00060138 (2) CITY OF CUPERTINO
BUILDING.DnaSION PERMIT CONTRACTOR INFORMATION: pp
(BUILDING ADDRESS: COSMOS ROOFING PERMIT N10006t711 JO
10300 PHAR LAP DR Y
1K'NL•N'ti NAME: APPLICAI 1 ti I
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JILLIE DON W AND DIANA B 450 SAN ANTONIO RD Y�000
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(41.5) 493-6373 SANITARY NO. CON'IAULNO.
O K G ARCHH EC'DENCINI IR: BUILDING PERMITINrO
Foo bLnc PI.Ecr • PLumB MIFCH
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LICENSED cocenRAcroR'sn1:c1.ARAT1oN Job Description
I hureb 0iam Oboe 1 mu licensed under f Cba t (conmarcin
'oPno yu prnviBlnnsa Deas g
„_- wnnsece..n7molnnlmiBimonnbeBmsbrssandrr,,mssi„nsa,de,amll„y°C1Ve T/O CEMWOOD TILE, RESHEET RDD 40 YEAR P
Y ie in full fomc Intl
���a Lieense( `��� � �-FO�9 COMP
i re D:na I fO convenor--�
a 3 H ARCHITECT'S DECLARAH N
ce= ? 1 unJersumJ my plum.,hull be used ax p„nlic rccnrJa
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1.iernseJ Pmfeoin.al l
OWNER BUILDf?R DECLARATION
�^— 1 hereby amr.Inns 1 aIli exempt from the C„mmclor.Liven.e lntw for the
following mason.(Section 7031.5.Business and Professions Cole:Any city or county
which remllrex a permit I..construct.alter,in,Prtrvq Jamolixh,lir repair any cove..le
j52E priormit,ifsmnce.nd punu6nmcm..ffisamlicanl l orwchpermil lolllcav,,iod,tamtncnt
that he is license :mm t the provisions or the contractors License Law(Chapter 9 Sq. Ft. Floor Area uation
(conmmncing with Section 71x110)of Division 3 of the laciness and Prafe,,ione Code)
or(hal he is exempt,hcrcf om and the basis lin be alle,rd eaempnun.Any violation
of Section 7031.5 by any applicant for a pem,it subjmv the applicant toss civil penalty
„fnot lm,mthm,bvehnndreddollam(S500), APN Number Occupancy Type
01,axowner..I he pr..Peny,onny employees with wages as their vole eon,cnsmion,
will Jo the bol k,and Inc ua,um,it nm mmndnt Lir oh Bed to,sale(See.7vIL 32839029-
B oinco.and Professions Code:The Contractor.Lice sse Law tine,net apply Io an equired Inspections
r n(prapeny Who builds or in,poucsthercon,and who does such work himself '
or through hi.,,wn all,pinycay.pro.nls.l In't...It il,Iprcwemema um n„I nomnaCst m G5 — FRAME
orrcred far sola.If,hnweva he building.......vr,ncm ix,old wahin one rear of - 3
,mple,ion.the ownernuiWe,will have the badroof Provingthal he did not build or 307 _ INSULATION
Itnpowe fnr puI'lsoc ut nate.).
Ell.as owner of the property.am eve Iusimly concocting with Iircnsed conamo nes In 601 — ROOF TEAR OFF
L,n.n"ct Ile (see.7044.E"Bina.,call I'a,, CodaO'The C•,mravmr. 602 — ROOF PLYWOOD NAIL
icense law does not apply to an owner of properly who builds or itmproves(hereon.
and It,,comma,fm such prolans whh a commands)licensed pursuant tome 603 — ROOF BATTENS
Coniraamrs Liam,,,Law. .
❑I am exempt order Secs .B If P C In this rca.on 604 — ROOF IN—PROGRESS
Owner Data
W'ORKER'S COMPENSATION DECLARATION
I hereby affunl under penalty ofperjmy one of the following dedumtion,
❑ 1 have and will anaintaill a Certificate of Consent to self-insure for Workers
Campamation, ns ......iced for by Section 371x1 of the Labor Code, for the
pco"ndanum of the wurk for which this permit is i...ad.
have and will mainmin Work,,',Compensation Imuranec,as mquiml bySectloI
�p00 of the Labor Code,for the perfommnce of the work for which'his permit i.
issued.My Wn�r/y'j pleatioa lavurmce Gurria add
Poolicy...liber arc:
Gamier. P4 42� . .Policy'No.:_4 V_�L1_75��L
CERnIgCAI'ION OF LX EMIT[ON FROM W RK:RS'
COMPENSATION INSURANCE
Crhi,xactiun need nal be enmplctcd it the perm;,is for one hundred dollam
($1(x)1 or le".)
1 andy butt in ba perbrmamea of ole wurk for w'htch thio Penni,is issued.,
.ball nn,employ any ,on is any manner,s"as ,,brc..nm mnjcct to Ila Walker,' •.
ComPeomtien law.of Cvllfort Data
Appllwm
NOTICE TO APPLICAN"1':If,ofmr making this Ccni beam of Exemption.You should
Weare sobject o the Worker's Compsm.on provisions of the labor Code,you must
Olonhwdh cmnPly with act,p ovNit m This Permit shall he doomed revoked.
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lir CONsrRUCrlON LENDING AGENCY
x 7 I herby a1Rnn Ihn1 Ilmrr is a connuuaion landing agency lot the performance
film soak lin which his Permit is i...ad(Sec.3097.Co.C.)
�v Q Lendar's Name
z IunJcr'e Mdres,
U 0 1 ccnify that I have land this application and state that the above inf rmmion is
L,, (.. correct.1 111.atcalnply wan all city amt county antinial,,:,m1 bola law,million, .
O U in building construction.and herchy amhod.e rcpm,emmives of bis cby,o a,ner upon
W he;ill o.a Inanuoned Pr..pen,roe Impacti"n or,sorl.
0. (We)ugrcc In v.vr,othnmify ane kccp heard,,the City of CuPnninouguumi r
J) liabilities,judgmenn,costs and expenses which may in any way accrue against said
U z City in ronse,Pmale of the painting of this permit.
APPLICANT UNDER 'AND WII. COMPLY WITH ALL N( POI T, ISSUCd by: Date
SOURCE REGULA ����Ov
Signature ofAppda,mtfC�,n etal Dam Re-roofs
HA%A DOUS MAT1iIIALS DISCLOSURE
Will the appl'c.m or futm Wilding occuptlnt.vtme or handle w.a,dous mmeaal 'Type of Roof
in,Jellied by the Cuparque Municipal Code.Chapter 9.12 and the Ilcmlth and Safely
Col,Section 255320)'
❑Yns ,, All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
m it hlvtnJor,air coria a., Lir Acpn y the bay Am,Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
Cites all non-point source regulations.
1 have lead the ha,rdum.mamrlak rcquircmcm,under Chnpmr 6.95 of the ,e
Califomia Health h Safety Cade.Sections 25505.25533 and 25534.I,mdersmnd that �- Q 6
if the hulWing docs nal cr,read,hmc a Imam,tial h is Iny n,pmnihility n,polity the -
reeupam of,h recurW-ats ich Bust he amt Prior m i.uuuna olu Cr IEcam nl
Signature of Applicant Date
th—air - D> /�d All roof coverings to be Class `B" or better