00060041 (2) CITY OF CUPERTINO
rT PERMIT CONTRACTOR INFORMATION:
commas ROOFING MIAMAMM41
[HRI.UING ADDRESS: ITRMI'1NOHAI I 1N 450 SAN ANTUNTO Rn jar,/917.
ry
OWNER'S NAMH- APPLICAIION SUIT LATE
HONE: `` - SANITARY NO. CONrROL NO.
m O Zp ARCHITEC;ICNOInS'ER: BUILDING PERMIT INFO
aBLDG IiLGCr PLUMB NIECH
y i l-_I IJ C:I -1
5 u= LICENSED CONTRACI OR's UECLARA'1'ION
�_ I heresy abrin that I art licenses ander pro lcnmmenams RE—ROOF Job Description
p!S with Section 700(hol'Di,don Sul Ne❑usincaan inyliccaw
sem^ is in full force andeller+317
rdQ Lrame Cla _ Lie.tt_ _ _
W ci LL u d
Done /� (. . .o sI__
AI1CHI I HM'S DI!CLARATION
I understand my plans dell b' used as public al
til is Licensed I'fofoss mad
a OWNER-RU1LDCR DECLARATION _
an-os 1 hereby affirm that I am cse nim Rmn the C,nllmlclm's Licersn Law or the
F Z Y fa14m'ing remon.(Section 7031.5.Bnsinext and proof e..i,.,Calc Any city..aunty
f F whluh rcyionco a permit m cnnsuuct.eller,improve,demolish,nv repair any stmetwe
ce . porno its issuance.ulsnrequire%the applicant for such Permit the a signed statm
eent
a. hal he.'1101,xm fanatical"I the proaallarai Sq. Ft. Floor Area Valuation
Iahmm,uming with Sedinn 911(111)of Divisionlo]'the Bnnlne.eand Pro ......is(:old.)
or that he is ccvmm themman and the basis]or the alleged exemption.Any violation
of Section 7031.5 by any applicator Fort permit suhiecls,he appllnm,m a civil reality
of not more than five hundred Jollan ISNW). A L1 Ill V& Occupancy Type
01,as owner of do progeny,or my employces x i]h wages as their sale conopensmion.
will Jo life work,and the structure in not inicmded or offered for sale(Sec.70L4, —
❑SpCCn(lnS
Business and Pmfesslans Codi The Contractor's License law does not apply In sea
r of pmpeny Who builds or improves thereon,and who Jas such work himwlf 307 — I 1\1
,or through his own enmloye—provided that such n,pnwamenis arc not imendod ser
otered for sale.IL however.the building or improvement i,tad watnm one year of 601 — ROOF TEAR OFF ,
innplerian,the owmar-hander wit huVC the mitten of proving that he did rot land or —
mprovefor purpose of.ale.). 602 ROOF PLYWOOD NAIL
O L as owner ofthe property.amexcrosinely contracting with licensed contractors it, 603 — ROOF BATTENS
Linstruct the project(sec.War.Business and Professions Cast The Contractors 604 — ROOF IN—PROGRESS
icense law does an apply ah nn owner of popery sura bald,or tmpmves menton.
and who-contracts for such pmjau with a cummcmrO)licensed panuam In the -
Co ruauudx I.iccnm L:,,.
01 am esenhpt under Sec. .B A 1'C for this reason
Owner Dam
WORKER'S COMPENSATION DECL.ARAI'ION /
1 hereby affirm under penalty of perjury one afire followinS declarations: a/
0 1 hove and will maintain a Cenilicale of Consent to self-imar a lilt Worker's
Co"a"'a or, .11 provided for by Section 37W of the LoMm Code. far the Q
performance of the wor for which this permit is issued.
main
I have and will tain x'nrker:Compun.utinn aq
In,mm,c.as ruirel by Scot nn
.7 )of the Labor Qsfe,for the pedorn:mec of the walk for which this permit is
issued,M' hnkc)sCmnpcne'fm�i7on�In�sur)u�ncu carrier and Policy hustler are:
Carrier ]N cY NUtyN�,�t
Eht13[ICAl l4O11lii:s rIONITSURxs)NCE62zRpt
(Thissection need not be completed if the permit is for one hundred dollars
IS I IN1lor less)
I Yl, had i ❑ p f Its A for hick m. M 1 . ssueJ I
nlmll n t pl Y > y man :I a,. n t I thewmko s -
Comp ]. i II le
Applicant
NOTICI TOA PLIC NI If R k gm Certificate' ofE Exemption,)' should
h,"ane nobject i or Vr kers Cs r,serr l I p : ,II lattanCod .....must
0 forthwith comply with such provisions or]his permit shall he dmrnN resaked.
FCONS'rRUCT1ONLENUINGAGENCY
I botchy mins that there is it construction lending agency for the performance
nfthe work far whtchthis pem,ll is somal(Sec 3097.Civ.CJ
S ❑ Lendcr'c Name
.7 7 I.cad r Ad,be,,
C O I vanity lit in 'Its iih t I t that o M' r enter
is _ /t
G.. E.. <irrecl 1 gree, comply 'Ih 11 ] J county ,million...and file I' It,g
U In[adding :mei dl rebyaflo prectt s fm city to I pun
the M I ds pony if p t i per
F y (N )agree .s . indemnify and keep l 1..]hefty f Cupertino against
lel
V] Ruby lues,yd seen,,and;,old exPcn.ws wh an n;,y h may way.men u against said
U G
City tncon.TUNDofineg ling of lbisgennil.
SOURCE REGUL ERS WILLCO LY WITH ALL NON;POINr Issued by: Date
SOURCE REGULA S. L
Signmmeal'Applican,/Cmona - Due Re-roots
HA%A US MATERIALS DISCLOSURE
Will the al,ptcamt nr ttmne building ocr;pilot store m hmhdlehv:adons material Type of Roof
as defined by the Cuperion.M1lorreipal Ceti,Chapter 9.12,and the health moil Safay
Cutin Swiun 45532(07 J
O Ycc D' All rool's shall be inspected prior to any roofing material being installed.
Will the applicant...home mild ingnecupamasoe,uipr,,mordes;ecewllilto If a roof is installed without first obtaining an inspection, I agree to remove
cmio,11 doe air cnnmminams as def nctl b>'Ihe Bay Area Air Quality Managemcm
Dtsnnnie,9 � all new materials for inspection. Applicant understands and will comply with
�
r OYex No all non-point source regulations.
I have coed the haeadous materials requirements under Chapter 0.95 of me
Cali t Tania l leahh k SUBq Gdc.Sections 25515,25533 and 25534.1 understand that
if the buildingJ,es nut cuvcntly have aler.m.that it is if,regsnwibi It 1,It,roti I Y I rte G / /nV
necupam of the res Clan which moa be ma prior m iswunre of a Ceniticme of -�
°"npam'y rem Signature of App icant Date
—�/ All roof coverings to be Class "B"or better
Ownc ora., is .D ugcid )tole
OFFICE