00060130 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HUILDINGADDRESs: ANTHONY ROOF SERVICE PERNIITNID0060130
10342 NOEL AV
41 OWNER'S NAME: 1655 FORMAN AVE APPLICA„OgIN,`®IY2000
CHEM
ONE: (408)265-5147 SANITARY NII. CDNTRGI.NO.
❑-Z ARCHI I Ict1ENCINHEI: BUILDING PERMrr INFO
Iv 00
EE IILDG I:I.IiC'r PLUMB MECH
auI'i
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N j LICENSED CONORACTOR'S DECLARATION .lob Description
Z_, 1bcreby nir.nm that 1 am llcenwrd undo,Pnrvl,inn,of Chapter 9(commencing
_ wahsceh,n]aro,"nymi-h,n3,nhena,lees,anePrare,.mn-caJe,anemyReense REROOF WOOD SHAKES TO LITE TILE
is Ile fall forte and erred.
oee< l"teen,-C)a-- C3 l /
3 yc.,U U am Cautracmr _yy�,yX.NJ_
t-=0 m ARCIII I EC'1"S DECLAR TION
S I understand my plan.shall Mused a,public rec oil
u�Wr
61 p Lrccared Pn,'csdnna
(Irat I am exempt
DECe Contractor
cto
uY7=v ON
1 hereby affirm that I 1 aline from the Cnntmctoo License: nyLaw for the
1-Z which ng reason, eratSection]031$Ituainess and vel de o demolish,
Cale:Any s'ity lireaume
520 whichmgwra-npermsmronsuuet.alar,rtinwa,h,,faillorea,i,anyanuowm
c. )whetslcened'areclvlu'vicetoaveme,tuba suonrctor mlilea,[am aammem -
3= (commencing
twit)Secant la040of D,ionsarthftheB Contractors latw(Cba Code)
Sy. Fl. Floor Area Iit0Y1@10
Ia that
isewitht hcmf,.anof Division3of theleged,oand Pri.A.,n, pion
at them he i, 31.5 F mcnrmm and the M1a,i-for she alleged euman, Any vi""Ity
of SeenoethI.5sanydrelidoll IlaaIRmtit nublandue uppliatm¢,acivil,snotty
of Bat mart man five hanamcJ enlwrs(550 ). APJ,J,..JXultl�e�'46. 00 Occupancy Type
01.as ownerorme properly.of myemploycex with wagesas their sole compensation. ao -04
will do he work,and me,Immure is not intended ,,offered for..me(See.7Or4' wired Inspections
fa,lne-,ont Prole„ian-Cade.Ice Connector'sucen,a Low dote..not apply to an X05 — F RRI� p
w r of,operb
Y Who uildi-or thereon, w
impnwes and ho does onto wad 3 mmulf -
Ar�nmugh his own employees.provided that such improvements are not imcndel or 307 — INSULATION
offered for sale.If,however,the Wilding or improvement if sold within one yens of
hmtplelff.the ownerhouder will have the burden of proving that he did not Wild or 601 — ROOF TEAR OFF
o'no'e her paTo,e of,me.).
01,as a a net of he pmv,
pcnamexcw.ively contracting with licensed contmemrs to 60E' — ROOF PLYWOOD NAIL
et he pmjecl(see.IIWL no.-ins.,and Profe,,kne,Codec The Cantmcmr'- 603 — ROOF BATTENS
Llnm
x efrwr donol,py ,enownw
er of Droperty ho build,or if.prm c-theme 1.
Sad sth a
°liar sucono moan, h p ojoe s wiih a.ontrac oo,)heen,ed Pa,,oam to life 604 — ROOF IN—PROGRESS
Cnmmefor's License Lou.
01 am exempt under Sec .B&P C for this nmo -
Owns, Date
WORKER'S COMPENSADON DECLARATION
I hcrebY"I iron under Penalty of perjuryone of he following declarmiom:
J 1 heve and will maimoia a("mr 'e of Cnn,vm m ssll=...porn fnr Wnrkcr's of
Comped-onion, a- ,formed for by Section 3]00 of the Labor Gala fur the
performance of the work for w hich this)smut is issued.
I hove and will muimnio Worker,ComPrn-ullnn Innurunce,ne re....i and by Senlnn
O�
X00 of me WM,r Cale,fnr the performnnoc of the work for which this pcTom f,
issmed.My Worker,Compensation Insurance anis,anal Policymber art:
Glnihr Tm& Fu1u6 Policy No 0/o Goa-s 1
CHEF IFICATION UP t.XiiMl'rION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if me penial is for one hundred dollars '
(8100)or loss.)
I certify that in the perfomunce of the work for which this permit is issued.I
,hall not employ any person in any manner sat as to Mcome subject m the W..se s' 1 ,-
Compcusmio i Law,of California Date
Applicant
NOTICE']0 APPLICANT.lf:Illy making this CcniRcale of Exemption.you should JUN 1 6 2000 L�
come,subo jecuthe WorkerLs Compensation pro, tuna of the Labour Code.you molt
0 Q Mfonhwuh comply w'uh,such Pros mon,or this permit,hull be deemed revoked.
CONSTRUCTION LENDING AGI7NCY
C 7 I but affirm that there is a eonsmuemm lending agency me the'nournance D
of the work for which this rental is issued(Sec.3097,Civ.C.) By
L.A lender's Name
7 Knee,',Address
I cerlfy that I have earl the-it,imi ion anar
and late mal she Mve information Is
k- F correct.I name m comply with all city and comm,o..Imem.,and ma¢law,mluting
V to hnildiugconxnfelinn.andleveby immunes ec'emasil'oflhi,city m enter upon -
the aWvennemionN rropeny I'or infection parpo-ro.
S
We)agree to save.indcmnifv and keep harmless the City of Cu,mino against
Fr N I abilitio.judgments,costs and expenses which may in any way acerae against said
V z City incomr,foreeof the gmmio,ot this permit. �` , / ^ ,-Y
�t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT IssDCd by: s- �C -- Date __:L0 10
SOURCE"REGULATIONS. _
Signature of Appicah "onuactor Dam Re-roofs
IIA%Alt DOUS MATERIALS DISCLOSURE
Will ate aprbeam m fame ho IMenpam snare ar handle omardou,neahel Type of Roof -
no derined by the Ca,miro Municipal Code.Chapter 9.2,snJ the Health and Safety
CWe.cion 25532(a)P 0 No
All roofs shall be inspected prior to any rooting material being installed.
Will the applicamorInce,Wilding,ccupem use ewipmentnraeeice,whuh If a roof is installed without first obtaining an inspection, I agree to remove
mit hazardous air contaminants m defined by the Puy Arta Air Vuulity}fonmganem
atrmtove- ❑N;, all new materials for inspection. Applicant understands and will comply with
all non-point source ilations.
I, 1 have lead the If et ymdous materials reyuinmena under Chapter fi95 of the p m n �• .��
Culifomia Health&Safety Gyle Sections 35505.23533 and 25534.I unJcrmanJ mat 7�. ",y�" `w`a""•"� ���_
if lh building encu nal reale, ly hmve a mnnm,mat is Is my issuance
rihilhy m Deify the
Dupont of the rnp,iremem,which nmw be met prinr e.i,,wanec ul a Crnilieam rel'
oaoaparc, Signature of Applicant Date
Owner aromm�rlyedagen Done All roof coverings to be Class "F3" or better
OFFICE