01050176 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: FERMI'INO.
29 STEEPLECHASE LA BUCK' S ROOFING 01.050176
OWNER'S NAME APPLICATION SUB DATE
MANNY 7 6853 W-P-IVERSIDE--W Y" 05/23/2001
PHONE: SANITARY NO. CON'IROLNO.
CacL ARCHI'I ECT/HNOINEER: - EUII.DINGPIiRMII'INFO
W O BLDG IiLECI' PLUM M1IECII
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H j LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby rill...,Ina I am Lee...d under pro.inion,of Chapter 9(commencing
O w will Sanioo 7000)..1'Oiv hlnn 3 of l he lfadnee,and Po'll,ion,Cude,;mdmy liceree
f Yi.s in litll force anA dren.
< ucen C_3°I. Lick�39 g3 REP,OOF.r COME. :,TO4�OMP1:}y •
o a u Date. �t�-p-1 cammeatr ,�JCf !/1-----
rY1 3 a.v �d ARCHI"I'ECI'S DF.CLARAI ION
11 .mrd ,is plsshnlmy l reeved a,public me o d, 1Vl T_J
j,0
�O Licemo nal
_e a, ' OWNER-BUILDER DECLARA'r10N
= 1 hereby eflin l that 1 ren exempt from the Contractor,License law for the
h Z a hdlowing massa(Section 70315,Basins,and Prolcnvium Cade:Any city an county
F-C is his It rectifies nit in consumer. her, p dernol ish, P y,IraUum -
mprior to itsalso theapda,ama 11 .units 11 ,,and lourourn
that lie licensed t meis of11 c t am',l.werne law,(cbaper9 Sq. Ft. Floor Area Valuation
mminmencmg with S,euon 7MB of Dno,imi 3 of llie Basins,,and 11rafesiom,C,Jc)
or that he is exempt therefrom and the Iasis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a Permit subjects the applicant to acivil penalty
of a.....,nm than live banned down($511.,). APN Number Occupancy Type
❑1.a,owner if the in",....or my employee,with wap.,.,their,olc ao...pe..mdon, -,eA4Q LAO
will do the work,and the suuaum i,not intended or offered for sale(Sec.7(W. '
Bw,mv,...it Profession,Cade:Ilse Coutracon,Liciam,Law disc,nut apply In ua Required Inspections
owner of pmpcny Who build or Improves them. ,and who does such work himself
or through his own elnrloyce,.provided that such improvements arc not intended or 305 — FRAME
nt'1'ered fu -1c.If.bowuvec the building or ilnprovennin i,sold within one yon of -
unaide.iaa.me"waer-bmme,will have Ile burden or proving mat he did no,build"' „07 — INSULATION-
,prove fin',"'e"r ole.).
❑I.as owner of Im),Et am exclusively contracting with licensed comments to 601,' —' ROOF-.:TEAR; OFF .
,nstmathe project(See.7Baa,Bminss and Profession%c(xlcun
'IheConcl"fs 602 -' ROOF...PLYWOOD NAI'Ls- .
I,ienr,e Law Jac,not upply turn own,of properly who htd ld,nr iniprnse,thereon. _
1 who ,ntmety r"r such projces with a.n,nact"ro) licensed pursuant Ito the .603 x— ROOF BAT 'TENS;'
nCommelorc'v Llceme law. .
(31 an exempt under Sec. .B&P C for this never 604 — ROOF T.N—PROGRESS:a' .
Owner Dale
WORKER S COMPENSA'r10N DECLARATION
1 hereby eMan under,pe
,,all,of pe ne jti,maul the fallowing declarations RIVALED
0 1 have it will tnaimai..a Ccnifeac of Consent m self-insure far Worked. MAY 0 2001
Compem,1.. uuum, as provided far by Section 37011 of the Labor Code. for the
p,A 11, 2of the wk fur ovoid, ]i,Penni,m unued. L 1
01 have and will nmintam Worker',Compensation Imurance,as retained by Scotia
3710 of the labor Code,for the Performance or the work for wbch this permit is issued. BUILDING
My Worker's Cnlnpensation InvariaInvariaInvariant, rc
carrier and Policy number a :
Cartier Policy Na.e
CERT IICAI'ION Ole FX1iMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
(Thi%rection need not be completed if the Permit is for one hundred dollars
(8100)or lc,,.)
1 ecnify that Ire the pxerfnrwanec of the wad ba which in,permit Is issued.I
shall non employ arry'r,mr in rely no become'off",t the Wt kers'
Cm le.�C.J e
NO' t
NOI ICI f NI ❑ aft g th C RII a m of I Pf you sh uId
Ap,hcc bj t t tl W k C 't p l'line Labor C d.you ext
QQ limhw'Ih,omplywth,uh F.M,urn,or the pvmt:hall be deannual evoked,
{ CONSTRUCTION LENDING AGENCY
1 hereby anise,that then is a construction leading agency for the permencon,
W (It he work for which h,i,pp.'it'n Isumd(Sec.V)7,Cin C.)
ALender',Nana
= z L,ndcr's Addm,,
U 0 1 certify that I have mad this application and Aute that the abrce information i,
correct.1 aFme to cmnply with all city ani amity ordinance,and store law,aiming
Q U mhnildingctmstmauon,and hereby:mil,mixem,ancentives of tM,citym em..upon
F
the h.......
entioned Pmpeny vu ne"c'0om pse
urpo '.y (We)agmemwvc,iedenndyund keep luendex,the Cityol Cupertino upain4
W liabilities,judgments,casts and expenses which may in any way accrue against said
U Z City in mnmee yuenof the Senting of this Person. r ) �,
APPI ICANT UNDERSTANDS AND WILL COMPLYWITH ALL NON-POINT Issued by: Date
?.Cr "EAI,B10
Re-roofsemtIm/c. U. nam
HAOS
MATERIALS DISCLOSURE
Will the applicant on form binding occupant.vac or ha dlc haranlum material Type of Roof
it,defend by the Callum,Municipal Code.Chapter 9.12,and the acalth and Safety
Corr,Section 25532nD! 0 No
0 yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfuture building oecaPratuse equipment yrdevices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hvardou,air conmminann as defined by the Hay Area Air Quality Management
District.' all new materials for inspection. Applicant understands and will comply with
eve. 0 N all non-point source regulations.
I have read the hazmdau,..ancriuls rctuinenteris under Chapter 695 of the
Catiftheuiling do&Safety Code.yhavetinmant.that itis yrespad 3J.lundcmmndthe
if the huildinde e.not current Idehcust hie etprior my msl*m>ihiliryu,notify me
sect pan be rete.mmemx which man M mot prior m issuance of a Cenincam of C J
Signatitre of pplicant Date
n ranthart;_etlaset� Dale All roof coverings to be Class `B" or better
OFFICE