02070007 (3) CITY OF CUPEWI'INO `� 11 11 1 ' ";
BUILDING DIVISION PERMIT CON--TRACTOR INFORMATIOLV: lip
EDILDINGADDRESS: TEO IS ROOFING LWAIF
10400 PHAR LAP DR 02070007
WNER'SNAME: 691 W SAN CARLOS APPLICATION SUB DATE
WILSON GERALD A AND CAROL J n 07/01/2002
PHONE: (408) 279-8797 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
Mae,
LICENSED LICENSED CONTRACT'OR'S DECLARATION Job Description
U 1 hemby affirm that I am licensed under provisions(if Chapter 9(commencing P
with Section 7000)of Division Sof the Blearmas and Profesions Codc,and my licence is
in full fora and effect. REROOF
74 License Class Lic.M
ZFp Date Conlracmr
14 qq ARCHITECT'S DECLARATION
2 1 understand my plans shall W used as public records
aOutyU
LLo Licensed Professional
OWNER BUILDER m Ce Contractor's
DN
I hereby affirm that 1 1. exempt from she Contranoo License law for the
�u—❑O following reason.(Section]031.5,Businessandmpr improve.
damons Code:Any city of county
$(< which reyuircs n permit us c"aims
the alma imprrsu demolish,or repair any structure
Prior in insissuance,alaerequires the inion of for suchpermit mfileasigned vammem
thathe is mecing wit pursuant to provisions of doe Contractor's nd PreclawfChapm,9 Sq. Fl. Floor Area y�12V�f�1100
C�$
(commencing exempt darefro7la and
basisnn3of de,al Businessandno An,vi Curie)of
bel be is exempt Urcmfrom end the basis for rte alleged,mmption.Any violation of
Section 7031.5 by any applicant fur s permit subjects the applicant m A civil penally of a Occupancy Type
not mom than five hundred dills.($500).
I,a owner of the property,or my employes with wages as their sok compensation,
will do Ne work.and the sbucture is not intended or offered for sale(Sce.7044,Business
and Professions Code:The Contractors License law docs not apply to An owner of 307 - IN SULAfj9MFd Inspections
property who builds or improves Hereon,and who does such work himself or through his
own employees.pmvidcd Nat such improvements ere not intended or offered furoate.If. 601 — ROOF TEAR OFF
however,the building or improvement is sold within one year of Completion,Ne Owner
builder will have Be burden of proving Wt he did not Wild or improve for purpose of 602 - ROOF PLYWOOD NAIL
fia1a1' 603 - ROOF BATTENS
❑I,as owner of the property,am exclusively contracting with licensed crnvamnn to 604 - ROOF IN-PROGRESS
construct the pmjecs(Sec.7(W.Business and Professions Code:)The Convectors Li.
cense law does not apply to an owner of property who Wilde or improves daemon,and 605 - FINAL REROOF
who contracts for such private with a concraelor(s)licensed pursuant to the Contractor's _
License taw.
❑1 am exempt under Sec. .B A,P C for this reason
wucr
Data
WORKER'S COMPENSATION DECLARATION
I hemby AM.under path,of perjury one of Be following dkdkratima:
I ham and will Oaimtln a Certifcate of Comer m self-imam for Wurkeri Compen-
sation,As provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance,As million!by Section
3701 on Labor Cate,for the performance of the work for which this permit is issued. Di
My Workers Compensation Insurance camper and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nus be completed if the permit is intone hundred dollars(51011)
,it less.)
I certify that in the performance of Ne work for which this pannin is issued,l shall not
employ any permm in any manner an A m become subject o the Workers'Compensation
Laws of Cali form..Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ceniticare of Exemption,you sbould
become subject to the Worker's Compensation provisions of the labor Code,you must
OO fmhwith comply with such provisions or Nis permit shall W doemed revoked.
z CONSTRUCTION LENDING AGENCY
Fa 14 I hereby after Nat there is a consvunion lending agency ties she Performance rf
gye > doe work for which this Permit is issued(Sec.3097.Civ.C.)
lostQ Lenders Namc
01, 0 Lenders Address
U C 1 cenlfy Nat I have read this application and stale that the above information is
D. h correct.I agree to comply with all city and county ordinances and sum laws missing to
O V building construction,and hereby authorial mumsenmtives of this city m enter upon the
U ahrvomcntion,d pmPcny for inspectum purposes. 42
(W,)agree to ave,indemnify and keep harmless Ne City of Cupertino against
V) liabilities judgments,costs and expenses which may in any way Accra,against aid City
U Z in consequence of the granting of this permit.
t--r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplinnVComractor Data
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building oecupam score or handle haardous material
a defined by the Copeman Municipal Code,Chapter 9.12,and the Health and Safety
Coda [Itnnzss3z(a)+ All roofs shall be inspected prior to an roofing material being Installed.
do ❑rex ❑Nr P P Y g 8
Will thuapPlicamorhous,buildingOccupantuseequipmentordeviceswhich If a roof is installed without first obtaining an inspection, I agree to remove
emit harardnus air contaminanm as defncd by the Bay Area Air Quality Management all new materials for inspection.
District]
❑Yes C]No
I have read Ne haxardrus materials mquimments loek,Chapuf 6.95of the Califon
ria Health&Safety Cole,SachAP25505.25533 and 25534.1 understand lav ifthe Wilding
does roll entitled,have A Meant.Nat It Is my raxprem ibilb,m minty Ia,acupanl rf the
requirements which mug the met prior to issuance of a Cenifcam of Occupancy. Signature Of Applicant Date
Owner m.altu old age.[ Dam All roof coverings to be Class nBn or better