99090193 (2) W101 Ron
CITY COP
FCUPERTINO " M. '" '"� -` "`� y''' ,;j
BUILDING DIVISION PERMIT CONTRACTOR .'O�RMAT....ION ,
11
BUILDING ADDRESS: PERMIT NO.
NN I
RESPONSIBLE ROOFING INC 99090193
OWNER'S NAME: PERMIT ISSUE DATE
y ONE: SANITARY OL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIF.Cf PWMB MECH
0 0 0 0
LOo LICENSEDCONIRACOR'SDECLARATION JobDescrip[ion
u 1 botchy affirm Net I am licensed under Provisions of Chapter 9(mmmcncing
with Section 7")of DiAs cm 3,du Business grad Professions Code.and my liana,is
^ N in full force and effect
5qz Lieenaccas. tie,. WOOD SHAKES TO COMPOSITION
nF Date cmuector
ARCHITECTS DECLARATION
1 undersand my plans shall W wed ar public rtc.Ns IRC
u. EXp G
G G Licensed Pml
fcssiana
OWNER-BUILDER DECLARATION
I hereby.(firm Not 11. exempt s an the Contractors c:LicenseAny c Law for the
p o fallowing mason.Permit
703 L5,B rhos and w.dogiobr Calc:Any city or coumy
m which its requires;a permit re inns the.applicant
impmw,demolish,fie a sir any tumture
pdormits tensed c,auomq am thn,isiocaof nt(o,sucCar peen's ..Low(Cstahaptementr
Valu tion
on (communcingwitpursu.rat.thepmvisions3dmConuaness; Llccnmlaw(Code)or Sq.Ft. Floor Area
Mfg that
I.c.main Section 7000)of,Division mfthe Business; PmfMyti ilmmt Of
that he u exempt tMrtfmm and the baro for the alleged eumption.My viaalion of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 3IW.t*er0 0 Occupancy Type
not mem Nan live hundred dollars(5300).
0 1,as owner orthe prop,ny,or my employcn with wages ad their mk compensation,
will,the work.and du a=,..amtimmaded.,Offered formle(Sec.7044,Business, Required Inspections
and Professions Cod,:The Conuscmrs License law two not apply in an owner of
property who builds or impraws thereon,and who does such work himself or through his
own employ.,provided that such impr.wmmes are not intended oroffean formic.If.
however.the building or improvement is said within ane year of completion.the Owner-
builder will haw the burden of proving that M did Out Wild or improve for purpose of
0 I,as Owner of am pr.peny,am achnoiwly contracting with licebred eonmacwrs to
construct the pmject(Sec.]OCA.Bwinen and Profovobr Cade:)The Cartrum,i U.
genu Law data not apply to an Owner or pmpeny who builds or improw.s Ilmrece,and,
who contracts for such prelates with a contractor(s)licensed punwnt as the Cmaamo(s
License Law.
0 lamexemptunder Sec .B&PCforthisrewon
Owner Dam
WORKER'S COMPENSATION DECLARATION
�\IC337.'00
1 hereby arm under penalty of perjury arc of the following declarations:
1 bsw and will maintain a Certificate of Consent m self-imum for Worker's Compo n.
ion,as provided for by Section 37M of dte Lobar Cade.far the pere mman of the
rk for which this permit is issued.
1 have and will maintain Workers Compensation Imuran¢,ar required by Section
of the Labor Code.for are performance dome were far which this permit is Wood.
y WmIxes Compensation Inman tunica and Policy number art:
rrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Diu seaim need not heeompleadiftim permit is foam hundreddmllars(SIIX) EXPIRED
or less.)
1 certify th.t in the perform.,of don work fa which this Permit u issued,l shall na
,..play any person many ammag,sa as m WeVag,subject to the Worker Canpensatim,
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become m1bject to the Worker's Compensation pmvisiow of the tsar Codd,you must
.,Q roMwith comply with such provisions m this p,rmitshall de deemed revoked.
zCONSTRUCTION LENDING AGENCY
`
[-n l hereby affirm that Vert I,.embraces..hading.pacy for da p,rrmagam,or
�i 7 the work fur which Nis permit Is Isswd(Sec.3099,Civ.C.)
W Q Lender's Name
Il Looderi Address
V i1 anify that 1 haw mad this application and sate that the show information is
I,F' correct.I agree m comply with all city and county oainmeco and grate laws relating In
nd
nter
0V buildin(We).,aw to,aw,indeyauthondepr handle.
the this ofCapstim ago the
W above-mentioned property for inspection purposes
FfY m,ju agree to ware,indemnify and kith harmless the City raCupcnsta against
N lisbilitiu.judgmcnu.cstsand capcbrta which may in any way acrna against acid City .
U in corvcgmna ofthe griming of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
Signature of Applican✓Camrantor
HAZARDOUS MATERIALS DISCLOSURE am Type of Roof
Will the applicant or future building occupant store or handle havrtims material
w darned by the Cupertino Municipal Code,Chapter 9.12.and the Hcalth and Safety
Cwc.Section 25532(a)9 All roofs shall be inspected prior to any roofing material being installed.
Oyer ON.
If a roof is installed without first obtaining an inspection,I agree to remove
Will are applies,or future building Occupant use equipment an&vim which
it hazardous air contaminants as domed by the Bay Area Air Quality Management all new materials for inspection.
istricR
O Yes DN-
I have mad the haz2adm smautrials requirements under Chapter 6.95 of the Califor-
nia Nonab&Safety Code.Scc mar 25505,25533 dZ534.1 undesswd thmif the building
at
not currently haw a anank dal it u my rupomi,lity to ratify the we"Pant of the
requimmcuts which mart le mel prior to issuance or a Certificate or Occupanry. Signature Of Applicant Date
Owner or authonzcd egcm
Dae All roof coverings to be Class"B"or better