01070025 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
5903 SUTTON PARK PL FIVE STAR ROOFING O1O7OO25
10 /MSIN RAZAI 387-A UMBARGER RD 20
01
PIIONE:
(408) 972-7855 SANITARY NO. CONTROL NO.
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0 ce O ARCHITEC TNGINEER: BUILDING PERMIT INFO
w- BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION Job Description
I hcoty,mffrtm Lha 1 am licensed under provisions of Chapter 9lcommencing REROOF.
with n7000)of Divisim 3 of the Business and Professions Cade.and mY license
a ull farce a fife
���� manse his u,.« �l/7 7/ y 40 YR. PRESEDENTIAL.
,o ate Contractor
se ARCHITECT'S DECLARATION
C OI understand my plans<hnll he used as public records
s1$ Licca sed Professional
FINALED
n u6K.o u. OWNER-BUILDER DECLARATION
1 hereby alBtm that 1 am encmpt from the Contractor's License Law for the I
J-z r following reason.(Section 7031.5,Business and Professions Gde:Any city or county J U L 2 01
i'x o which requim.s a permit m construct,alar,improve,demolish,or repair any structure
i3 priurwts 1 sal th ppl tf uch pend t fl 'b dsutemem .... - .
imine l vdpursuan)toticpro -Ions rmec tractor Ler La (CWpter9 A —,. ,Sq Ft'. FloorArea t, 5, 1 ,s.; Valuation
(co ,sithSm 7000) fD' ki l fth B .na ndProfession,Code) i i�l t of 9�: Y r e`. • %+t ' ?. . `� �- :BUILDIN
or that he s exempt therefrom and the basis for the alleged 6iroulon.Any violation '
of Section 7031'.5 by any applicant fur a penottu.lb the apph.m m a civil penalty
of net more than five hundred dolma(5500). APN Number t . . - Occupancy Type
❑1.as owner of the property.or my employees with wages as their wile compensation.peation. 305 - FRAME _
will do the work!and the smote is not intended or offered for sale ser.70441 3 0 7 - INSULATIk
wired
Business and Profession..Calc:The Connearim'w appm License Law does net ly an Inspections" '
her of progeny who builds or improves thereon,and who docs such work himself 601 - ROOF TEAR OFF
orthroughhis own employees.provided that such improvements oR not intended or
offered for sale.If,however,the building or improvement is sold within one year of 602 -- ROOF PLYWOOD -NAIL -
nmpinion,the ownrobolder will have the burden of proving that he did not build or 603 - ROOF BATTENS 0
improve pmFoseu
-- 604 -- ROOF IN-PROGRESS
-. .. ..._ ... ._ .
❑L as Owner project
(Sm.
7(am exclusively rommctssions h licensed romrnctors m t i
License the project(Sec,7044.Business and e m who
CW<:1 The Contrxto n,
> - " and who
Law tics not apply m an owner of a Ionto who builds or improves thereon.
f '. ..and what rnLicens L- weM1 projects with a.contortions)liccm¢e.pursunnt.the .. ._ --_.__ .._. ... .- _ .._ ._... ._.. ....
Cal a.
Contractor.,Cleans Law. „e, -
- - ❑1 am caempt under Sec: .R R P C,fonhis mon . .. .. ..
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Pemwhy of perjury one of the following declarations:
(] 1 have and will maintain'a Certificate of Consent to self insum for Worker's
Compensation, as provided for by Section 3900 of the Iabar Gde. For the
performance of the work for which this permit is issued. .,
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the p<rformarm of the work for which this permit is
' 'ws y Workers C ps .�i Insure¢e carr cr mJ Pnl y bet nr<', ,, ,
cane St'arrF✓n 'Pou<vNa O i I;" "i t s.(..i . +., is�('l`.Se.,. tri`f`a*
t' CERTIFICATION OF[SENPTION FROM WOR S x
o
. "i ..'COM1IPENSATION INSURANCE i,' •' r , .._._._..-._._ _,. ._.___.. ___..-._...-.____.._t..__ — _. ... . .. .-_.-- ._-..
(Thr section n d not be'cmnplmed it Om gctmit s f rr ane hundred dollar , ) '_ - :I: 1 .
ISIOO)ml[ssJ
I
cenify tM1a in the txrfomnnec id the work for which this permit ie issued.
'shall not con 'any persmh in any manner.an us int bell.,subject nt the Warkcri
Compensation W ws of @lifomiu.Dee
.Applicant _ -
NOTICE TO APPLICANT. ..afro.making this CeniGcma of Exemption."m should
become mbcn to the Workers Cuno nsm.r pmioamofthe Labor Code,You must
Q Q funhwith ennnply with such previsions or this permit shall be deemed ranked.
Z . . - .- .- ... ...... _ _ ... .-
F'� " CONSTRUCTION LENDING AGENCY - 1,
1 hereby affirm that them is a construction lending agency for the performance
of the work for which Ihia pemnit is issued(Sec.3097,Civ.C.)
Lenders N
's mnr- . .. - _... ..,... ... .. -. - . . .. - .. ..
Z) z Lender's Address
U'G . I certify that l have mad this application and state that he above informations
unreal.I agree to comply with 511 city and county ordinances and state laws odthing '
in building constmefmn.:mdhereby amhnrizenprecemmives oftni,city menter alum
}i:2 the aborememioned pmpeny for inspection purfuwa,
y (%Vc)agree to save.indemnify and knep Wanless the City of Cupenino'against
.E.'5 liabilities,judgment+,casts and expenses which may in any way accrue against said
City in com<yucnce n S go ti ng of thispam ',
APP CAN'T Ui RS ��` ILy 'PL �`LL NON-POINT Issued by: DBI,
� �f' f.2CG�/i
7-10 0
iiiiiSignaturc of AppinanUummoctor _ Date Re-roofs
'. HAZARDOUS MATERIALS DISCLOSURE.
wll d pplih 1 r t re building p' t star.or handle hm,wonx n t 1 .Type of Roof
.. .
as defined by the Cuperi oMPncpal Code.Chapter9.12.and the Health and Sfty, ` , .
Cale Section 553211, "i �,k.-I i.`,:' Iv f] L "`. "'L '•, I (;h.;
❑Y', ' ',I,oNa ` i.:' - _All roofs shall be inspected.prior_to.any roofing material beinginstalled. _..will heapplicant norinmebmisho,ocemount.ceynipmamnrd,,i,c,an't,lb If a roof is installed"svith'out first obtaining an'inspection; Pagree to remove
..it hazardous mrcnnu.iwnts as defined by the Hay Arcm AIr Quality Management
District. all new,materials for inspection. Applicant understands and will comply with
D Yet 4` - all non-point source ulat'ons
1 have real n Cu hazardous t a y ' t orderChaptero no of the i/
C f mi H hh&S f tyCW Sets 5505 25531 d 5534.1 d mndmat
ifthe Wildingofteoesnotc Currently have ten Metthat itPoi responsibility to notify the /v V
rc<uPam of the requvenrents s+h ch must be ren prim m issuance of a Ceni0cate of �_�
hey.
.r - 7—/G"G Signature of Applicant..,. - Date .
Ownmmnmhorizct gem Date All roof coverings to be Class "B" or better
:I
�. '.. .... .. ... .. ., - OFFICE. _ . -