07110171 CITY OF CUPERTINO
B��LS�:.^-�v�s�oN PERMIT ��`1�T��.��� I���AETI�1�« ;
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PERMIT NO.
sui���c.pR�Res�:TEVENS CREEK BLVD ABOVE A �L ROOFING 0'7110171 ,
/ ti
OWNER'S
SAMTARY NO. CONTROL NO.
(408)29�-4188
ARCHiTECT/ENGINEER: BUiLDING PERMI'CINFO
BLDG EI,EC[ PLUMH MECH
� � � �
u o p LICENSED CON7RAC1'OR'S DECLARATION JOU DeSCT1pU0I1
;� V I hcrcby aflirtn that 1 am liccnscd mufer provisions o( Chaptcr 9(commencing ��
� wiihScc6on7000)o[Division3ofihcBusincssandProCcuionsCode.andmyiiccnscis RE-ROOF T/� SHK RF, INSTL 1 LYR �F 7/ 16 �SB INSTL
�� y in full (orce and c(� � �� � �(� (.�.`( 3 5 3 0# UND � LYRMT � C LA S S A, 4 0 YR GT EE
� z Licenac Clus
�'^� F ;, p Datc Conlraetor
� ARCHI7ECI'S DECLARATION
��� 1 undcrsland my plans shail bc used at public rccards
�yU
� 0 y Liccnsed Pcufcssional
y � OWNER-HUILDER DECLARATION
I hcrcby afGrtn Ihat I am excmpt (mm �hc Coniractor's Liccnsc Law Cor thc
�t� ae
y O O following rcason. (Scction 7Q31.5, Busincss and Profcssions Cafc: Any city ar county
K, Pi which rcquiccs a pccmit to rnnswct, altcr. improvc. dcmolish. or iepair any swcwcc
y Z y prior w ils issuancc. ilw rcquims thc applicant for such permit io filc a signcd stammen�
< �ha� he is licenscd pucsuanl to thc provisions o( thc Convactur's Liccnsc Caw (Chaptcr 9 Sq. Ft. Floor Area � 5 0 0 O Valuation
Y I = -� �(commencing wiU� Secuon 7000) of Division 3 of ihc Business and Rofcssions Codc) or
y�� that Ae ia exempt thetefrom and Urc batis for Urc allcgcd exempUon. Any violauon of
Secuon 7031.5 by airy applicant tor a permit subjecu the applicant ta a civil penalty ot 3 4 214 0 01 .� Number Occupancy Type
not mote than five hundied dollars (SS00).
� I. u owner of tt�e pmperty. ar my employces with wages u their solc compenaadon,
wi]Idothcwork.�nd�heswcwmisnotintendedoroffecedforsale(Sec.7044.Businesa Re uired Ins ections
and Protessiona Code: The Conuactor's License Law does not apply m an owner of Q p
property who builda or improves �he�eon, and who does such work himself or Uuough his
own emplayces, provided �at such improvements are not imm�ded or oQered (or sala lf.
however, U�e building or impeuvement is sold within one year ot wmpleuon, tl�e owner- �
builder wiR have the burdeo o[ proving ihat he did no� build or improvc for puryose of
saleJ.
❑ I. u awner o[ ihe propeny. sm exctusively conuuting wi�h littnaed convactws W
constmct the pioject (Sec. 7044. Businesa and Professions Cade:)'Ihe Contracwr's Li.
cense Law docs oo� spply �n an owner of property who huilds or improves the�eon, md ,
who convacls for such pmjects with a convactor(s) licensed pursuant to �he Canvactor's
License Ltw.
� 1 am aempt under Sec. , B& P C for ihis rcason
Owner Date
WORKER'S COMPENSAT[ON DECLARATION
I hereby aflimi under penalty o[ perjury one o[ Uu following dalarations:
1 hz+e and will mainuin a Cenif cam of Consent to xlf-insure for Workers Compen-
sation, as providcd (or by Section 3700 of �he Iabor Code, for �he pedormancc of �he
work for which Ihis pertnit is issucd.
❑ I have and will maintain Worker's Compensalion Insurana, ac rcquired by Section .
3700 oC �he Labor Codc. Cw ihc performance of �he work for which this permit is issued.
My Workers Compenu g ca►�e artir� a�d Poliry number are:
Grrier. ThriTL �1 v�� �u No: s�l -r.�d �9,'�5
CER77FICATE OF EXEMPfiON FROM WORKERS'
COMPENSATION INSURANCE ' '
(fhis scction need not bc complc�cJ if the pecmit is for onc hundrsd doilua (S I00)
or Icss.) �
I cenify �hat in tdc performance of Ihc work for which Ihis permit is issucd. 1 ahatl not
employ any person in any manner w u w becomc wbject to the Worke[s' Compensadon
Laws of Cslifamia Dalc
Applicant
N�17CE TO APPLICANT: If, aficr making �his CcniGca�e of EaccmpGon, you should
bccome subjcct to �hc Workcr'a Compcnsation provisions of �Ac Lalwr Codc. you must
, O forthwil6 comply with such provisions or this permil shall 6c dccmcd mrokcd.
z �"" CONSTRUGTION LENDING AGENCY
[-~.� ►�-� 1 herohy ellirm �hat thece ia a consuucGon Iending agency for ihe perCormance o[ _
�� ihc work for which �his pertnit is issued (Scc. 309'1. Civ. C.)
W� Q L.endcrs Nunc '
� z L.ende�s Addtess
V � I certity U�at I have rosd this applicuion and suic iAst �he sEo�e infamation is
w►" cortec� 1 agree w comply wiih �II city and county ordinances and s�ate laws relaGng m
0 U building consuuction, and hereby authoria ccprcsentaGvcs of this ciry to cntcr upon �lu
� W atavc-mentioncd propcny [or inspcctian purpos�a
a (We) agrce w save� indemnify and keep harmless �he Ciry of Cupenino against
�� liabiliues, judgmcnLS, cos�s and expenscs which may in any way accrue againsl said City
V z in consequence oC �he granting aC Ihis pertnil. Date �% ' ���
�"� APPLICANT UNDERSTANDS W COMPLY WITH ALL ON-POINT Issued by:
SOURCE �
�b d Re-roofs
"" ° `�° ` °a Type of F'.00f
HAZARDOUS MATERIALS DISCLOSURE
wll drc applicant or futurc building occupant store or handlc ha•rardous malcrial
as defincd by the Cupertino Municipal Codc. Ct�ap�cr 9.12. and �he Hcalth and Safety
c«k, s�uo� zssszcs�� All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs �No
�11 ihc applicam or fuwrc building accupant usc cquipment ar Jeviccs which
If a roof : s installed without first obtaining an inspection, I agree to remove
� ha•r.ardous air contaminan�s u dcfincd by the Bay Area Air Quality Managcmcn� all new R iaterials for inspecr.ion.
u�strict?
Q Yes �o
1 havc rcul the ha�ardous maierials �cquiremcn�s undcr Chap�er 6.95 of �c Califor-
nia Hc�l�h dc SafctyCodc, Scctions 25505.25 3 anJ 25534. I undcrsmnd that if ihc building
does not curtcnUy h a y responsibili�y w nouCy �hc occupant nf �he
��; � �u��orac�Nr��oro��� . Signature ofApplicant Date
'3a G All roof coverings to be Class "B" or better
O r author'vcd a ���