01120036 (2) CITY n DING DrnsIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
100`75 SANTA CLARA AV COSMOS ROOFING 01120036
APPLICATION SUB DATE
DVH9d1T JOHN W AND KATHLEEN J 1901 OLD MIDDLEFIELD WY 12/06/2001
PHONE: (415) 493-6373 SANITARY NO. CONTROL NO.
O m Z ARCHITECT/ENGINEER: BUILDING PERMIT INTO,
O❑O❑ BLDG ELECT PLUMB MECH
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S m i LICENSED CONTRACTOR'S DECLARATION q p
O I h<rcby affirm that 1 am licensed under provisions of ChaP¢r 9(commencing T/O COMP ROOFS J(2 )eSAJTDo 3 0 .FEET.ADD 4 0 YN E
'yf-,u wins Scninn]Wfl)of Dlvirion3 of the Business and('mfcnsiom Coda and myliccnse
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is in lull Imcumd,Qfcsy
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ARCHITECT'S DECLARATION
n ,g I understand my plan,shall he used as public records
ise p O Licensed Pndessional
z OWNER-BUILDER DECLARATION
1 hereby aRna that I am exempt from the Contractor's License law for the
F i< following reason.(Section 7031.5.Buxmess mal Prorecsions Code Any city or county $5865
I O hich requires a Permit t we,,-Imr.i mprose demolish.m repair any suuevm
ter ; fear.,t issuance,c I. o thetill oat for such perm to fk gned nmmeen- - q R�� - - --- - --- --
thate T sedP a to thep- of the Contractors License La (Chapter9 ..,w„(,1,3,tl��5(�rb/R 7,@dr , v -�-Valuation
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(comerg with Seui ]000)of Di,k on Sof the Buviness i d P fie"i.as Code) N s ' ♦ ,
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 703 13 by any applicant for a tenni,subjectsrhe applicem no a civil .at,,
.of not mom than rive hundred dollars(SSW). 3 0 5SPN SIE Occupancy Type
❑Las owner othe prepedy.ormyemployees with wage.atheir sole«,mpen.aann, 307 - INSULATION
will do the work,and the structure is not intended or ofered for sale(Scc ss muw, 601 - ROOF TEARFgtf4lF�Inspections'
Busineand Professions Code:The Comm etor's License Law dues not apply an '
owner of proper Who Wlids or improve,thereon,and who does such work himself 602 - ROOF PLYWOOD NAIL
ar mmugh his own employees,provided dirt such improvements ate not intended or
offered for sale.If,hdwevea,he building at improvement is sold within one year of 603 - ROOF- BATTENS -
iompveforPemwee-de.).will have me burden of proving that he alta not hndd o. 604 - ROOF IN-PROGRESS
mprove the own of
O 1, f a p pert',ton exclusively contracting with licensed t t rs to
consumer the project(Sec 7044.Business mad Profcis ons Cods:)TMC to Inr's
License Law does not apply to an owner of p pony who Wilds or imprem,,hereon
and who contractsfor such proses with a commumes)licensed pursuard to the
Couteri License L w
❑I at exempt underSee. .B&PCfonhsrcaso
Owner Date p// \
WORKER'S COMPENSATION DECLARATION IF
I hereby of eat under pm ulty at perjury one of the following Aeclamtions D/
have and will mainmia a Ceniricae of Consent to self-insure for Workers
Compensation, as provided for by Scene. 3700 of the Labor Coo, for the
"sib
of the work for which this Permit is issued. _
All have and will maintain Worker's Compensation Insurance,as required by Section
r PM of the Labor Code,for the performance of me work for which,his permit is
` issued,My WmkersLCnntpensauon 1 cototrce tamer and Policy number arc:
I - �- %ky Ne 11 - 00- //7sS r _,. 6°'...
CERTIFICA ]ON OF EXEMPTION FROM WORKERS'• - '
COMPENSATION INSURANCE -
(This section need not be completed if the permit is for one hundred dollars
ISI W)or less.)
f
I certify that in the performurce oth
r e work a which this perms is issued,I
,. -. ..15,'27 t r.• •..
stall not employ any ,on in any moaner so as,n become subject to the Workers'
Compensation Laws of California.Dale
Applicant
.NOTICE TO APPLICANT:IL afmr making this Ccniricam of Exemption,you should
become subject o the Worker's Compensation provisions of the labor Cade,you must
0 O forthwith comply with such provisions or this Permit shall the dammed revoked.
Z
Vi "' CONSTRUCTION LENDING AGENCY
.E (4
1hereby'afirre that there is a cov,nociion lending agency for the pmfdrtnance -
i5 of Ihxwmk forwhich thispermit is ixxmd lSom 3097,Civ.C.)
P: 0 Lender's Name
7 Z Lendeh Address
t.7 1 certify that I have read this application and state that the above information is
W E., cone,I agree to comply with all city and county ordinances and state laws relating
Q V to building commr,ion,and hereby aathuriAm,msenm,ives of thus city to mace In
me abovemendoned prole.}for inspection Purposes..
Or (We)agree m so.e,indemnify and keep hamile s the City of Cupenino against
Z) liabilities,judgmenm,a ds and expcnms which may in any way act..against said
City in conxqucncc of th gamin of thin permit.
APPLICANT UNDERSTA SAN WILL CO LY WITH AL!,'ONsT'OI!{f f Issued by: Date
r SOURCE REGULATIO - !?YC/01
Signature of ApplicintlContmetor . , OaRe-roofs ^
HAZARDOU MATERIALS DISCLOSURE �
Will the applicant or fmrc Wlding devotion stare or tannage haaWws material Type of Roofas cement by the Ctiperoom Municipal Code,Chapter 9.12.and the Health and Safety
Code,Sector 25532(a) - f :q •,�
❑Ye, `en! ''° , l ,Al] roofs,shall be inspected prior to.any-roofing material being.installed.
• ..
Will Its,applic..,ormjarc Wilding acupsenuse equipmentordevieeswhich If a roof is installed without first obtaining an inspection, I agree toxemove
emit hicendous air commensals as&food by the Bay Amo Are Quality Mareagemem
Owner? all new materials for inspection. Applicant understands and will comply,with
:+ - oY �"9� - all non-point source regulations. . .,
I
base read the hoimdoud mammal. req itis unde Chepier 6.95 of he
Calf a Health&Safety Code,Sections 25505 25533 and 25534.I understand rho -
iftlass bidding does not torrent,have a return.mat it I,my rmpoessal,Itry m notify In
occupant of the requirements which must Mand prior to issuance of a Cen, t f
>. Occup”"` .. Signature of Applicant .. Date .
C7 L OI! All roof coverings to be Class"B"or better' 1 owreroramhod„sal.. _ Dem g
_: - .' . . . . . .. . ,.. OFFICE