00100113 (2) CITDIVISION
NG DPERMIT CONTRACTOR INFORMATION:
BUILDINGADDRES10392 LAS ONDAS WY WESTSHORE ROOFING LI{51ITbo. 0010031.3
owaElts NAME. WANG 5869 WINFIELD BLVnprLlcnTlDN suu10%17/2000
PHONE: SANITARY NO. CONTROL NO,
(408)629-2100
❑s p. ARCI UEC-UHNGINCCR: BUILDING PERMIT INTO
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S 4 uCIiNSIiDCONTRACnder r vi,io-RAnoN Job Description
0 z 1 hcrenr:dfnn Ih:n 1 am icenwd 11..panlsaoo,or In C 19lcommewug
°��° wnh all form Classand efuta 1 n1,rBa.ine..a,tp r,..msslo,tarPolI,.,y lie -REROOF OVER SHANE WITH E
F— in fall anderreel. } GERARD STEEL T
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ARCHI'IECI" I)ECIARN'ION p ,/
L understand toy mmnanau be ossa as public. rd
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yi o o Jemed Pmfcssionl
OWNER-BUILDER DECLARATION
I rvo h,vnirm Nut I onesmnpl Inmt the 0 onsc or',License law for the
h Z< following reason.(Section 70.11.5.Nu,incs,and Professions Calc:Any city or county
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� p win 'ce
1 p ll t t ale t! I I.h p w
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i3m pr tort I I. y ',h pal all ch pc a ,l g J:,Wmncn
that he is limited brostaintl itheprovisions adRhee I t r%Linerve Lo (C'Lap,m9 Sy. Ft. Floor Area valuate
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on m .ng w th See91XXll fDi,st fh Business dl f r,CUJeI oe!17000
or stat he is rxnnpl Ihemlrnm and the baa,tot for alleged exemplik Any vwinion
of Section 703 1.5 by any applicant for a permit.subjects the applicant to a civil penalty
at ont mac than five h... ind dolor,(S500t APN Number Occufaro Type
01,a,owner ohne propenx or my employee,with wages a,their sole compensation. 36928035. 00*
well d.t the work,and the amemre is oat imcvfed or offered for sale(Sec.7044,
Roan's and Profusion Code:The Contractor,License Law does nn,apply ,,an Required Inspections
owner of prolenr Who build.lir improves thereon.and who doe,such work himself 305 — FRAME
or through his town empluycer,provided mut such inipmvcmem,core not amended or -
offered for ale.If.however,,be building or improvement is.sold within one year of 307 — INSULATION
omplaion,the ownerbui der will have the buMen of proving that he did not build lir
intpro..lnrpmpowul,:de.). 601, —. ROOF TEAR OFF
01,a.,owner of he proper,.am esmn,ively c inruefing with limned corrector,to 602 — ROOF PLYWOOD NAIL
Lamsueate Project(tic,.71144. ;.oil,dd,Basin—,u, P...I ..nm CuJc:)'Ihe 0 anclnr'e
ieenseLawdoesourapply ,,unownerafprc,nitywnobuild,ro nprovesmereon. - 603 — ROOF BATTENS
nd who commcts fin such projects with a contraction,)licensed ponuanf m,he
ac'mnmctocs Lhensc Law, 604' — ROOF IN—PROGRESS
01 ant exempt under See. .B&I'C for this reason
Owner Dam
WORKER'S COMPENSAI ION DECLARATION
I hereby affirm under penally ol,crjmy one of in,fnllnwing Lelurmlons'.
0 I have and will n nintnin a Certificate of G.nsen, cot half-iunure Ion Workers
Compersaeon, as provided ler by Seclii 3710 o1the Labor Cone, for le
peufomtznce rffhe work for xmich,hi,permit i,issued.
01 have and will rounmin Worker's Compenation Invamnce,as nyu rad by Secure. '
57110 of the tabor Code,for he performance of the work in,,which this permit is
isxunl.My W. n : ' n Lnsurunce c�rrJ'�r imd5j( tic gI'rc`r arc:
' Canicr._ Policy No.:L/1Q(_JX� v
CFRTI ICATIII t,l?%EMFf10N 192 WUR RS'
COMPENSATION INSURANCE
(Thi, mlion need cool be eL letul II,,,coni,is Inure one hundred dollar,
ISIIXI)ar IosJ
I crony,bat in,he pm tonna v in he sunk for whish this permit i, and.I
shall not employ any person in any,banner so as to become.subject to the Wn,ken'
Compcnenion laws of California.Uam
A,,heata
NOTICli TO APPLICANT:R:after making his Certificate of Emmptinn,you should
becsannwbjcm to the Worker's Compena,ion provision of the Labor Code.you into
Q O li,nhwi,b c ply with meb Ina.ki...u Lara...perm,,rhA1 he dm,aal revoked.
Z
CiINSI'RIILa ,un LENOLNGAGENCY
> 1 harchy affirm thin IhmC as u csue (Sm. I0G.C agency far the perfurnunmc
W of the work for which Nis permit ix issued ISm 3UN7.Civ.C.)
L ❑ Lender's ddre
= Z IsnJcAddress
dJres..
U 1 cepity Ihm I have rend,his opplicmi.0 uu1 ,are that the above informmion is
firs [ter conern I agree to a+n.ply wish all city and county ordinances and elute laws reining
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in budding construction.and therebyanthori,e representatives of hi.:city u,error upon
he ahnvo-mcnilooM pro sen,to,inv,miinn pn.pows.
F. p. ("a)ugnontsave.indemnify and keep en.... ss,hd City of Cupertino against
W) liabilities,judgmmm,ensu and expenses xhich may in any way aacme again,,.said I /,
U ,Zi City In can acqucnre of he gmntingof lhislermit,
AOURCE REGULATIONSNUS NDp WILLC LY WITH ALL NONd'OINT Issued by: Date
'ignmamf
oAp,licantlm
Contctin r v�1Y,1. [)air Re-roofs
HAFARIIOUS MATERIALS DISCLOSURE
Wib(he,ppbemn or comm bmdmgocm,ant store or handle hu,:I o,material Type of Roof -
as defined coy the Cnperino Municipal Code.Chapter 9.12.lad me Health and Safe,y .
Code,Semi ton 25532,11
O Yes C1 No, All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Lure building occup:uu use eyuipmem or device,which If a roof is installed without first obtaining an inspection, I agree to remove
coni,hvanlous air amnaminunn-defined by the Bay Arca Air OmJhy Manngcmcnt
Diane, all new materials for inspection. Applicant understands and will comply with
ore., ONo all non-point source regulations.
I have mad,he Safety
CuAu,materials myuimmmns under 34.1 an 6.95 of the tS
.I hetrnildon,hn&Sufctyensir.ave Sect aun"no that
and ou"c'p5bf.tundvn.amllha 1`1TI`'a\y' 1
occupant
omgdcesno,cuncn,lhich ust he mbmiismyssuance of rymifictNc r
cupam of the n'yuirtmm,n which mull be met prior m issuance of a Certificate of
"1 I1���xoo Signature ofApplicanl Date
flwneror darea 1/ U Ila,r — All roof coverings to be Class "B"or better
OFFICE