02100117 CITY OF CUPERTINO ' n'•'>>" - •I
BUILDING DIVISION PERMITCONTRACTOWINFORMATION:Ja
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BQILP1601A61TESIGLENVIEW AV EL CAMINO ROOFING CO INC PERMTTN®2100117
OwISUI9MAKAR PATIBANDLA 1650 S 7TH ST APPLICATTlO"SY 2002
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IONH: (408) 292-7644 SANITARY NO. CONTROL NO.
ARC]It MCIPIENGINEER: BUILDING P17RMIT INTO
BLDG ELECT PLUMB MECII
00 LICENSED GDNTRACrder E osuiomDECLARATION Job Description
�d ]hereby ion74union bar 1amlicensed hsneer pevisiI aarsCdcr 9E Imense is REROOF
with Section 74)0) I'Division 3 of BC BusincMsanL nftainns CnJc,unJmylicensc is
H in full force and sffrr,eeNt� 11
Z Li m CP 1.Z. l.ic.x 0.
owg, Dam K3�s — Contrazt.,
52qqARC]IITELTS DECLARATION
:Q 3 U 1 understandmy plans shall be used as public recordsA.
LL Licensed Pmmmional /
OWNER-BUILDERexempDECLARATION Q
r�i<4 I hereby ullirm mm 1 oat exempt from the Cnngaanr's License Law lin me $6500
,EOO following reason.(section 7031.5,Business and Professions Coale:Any city tar county
which requires a pcmtit m conswct,alms,improve,demolish,ar repair any structure
prior to iia is fiance,also requires the applicant for such Permian file a signed statement
�Z< that he is licensed pursuant n the provisions ofac Cummctnr's License Law(Chapmr9 3Sq9f31JF07)i3ArQI0 Valuation
As (commencing with Section 7Wo)of Division 3 of the Business and Pndessions Cale)or
that he is exempt therefrom and But basis for the alleged exemption Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofPN'N Occupancy Type
not marc Nan five hundred dollen($50% 307 — INSULATION
0 1,a owner of the pmperly,or my employees with wages es their ode compensation,
will do Be work,end me swcture is not intended or offered for sale Este.70aa,Business Wr gpQ�j
Add Professions Code:The Confactor's License Law does not apply to an owner of 602 - ROOF P T I`!V nWA J.IpnS
property who builds or improves Ouncon,and who doessuch work himself or through his
own employees,provided that such improvements arc not intended or offered for male.If. 603 — ROOF BATTENS
however.fee building or improvement is mold within one year of completion,me owner-
builderwinhavetheburdenofpmvingthathedidnmMndorimproveto,tompme,of 604 — ROOF IN-PROGRESS
:ala.).
0 1,as owner of the property,em exclusively connecting with licensed contractors In
construct the project(Sec.7044.Business and Professions Cade:)The Contractor's Li.
cense taw does not apply to an owner of property,who builds or improves Berson,and
who contracts for such projects with a comector(s)licensed pursuant o the Contractor's
License Law.
0 l am exempt under sec. ,B&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby.1 irm under Penalty of Perjury one of the fallowing declarations:
I have and will maintain a Cenirteam of Chosen,a.xclGiaure for Worker's Coml n.
sation,es provided for by Section 3700 of the Labor Code,for me Performance of the
work for which mix permit is issued.
0 I have and will maintain Worker's Compensation Insurance,a required by Section
3700 or the Labor Code,for Be performance of the work for which this Permit is issued.
My Workcf C penmaIinn Instar x rlicr and Policy n tuber
Cartier: . Policy No.: 0 D_
CERTIFICATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rfhisectlon need not hccompleted ifthc Permit is for one hundred dollam(SllkO
or las.)
I certify that in the performance of the work for which this Permit is issued.I shall not
employ any Person in any manner an az m become subject ht the Workers Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
OO forthwith comply with such provisions or this Permit that l He deemed revoked.
z 7) CONSTRUCTION LENDING AGENCY
P1 hereby affirm that there is a coasfection lending agency for the performance of
C Nc work far which this permit is issued(Sac.3097.Civ.C.)
Ri0 Lenders Name
z Lender's Address
V O 1 cenify that I have read this application and Mutt that do above information is
L4 P colla.1 ague to comply with all city and county ordinances and sure laws relating no
DU building construction.and hereby aothoriac mPrcsenutives of this city In enter upon the
[kl above-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep ha akeal the City of Cupenina against
F' ra/3'
liabilities,judgments,costs and expenses which may in any wry name against said City
U 7 in consequence of the granting of this Permit.
t�
APPLICA,NT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURC9EGULANS.
�-� iz� Ii)-6 Re-roofs
Signature of ApplicanYConractor Dam
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant tar future building occupant store or handle M ardous material
as defined M1y the Cufcnin.Municipal Cole.Chapter 9.12.and the NcalB and Safety
code,Sc Yes zss32(a)P All roofs shall be inspected prior to an roofing material being installed.
❑Yea ❑Na P P � Y g 8
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit bomntous air conuminanu As Jefncd bleBe Bay Area Air Quality Management all new materials for inspection.
1'.0.rimor
istrict/
CYes TNn
Ihaw rSaet thehvardous materials 3And25534.
5u.1 umdx uMIOatder of the Califon, —O,�—
iancalN&x 0iyhow A sections utiti my a"Ambils.i undtmm�J thmifmt Milling
res m only hove n chant,Ba itis my rarytaiM1ility m nmily Bc Occupant of We _
qutmcmwhichOrMy et PH It,I....ar.cenmcamafwtupaney. Signature of Applicant Date
to aatnaaaed as Data All roof coverings to be Class "B" or better