09060149 CITY OF CUPERTINO ■/
BUILDING DIVISION PERMIT
a
PERMIT NO.
BUILDING ADDRESS:
22640 RICARDO RD. LOS GATOS ROOFING 09060149
PERMIT ISSUE DATE
OWNER'S NAME:
(408) 29:3-9399
BUILDING PERMIT INFO
ARCHriECf/ENGINEER: BLDG ELECT PLUMB MECH
p ZO LICENSED CONTRA TOR'S DECLARATION Job Description
UC 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
E
with Section 7000)of Division 3 of the Business and professions Code.and my license is RE—RF R]4V EXTNG S HK RF & I N S T L 7/16"OSB F I BRGL S
e s in full force and eff 70 7 D
�'�z License Class - Co Contractor
RE—INFO:ZCD FLT&WOODCRST SHNGLS BY OWENTS CORNING
Date +
ARCHITECI'SDECLARATION CLS A 4 ISQ
I understand my plans shall be used as public records
�yU
w O y Licensed Professional
OWNER-BUILDER DECLARATION
i<l 1 hereby affirm that I am exempt from the Contractofs License Law for the
a0 following reason.(Section 7031.5,Business and Professions Code:Any city or county
e$9 which requires a permit to construct,alter,improve,demolish,or repair any structure
o—y prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
% (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $12084
y that he is exempt themfrom and the basis for the alleged exemption.Any violation of APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of um
not more than five hundred dollars(5500)- 35601033 . 00
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conuactoes License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law' B&P C for this reason
❑I am exempt under Sec
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
I have and will maintain Workees Compensation insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Com enation Insuranc artier and Policy number am:
Carrier. Polity No.: 0
CERTIFICATE F EXEMPTION ION FROM WO ERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O forthwith comply with such provision or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
I hereby strum that there is a construction lending agency for the performance of
pro> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
0.
0 Lender's Address
V 0 1 certify that I have read this application and stare that the above information is
IL correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
04 -a
agree to save,indemnify and keep harmless the City of Cupertino against
tE'"y s which may in any way accrue against said City
rA liabilities,judgments,costs and expense r C•
V Z in consequence of the granting of this permit. Date
►�
v
Re-roofs �—�--
Signature of Applicant/Contractor Dare T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? - All roofs shall be inspected prior to any roofing material being installed.
[3 Yes No
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
,it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
vistrict?
❑Yes ET9.
I have read the hazardous materials requirements under Chaptcr 6.95 of the Califor-
nia Health&Safety Code,Section 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
tPAert °r�cert;feate�°e°°pan�e Signature•of Applicant Date
/✓ All roof coverings to be Class';.'`or better
Owner or authorized agent Datc