02100138 (2) CITY OF CUPEWI'INO - I -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: "
Buli.1)d8GQO)kfAi1 0229 WILL CT T D ROOFING PERMTTN®2100138
l#' ING MARIA N 3540 MARGATE AVE . APPLIcATT10aM9Y2002
YDONE: (408) 892-8872 SANITARY NO. CONTROL NO.
ARCIII3]3CTIEN(BNEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECD
0 0 0 0
heI hereby alfirm that I am IncLICENSED ensed unndder provisions Ri f Chapter 9(commencing Job Description
witn S«Ben]ag�nrDrvu Inn 3OrNe Bn..`• '�alnJP/rofc. mCode.andmyliccncts REROOF
F ON
ZjQ in lull�nCRs�aJ el�fLcl.� �SU!!CLARA�TI�—I�ROO FONALE®
ZCLIK Hyl—•.r,1�7 '.y-1 NOV q
�.e —1 made—r..umid my plans shall he used as public hmod, NO y O '5 [00[
OyU
re C.
Licensed Professional
Fa03 OWNER-BUILDER DECLARATION
Y > 1 hereby affirm that 1 am exempt from Ne Contractors License Law lir the �IJYLDING $H O O O
ip O following reason.(Sccwm]8315.Busincsa and Pnfcxsinns CnJe:Any city nr ceunly
R m which requires a front to construct.alter,improve,demolish,or mpair any structure
d'w+ pnorto its issuance.also requires the applicant for.such permit o file asigned ualemenl
that he is licensed pdsuanuo the provisions of the Contmnnr's License law(&pmr 9 69.`11DOo3>SAIQ� Valuation
yF0 (commencing with Section 7000)of Division 3 of the Buxi rata and Professions Code)or
i 3$ Nn M is exempt Nerefusm and dre basis for the alleged exemption.Any violation of
Section 71131.5 by any applicant for a permit subjects the applicant to a civil penalty of -3 UXPN-NTrR4TE Occupancy Type
nor more Nan Eve hundred dollars(9WA 3 07 - INSULATION
I.as owner M the progeny.or my employees with wages az their sale compensation,
will do the work,and thestructure is not intended or offered for sale(See 7W.Business III �p
and Professions Code:The Contractors License law dors not apply to an Owner of 6 0 2 - ROOF P IHV n yy AG�ltns
property who builds ser improves thereon,and who doessuch work himself or Nmugh his
r employee..provided that such improvements are not immndcd or offered for sale.If. 603 — ROOF BATTENS
however.the building or improvement is sold within one year Of Completion,the owmr- 604 — ROOF IN—PROGRESS
builder will have the burden of proving that he did not mild or improve for purpose of
sale).
❑I.as owner of the progeny,am exclusively contracting with licensed contractors to
construct the project(Sec.70W4,Business and Professions Code:)The Contractor's Li.
cense few docs not apply to an owner of property who Wilds or improves Neuron.and
who contracts for such projects with a conuacmr(s)Incesed pursuant u the Contractor's
License Law.
I am exempt under Sec. .B is P C for this reason
Dale
WORKER'S COMPENSATION DECLARATION
.1 (hereby affirm under penalty of perjury or¢of the following declarations:
I have and will maintain a Cenificam of Consent o self-insure for Worker s Compere
cation,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 Worker's Compensation Insurance,as regvired by Section
37110 of Ne Lahr Code,for the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance Cartier and Policy number ate:
c
Policy
—CER( P ATE � 0WORKERS I
COMP ENSATIONIN RANCE
(This acerion need not he completed if the permit is for one hundred dollars IS 100)
less.)
I cenify but in the performance of the work far which this permit is issued,1 that ctrl
employ any person in any manner so alio become Subject o the Wnrkeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Nis Cemilicale,of Exemption.you should
become subject ds the Worker's Compensation provision.,of the laMn Code,you must
OZ forthwith comply with such previsions or this permit shall he deemed revoked.
zO CONSTRUCTION LENDING AGENCY
t~ gn I hereby aflirm that there is a con.stmcdnn lending agency lnnhe performance of
(Yr > the work for which this Permit is issued(See 3097.Co,C.) �^
D] 0 LenJcr's Name
11 Lenders Ahimss
U 0 1 Certify that 1 ban read this application and sure that the alxwe intimation is
W I~ correct.1 agree In comply with all city and county ordinances and stale laws relating to
DU building construction,and hereby authoria representatives of his city to enter uram the
chow mentioned progenyc
for insfa tinn purposes
a.
a (We)agree us save,indemnify and keep Wordless;the City of Cupe rims against
!n
liabilities,judgments,costs and expenses which may in any way accrue against said City (f
U zin commicurec of the grading of this Permit.
APPLICANT UNDP S"TANDS AND WILL COMPLY WITH ALL NON.POINT Issued by: Date
SOURCE REGL TONS tl� I
t Re-roofs
Si lure of ApplicanUContracmr Darc
I IALARDOUS MA (ALS DISCLOSURE Type of Roof
Will the applicant or future building,wcupad store or handle hvardous material
s defined by the Cupertino Municipal Code,Chapter 9.11.and the Health and Safely
viSecfon 255321x)'' All roofs shall be inspected prior to any roofing material being installed.
e.
C ❑Yes )bNo
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
mil W/ardou.v air ennlum'mants as defined by the Buy Arca Air Quality Management all new materials for inspection.
District/
❑Ycs po
I have read the ha m Ions materials requirements under Chapter 6.95 of the Cabin-
ria H
abin-riul eaW&SafnyCsk.Scctios255n5,25533 and 25534.1 on&Od thv ifthe buildingOZ--
does not conepppdX h{ve a¢rant,that it is my resrymsihility to noddy rhe wtupam df the t�
reyuirement`,pM1ith lnuu lc mel goer le isavana eh cenrB=amdra= a' Sl nature of Applicant Date
.YW�CTI J� V15,
neror ad@mixed.gear Die All roof coverings to he Class"B" or better