01030111CITY
1
NO
BUILDING
CONTRACTOR INFORMATION:
I DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
18971 PENDERGAST AV
COSMOS ROOFING
01.030111
OWNER'S NAME:
APPLICATION SUR DATE
DON GODSEY
450 SAN ANTONIO FD
03/20/2001.
'HONE:
SANITARY No, CONTROI. NO.
ass- � 4 ► 9
(415)493-6373
ARCHI'FECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MITCH
I_1 G"I C1 1_I
LICENSED CONTRACTOR'S DECLARATION
Job Description
I homby:dBnn than 1'e, n lwe-ed under pminions of Chapter beloominain,
with Section Il9)(q of Divisi lit afhe Bwin,ss vnJ Rufevsions Cdlc. send tiny license
Dm fall bate abdy} . C�— �4 (
T/O TAR 8 GRAVEL
umb.e
Umc_.
ADD TAR 8• GRAVEI_.(4PI_Y)
AIiCHII'ECRSDECLARAI[ON
1 understand my plans shall M used as public record,
,
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Licensed Prom ionll
OWNER-BUII.D ik DECLARATION
I hereby orf nn that I an, exempt front the Cnmrenor's License Law far 1be
following reason. (Shinn 7131.5. Business and Profesiom Carle: Any city lir county
which require, u permit ,, noartenl, alma ingmwe, demolish, or repair any structure
prior a, its issuance, alw requires the applicant too such pentritto Elea sign l smmmenl
Sq. Ft. Floor Area
Valuation
that he is licensed put,anot to the provikinnisia the Clannoroors Licetv,c Law (Chapter 1)
benmmane r, all Section 71)(10) of Division 3lithe Bu.inas and Professions Coda
or that he is eaennpl themlrom and the hasis it,, the alleged exentptiva, Any violation
of senior 7031.5 by any a1y,lic:::n for a permi subjects the applicant Ina civil Penalty
APN Number
Occupanc4SJff15
olnmmonTfisehundred dollars (S5(X)).
❑ T. as owacr of me progeny, or illy employees with wages as their sole avmpenation.
3753303'RFtlkfed Inspections
will do the wwfk. and the structure is nor imcinko lir nBered for sale (Sea. 7144,
Monaco, ,,,it Pmfe..it:,a Code The contraemr_s Lloense Law doe, not apply 10 an
property who build, or improvesthereon,it thereo, wwho does act, work himself
oidoorof
r through his sewn employee, p:onded that such improv mans are not art or
coarct for ,ale. If. M1osrcver, the !wilding lir imprmemrovin sold within line year of
he building
vabeledon.me nIf.humilder l aroe the olne infidel beim not build of
305 — FRAME
innprnvcnnpemnseaf,ale'
307 — INSULATION
❑La, nwmr of he progeny; e,m.iv-elY enal.ba, with licensed contractors to
tact the project (S. 7044. linsiress and Professions C,dl The Contractor'.
conec
601 — ROOF ..ERR OFF Ol �
l ,,o- Law does mil apply In an owner of Profwny who bullar lir in, a, heru,n.
and who cnnfaats for such projects with a contractor(.) licensed pomnas m the
602 — ROOF PLYWOOD NAIL
Corllrucmh License Law.
❑Iame,cmplunder See . .BdPCfor this mason
603 — ROOF BATTENS
Owner Dan,
604 — ROOF IN—PROGRESS
WORKER'S COMPENSATION DECLARA'll
I hereby affirm tinder penalty of perjury one of the following declarations:
] I have and will naninlaill it Certificate of Consent m ,cif-insure for Worker's
Garn,mmlon, as provided for by Section 37011 of the Labor Cal, for the
perhnnmviceal' the walk for which his lennil Is i.sacd.
have and will nminrfm Worker's Co npenwtion Insurance, as required by Section
3700 of the Lahor Col , far the performance of he work for which this permit is
-
istal. my" "nInwmntt caber and Policy numbs
Carrier: XIiM No 7f'w—//
CIiNIIIRC OF EKIiMPI'10NRANC WORKERS
COM
COMPENSATION INSURANCE
Thi, se,lo n need nm 1, emgnetW Ifihe pe'mh is Ibr one hundred ddlvr.
'
ISUM) lir lewd
I ceriry mw in the peatormance of he work Tim which 1his .it is rowed I
,hurl not employ any person in any manner w as to become subject to the Workers
Cnnyren, i T aweof Cablbfni, Done
eIL otherCommaking this Certificate of E.enpt inn. You should
NOI let:APoI.he
Wo,':
beeor eI tdbj minor, the Code. You mull
bccomch Colon nor ian per
sea he Wuch
clMd
not
IonM1with n,n,ply wilM1 .web provi>iona or this pencil shall M JccnmJ revoked.
coni pr
.
' CONS 'rRUCI'[ON LENDING AGENCY
I hereby affair than there is it coop motion lending agetay fon the perfamnnce
of me work for which his pencil i, issued (Sec. 3197, Civ, C.)
Ixmdcr's Nance
Lender's Allots.
I certify that I haves read ids agphcatloa and wrc that aha vMtc lot action is
nen. I agree 10 comply with all city amt county ordinances and slate laws relating
to building comlwedon, trio hereby nation, rePmnwn:uivcx of this cit, to parr, upon
the nhoven,cnOnnml property for itvpeetion purpows
(We) agree to save. indemnify and keep hart,,, the City of Cupertino ngu rni
'
Ilalaines, Tud,mmn,, mala : it aspen,,, which miry til any way accrue ugvirvd said
City in conoquenca of the granting el his permit.
APPLICANT UNDERSTA' T W ILL C MPLY WITH ALL NOPPOZI
D O
Issued by: Date
SOURCE REOULA'rll �/al
y'
Re-roofs, -
SilaoLum of Appll,;L,iU mnelor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m mtmre building ocenant .teem handle hmmdm„ mttmr:d
Type of Roof
. di fmcd by the Cupertino Mnacipal Code, Chapter 9.12. and the Health and safe,,
,cal,
Seninn 2.553200 /
❑ye, .4
All roofs shall be inspected prior to any reeling material being installed. -
Willmeappdcama Winne boildiogtenupLal,,aripnentorde.iceswhich
If it roof is installed without first obtaining an inspection, I agree to remove
mth:vafdou, air comamiwm, as defined y the tray Area Air Quality Meagcmcnl
oi.n.,
all new materials for inspection. Applicant understands and will comply with
°Pel
all non-point source r ,ulations.
I have mall line llarardo,:s ...,,lard., ,ai,enwrr, ander Castile, 6.95 of the
California Health h Safety Coh, Sections 25305. 25533 and 25534, 1 understand that
r
it the hi iidingduc. col oulanlly have a tectum. hal no is n,y,e...... dllil. u, anify the
I
Q/
u w
cu,n1 lit the re. i octo a 1, hich nest be sen prior m iauunce or a cenircam lir
(kcucy
/
Signature of A1415ificant Date
— 3
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All roof coverings to be Class "B" or better
All
Owner orantion, .gen, Dane
OFFICE