00110065 (2)CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
RUILDINGA 1 _.,
LOS GATOS ROOFING
PERMI'fNO'00I 101165
OWNER'S ry 1: V ROBERr E AND SEVERENE
1771. SMITH} AVE
APPLICATIO1 eOIf IY3/20700
PHONE:
(408)3SB-1233
SANITARY NO. CONTROL NO.
ARCHITISC'I IENGINHER
BUILDING PIIRMI'I INFO
BLDG ELECT' PLUMH MECII
I=1 I� IJ i_I
LICENSED CONN RACrOWS DECLARATION
Job Description
I hereby affirm ;hat I an licensed antler provimaw of Chapter Y fmmrtrencing
SHAKE TO FELT
with Section 7(XX)) of Division 3 of the Business and Professions Cmlc, and my llceme
H in full force and effect.
sc Clax. 3 hies«_ _
� l-� Cnmmnnr
ARCHEI fC'1"S USCI.
I era ,land my plana shall be used as P rm¢+N..
-
Lacmed Prolnsintml
OWNER-BUILDER MCLARATION
1 hereby of@m that I am exempt front the Contractor's License taw for the
fulkoviu, va,un. ISceiion 003L.S. Bususand Pomemi Cod, Any city" aunty
whicM1, a permit to construct. , o any ntnmmm
,, "x
flue ,flfi rt f—., , ,., I We
prim m IIx i i,ii,aae, also require.. Ire applicant lar men pann'u ,o Illc s aignnl Ch a ter 9
thigh, encin e,he mLlemwe Law (Chapter
Sq. Ft. Floor Area
.I�t1�46}0
CmrY
(cora cis u Section XH)pnwlivision 3 Cale)
Section lid tumor l of the Emmett and proion.
Any violation
I1,,d An, vi
ad t e for the alleged
is exempt Ianyefmm and the
of thin c.cm
of on 7 peri applicant to
Section
5iv nnydredd IBIraM)(h), subjectsthe applicant macivil Penalty
typli�OF.
Occupancy Type
of not marc than five hundred dollars (SS1Mp.
not than
0L3
01. asnwn,aldw pa+per,or my cradoyem with wagm a, their ... - cumpemmion
30-9 — FRAhPtEquiredInspections
will Jo ;he work, ; I the mucone is not intended nn olremJ far vale (Seo. 70,14,
is, Comn..Imr.l-xiniveLawdoes
emir-, and Pn,I..im0Cmde: uAappytinan
owner of property Who builds err improves thereon, and It,, dura., eu,h work hinudf
nr through his own eniplayces Provided that such imlarmonnnt, arc not intended nr
307 — INSULATION ,
ofleral for sale. IL hwever, the building or improvement is sold within one year OF
completion, the owner-builder%ill hosa the burden afpmvlvg that he aid not build m
601 — ROOF TEAR OFF
improve far pagm« of,ale.).
602 — ROOF PLYWOOD NAIL '
01.a+wncnrfheproperty.aneedusiveycontractingwiml'memodcontraotorsto
60� — ROOF BATTENS
"troth "ter p...yvt (see. 7044. Btu and Prorea s Cotic:) I he CommJtots
ima.
n.
andan Law docs not apply to "i uwncl of Popery who+nouns ofd IM1l,,
, v
6¢+4 — ROOF IN—PROGRESS
lar, in I
and who c.1.1'em Ira such prnjsct, wl,h a u+mruaogsl licensed purxuam m ,M1c
mc3,cr Lkendelaw.
.
❑ I am eXemPt amain Sec. . B & P c far this recta+
01
Owner Date
10,
H'(IRKER'S COMPENSATION DLCIARAr1ON
I hereby ul'lirnt under perkily of Periory one of the klleaing declarations:
❑ 1 have and will nmimaln a Ccrilinne or Consent to self-insum for Worker's
for by Seehmn 37Y) of the Uttar Coda. for the
/
Compensation. as provided
pedormnee of the and for which,his pcnmit is issued.
V
�\
❑ I have and will maintain Worker'. Compmnxation Insurance, as required by Section
\/
37(s) of the Lubar Cotc. for the perfomwnce of the work for which this Nona I.
sued. My Wofloerker's Compp/molswvtmn Inxumnec curticKrr-mt✓d�I'nliey north, are
0/
.m I.I._ :ICAnOR"tt -TION FROM RKpItS
'':IfIT'
COMPENSATION INSURANCE:
This union recd am be completed if the pennil is for one hundred dollars
($100) or let..1
I verify that In the pmrhmnuance u1 the work fur which this permit is isxunl, I
,hall not kalif, any ry',,an in nny aware, , as ,, be.orm xuhloo v+ the Workers'
Cn openantion Lnwx of Califumia. Dam
'
OTE EIf. afnrrnwhimhis
NOTICE
Ncrome sTOAIis,the Latnptiode. you
ovisiocac the you must
becomeh rikers provisionsll the WMm Code, you moot
Wuch [mons
complothe ortinn
limhwith comply with such Provisions or this permit shall be, AcmhreJ revoked.
pr
CONSTRUCI [ON LENDING AGENCY
I ha why affirm that there is it smnamctie i landing agency for the Performance
of ,he work to, which this lannit is l.suml (Sea. 1097, Civ. C.)
I.cnJcr'.a Name
-
Lender'sAddreea
'
I carry that I have d,hi, application and s.In flun ue alive information is
enrre'. 1 ,gra us comply with all city and county anim... ex and ,am lax, belming
to building Constme;ion, and hereby authorize representatives of this city to enter upon
dna alan'o-memiunal pmpeny far imlwnion parq+.ea
mlns Ola City of Cvperi no against
(We) ngwe,,, ase.ind,und,:md keep haa
-
hadalhlea,;ndgnwnls, ."Is and cxlren,.e. which may in nny way account again', said
'
City In eonxequureu of the grunting ol'illO permit
APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON-POINT
Issued by: Date
y'
SOURCE RF.GU W'IONS.
Re-roofs
Signature of Apphcant2mmmcw, Law
IIALARDOUS MAIERlAl S DISCLOSURE
wllmeapidntorfutum MhildingtccupmnLa,nmmhamuebwadoustwte6al
Type of Roof
Ix delinul by the Cnperinm Municipal Chale, Chuptn Y.12, and Inc Ilcullh and Sutcry
Calc.D ye, 25531(a)?❑vex ❑No
All roofs shall be inspected prior to any roofing material being installed.
Will me.,dicmtor from Buildingoecupanl me egaromemo, devices which
if a roof is installed without first obtaining an inspection, 1 agree to remove
mit ha�ardoms air e.....inmum, a. defined by ;he Bay Amt Air pushy Managetttcm
niatrust"
all new materials forinspection. A •ant understands and will comply with
PF
❑,•es ❑No
all no lint source reg IO
"Oe 1 ea mail ter ha.�raotls ttllnedw. rega'I rater entlmer h95 m ,ea
--
Culltomiu thealln h Sutcry Coda, Sections 255115, 25511 mud 25534. 1 unJun;mul Had
if,he hlliking does rat cunen,ly have a ramal, that i, is Iny responsibility in mtily the
occupant of the mquirements which mml be met prior to iswanec of a Cenilicu,e of
Oce.,zat ''nature
of Applicant Dat
All roof coverings to be Class "B" or better
md.agent Dae
Owner oraathtn
OFFICE