01090099 CITY DPERONG
NPERMIT CONTRACTOR NORMATION:
' BUILDING ADDRESS: PERMITNO.
19766 VICKSBURG DR SHELTON ROOFING 01090099
OWNER'S NAME: APPLICATION SUB DATE
VGEERS JAMES H JR AND VICKI L 1988 LEGHORN ST 09/21/2001
ONE: (650) 961-7699 SANITARY NO. CONTROL NO.
e O O ARCHITEC `ENGINEER: BUILDING PERMIT INFO
F 0 c BLDG ELECT PLUMB MECH
y6
LICENSED CONTRACTOR'S DECLARATION Job Description
5240 I hereby ).f that I um athelicensed under provisions OfChapter-and my license
with 5eaion]o01BofDivision3oftheBusincssendProfessiansC amyhcenae REROOF.
is in full forte and ZL/
:mea "a"a,erlp Lie.«_ T/O B.U.R. W/ CAPSHEET
a°O,`" °"` y�'�� 'S DECLARATION (FLAT SECTION OVER GARAGE ONLY)
OU CCSontra , ON
1 understand my plans shall be used as public reeme!
i i
it
e,O Littnsl Professional
OWNER-BUILDER DECLARATION
m= I hereby affirm on 1 ora exunpt from the Cosiones r'e License Law for the
t? following¢assn.(Sornitt ]onsumBusiness and
vc.de ora Cods:Any city or county
E F C which req ms pc it t consumer. tmpmve.demolish, p any swcturt
i 3$ _prize 1 1 Iso q, lha ,,cant larsuchpermiu fl 'gnlsmertum .-. - .... - - -- —_ _.___- ---
... _.. -.
that he,7 gwishSetion map ismnsnf thethe Buctorsu load...cashed
�r' S 'Ft Floor Area . . ,i ¢[ion
(comm nnnB with Sm on]000)of Division J of the Business arW Prpfmsrans Code) l`f in'ti l ti.k I.,S i. ,5. './2.. 1. t P 1:J, �2 8 ' V
or that tie is ekempt therefrom and the basis births alldged eaemplmnAny violation
of Section 7031.5 by any applicant for a pewit subjects the applicant to a civil penalty
of but mart than five handiest dollar,(ssdo). 3 6 99.'M°b6 i • ' Occupancy Type
❑1,as owner of that property,tar or,employe,with wages as Noir salt compensation.
will do the work,and the swcmrc is not imendl or oRerW for ale(sec.7!M,1,
Business and Professions Code:The Conwmor s License taw does not apply to an 305 - FRAME Requited Inspections
3 07 - INSULATION
r of prapeny Who build,or improves Merton,and who does such work himself
owner
his own employ¢,.provide¢that such improvement,art not intended or .
altered for sale.If.however,the wading or improvement is sold within sae year of 6 O 1 - ROOF TEAR OFF -
completion,the owner-wilder will have the burden of pring N
ovat he dm not build or '
immaveforpurposeofsale.). 602 - ROOF PLYWOOD NAIL
-O[:as owner of the pmpeny,.am exclusively conuac.ung with licensed)contractors to 603 — ROOF BATTENS
command the project(see.70u4,Business aad aroma,ions Codeq The Contractor's 6 04 — ROOF IN-PROGRESS
License Law docs not apply so an owner of property who builds or improves 11mmem,
and who contracts forsuch projects with a cantrvetogs)Immsed pursuant to the d .._ ..
Cnnuacam's Liceme I,aw., ,
❑1 am e,cmpt under Sec. .B'&P C for Nis reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury sine of the fol lowing declarations: FINALED
1 ❑ 1 have and'will maintain a Certificate of C"nseni to self-insure for Walkers
Compensation, as provided for by Section 3100 of the Labor Code, for Ne NOV 0 9 2001
`pe1rfari of the work for which this pewit is issued. .
qN mein— Wpt i 1 nc q tumr: Section
Y d II
00 frit lab Com f th performance of the rk f which this penin[ s
d My amp f Inun<,N dra�y� io8[� _.. BUILDING. ..-
. CERTIFICATION OF EXEMPTION FROMWOR duFS - ° ''s` I '`••Qjs t' -� l a V is F"A s'3, r'. I l`� 7• 1
COMPENSATION INSURANCE "...
"ffbid section vel out be emnplaed if the .it is for one hundred dollars
I
me of so . . .... . .. `- .. ..-. .. .. -
certify ghat in the n in mrynec of tbun t for which this permit is issued,I
shall nm employ any person m any u w become subject m rite Workers'
Compcnsation Laws of Celifomie.Dine
Applicant r
NOTICE TO APP LICAormi'sIf,Compensater Amazingion
this Celliurate at Labo iode.y uhmost
becomeh comp y the such pr Componmtian pminut shs m the dared Code,you must
Q �
forthwith comply with such provisions or this pcmtiuhall be dmmed mvakl. �
i
Ffin I ' " '' CONSTRUCTIONLENDING AGENCY f
a.5: I hereby affirm that them is a construction'Icni ing agency for the pafurmm¢e
of the work for which this permit is issued Sec.3097;Civ.C.)
S Q lender's Name
Lender's Address t
V 1 certify that 1 have mad this application and state Net the above information is
kr g.
correct.I agree to comply with all city and county ordinances and state laws ulating
Q f.7 rebuilding e.acomia,and heuhy authorize representatives of this city to enter upon
the above-mentioned property for inspection purposes. _
tiL (We)agnea re save;indemnify and keep harmless the City of Cupertino against
rq liabilities,judgments,costs and expenses which may in any way accrue against said
V'z City in Fonsrqucn<e of rite grunting of thin pewit "' `
APPLICANTUNDER aJ.NDWILLC MPLYWrmAL1yA PO T Issued by: Date
OURCE REGULATI ! / Q Y'
Signati eofApplicwtlCmurou Date Re-roofs
` HAZARDO s MATERIALS DISCLOSURE. „
r.Will the applicant or future building occupant store or handle lwzaNaus material Type ofRoof "'--- - -- '
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safay
Codi.Station 2553200'.
❑
Yea
..All roofs shall.be.inspected prior.to any roofing material being installed. .
Will NeapplicamoIfumubuilding"ccupantuucquipmentordeviceswhich If a roof is itistalled without first obtaining an inspection,I agree to;femove
:mithamrdml air cmmaimnts as de fined h the Bay Arta Air Quality Management
i,met+ all new materials for inspection. Applicant understands and will comply with
°Y" all non-point source regulations.,.. ...if
have:email he hazardous mamma,mipi4comms rude;Chapter 6.95 of the
Celifomie"Ibb&safe"Code.Sections 25505,25533 asW 2553,1.1 understand that
tithe in,, cromady have a nenam,that it is my usponsibilitym notify the . .2J -'�
acupaht of the requ' ts'which must be tan pdono issuance of a CeniBcete of ,�
Signature of Applicant _ Date
her or.amodren¢gene Dam All roof coverings to be Class "B"or better
OFFICE