labor Cale,for the perfnmtantt if the work Iia which This permit is
issued.My nrA is Coyy,nJJ�/P�P,e�num nn Insumnvc canieran�d Policy numMr are:
Cartiee t '^� Pulley No.:4-7 ALO �I�
CEIi'1IIlCACION OTT%hMI'1'ION PROM\VrlRIGiRS'
COMPENSATION INSURANCE
(Thiscticm need not he completed if tireIm
per nit is for o hm,dred dollars
($110)or Iew.,
1 certify Ism in the performance of the work far which this perms is irsueJ.1
shall not employ any person in any manner ro us to becume subject its the Workers'
Gnnpensation law.v of CPlifncia.Dam
Applicant
NO110E'10 APPIACAN'1:It,after mm
making then Ccmfiue lit E ;M
eeaim,.yea ehrndd
becmne,,bjco fo the Warker',Canp,eowtiou pmv'n,an,ol'he Labor Clair.roil oust
Q Q forthwith roundly with such provisinm or UP,lrcrme shall he dccmcd revoked. -
E” = CONSTRUCTION LIiNDING AGENCY
4' I hemby whims this m is a conrva ce. lending agency for the performance
of the work Ric which this permit is issued(Sec.3097.Civ.C.)
D Q Lender's Name
7 z Lcndar'<Addmss
U Q 1 ccrity Inns I have Iced it,,,up"Ifiwinn and mmc Ihnt the above inrormution Lr -
Lsc correct.l agree to cmnply with all chy Pull canny uNinmmes null stale laws relmhng '
Q [� :P Wilding construction.and hereby aorepresentativesn
onue representatives of this city ,enter upon
the aMve-mentioned P ),my for mr,,embn porpaws,
(We)agree to save,indemnify and kccp harmless the City of Cupcnino against
tq liabilities,judgments,costs and expenses abmh may in any way acme against suit
�,J Z tINIA,14i
ee of the granting of this permit.
DP ND ANDWILL COMPLY WITf��NO -POPPY Issued by: \, �(/ Date (� (G.�•V
—
' mracmr Dale Re-roots
LARDOUS MAI HK ALS DISCLOSURE
Will the applicant or future building occupant store lir battle havNcws mamdul Type of Roof
us dermis]by the Cupertino Municipal Cole,Chapter 9.12 and the Health and Safety
Cole.Section 255331st)"
O Yes ❑No All roofs shall be inspected prior to any roofing material being installed.
Will the applicortortuturebuilding,.eapantPNC cyaiplucotmdeviecswhich If a roof is installed without first obtaining an inspection, I agree to remove
moil baaer loos ail'cont urinann r dchncd by the Boy Acca Air Quality M'nu,anent
ly;,,,;e„ all �Gwaterials for ins eclioh. Applicant understands and will comply with
0Yes El No n0 oint Sour r allOnS.
1 have read Inc harardnur material,reyoirements under Chapter 695nflne
fnm
Coliia health R Safety Code,Sfcllan
oos 25505.35533 and 25534.l denmal lhm /
X't."
s nm currcmly M1uveamnanl,Ihm it is lay re,ponsinday m Panty Ine `ll Parri which must ht'Piet prior nl islem Ceof.t rtlftcnC n
Z;/ e of Applt a Date o-,e I roof coverings to be Class vB" or better
OFFICE