00120055 (2) CITY OGI UPERTINO
BUILDING PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20710 SUNRISE DR ROSSETTAS ROOFING 00120055
OWNE'R'S NAME: APPLICA'T'ION SUB DA'I'S
MILICHEVICH NICK M AND J ANNE 401 LINCOLN AVE 1.2/08/2000
IIONP_ SANITARY NO. CONTROL NO.
(408)294-4400
❑:EZ ARCHITECTIIeNGWINFR: BUILDING PERMIT INFO
00
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Hj LICIiNSED CONTRACTOR'S DECLARATION - Job Description
zZ�+G 1 Immby afEvn Ilan I am liean..d under provisions of Cnamer 9lmmntcneing
u with Section 7000I of Divixion 3 of the limine,,and Pm1c,,iam,Calc.and my license
¢' Is in roll foreen d t. I
s xa Licca cd.. N 'l REMOJE SHANE INSTALL 1/1/2" CCX 30 TEMP
Dale��b L117 a,nlrnZCt�ekS
AltClll❑iCl"S IIIiCLARAI'I(1N
tg O 4 I understand my plans shall he used as public mcorits
Liccn.uJ I'nde.,innul /at
n a OWNER BUILDER DUCLARAI'ION
I hear,flub,Thal 1 an,eviden form the Contraaol.,License Law for she
f_Z following resson.(Section 7031.5,Business and Pmfesions Cade:Any city or county
O which reiluiren a pen pit in construct.alma improve,denadd,h,or repair any.structure
a,jm p..oreal, . 1 per, If 11 I.I 1 -E d.l l•nwm
that he is I . t ptextemnal the p s fthe tr ',License U.(Clrptm" Sq. Ft. Floor Area m
(commencing with Section 7EMB of Di.iont f the Il and Pro Rv,lort Core) $ 287
or that he is excerpt themBom and the basis ln ithe alleged exemption.Any violation
,it Section 7031.5 by any ap,l earn kora nnit,ubjco, he appllcam n,it civil Penally
of net more than ma waded dollar,($500). APN Number Occupancy Type
OLle,nwnernfinepmpcity, out,employee,,siffivage,aaneirsale cnmPea.amir 3591 00
will do Ire%ork,and Ire structure is not intended or uttered for sale(Sec.7044.
uoint„lord Po@..h,.„Canlernm ConIractor',Liccow,Law doe,nd:),ply to at Required Inspections
or ,of popery Who budd,or bnpowe,mneme.and who doe,,nn,work broself 305 — FRAME
through his stem employee,.provided that such impovereems arc nae mended or
ollered for sale.If,however.the building or improvement is,old within one your of 307 — INSULATION
im,:,"moon.Ire awna.bwlder will Novelle hidden of pn.It.,tom ha did not bold or
provetorpurposeofhale.). 601 - ROOF TEAR OFF
01,a,wine,of oopen,anexclusively c:nraamgwith wermeonamctor,1. 602 - ROOF PI_YI400D NAIL
ismnsBmet nee pojert(Sec.7014.Hue and Proro.. ,Code,The contractor,
e Lavish,nil apply. L„f„operty who fold,of impr es meters. - 603 '- ROOF BATTENS
and who contracts for xuch prnjm,wilt.v raoorlo licensed pta,ma, or the
Carter 604 - ROOF IN-PROGRESS
❑l alb Lecnnpt under See. ,B A P C for this reason
Owner Date
Wo RK17R'S COMPF-NSAI]ON DECLARATION
I hereby nlBnn under penally ofperiary one of the following declaration,:
] I have and will maintain a CeNlicate of Consent to self-istre for Worker'.
Campcnwtion, as provided for by Section 3700 of the Labor Cad, for the
perfomrater of IM work Eunuch this permit i,issued. -
❑1 have and will maintain W'mktr's Compensation Lnurxnec,as ,.,,cd by Seclinn
37W of the Labor Code,for the perionanee of the work for which this 1,coun is
` I vaird.My Worker's Compensation Insurance canter and Police number are:
Cnrricn-�-]Ic3 TIAXXk—Policy NaC.
CERTIFICATION OI:EXEMI'fION FROM WORKERS'
COMPENSATION INSURANCE
(The ecetinn shod not be cm;plated if are permit is for one tordred dullnc
(1110)or fell I
1 certify that in the performance of the work for which this permit is issued,I
,hell net employ dry person in ury remove na e,beeline.subject to the Wodcrd
Coru'remtion I,—of Culifomia.Datas
Applicant
NOTICE TO APPLICANT:If,after making tris CeniGc.m of Exemption,you should
become abject to me Workers Cni"cnsation pnrvis hal the L.al,n Calc,you mu,,
p O onr"Ill co..fly with...1,prvv'ui; res hi, cr it,fall he nice:heal eevoked.
Z
FN.: C(1NSTre is a oN LENDINGlen AGENCY
' I hereby which mat Petra i,a con.swSt a lending agency Tor the pedi,mmnce
L7: of the rod for whichd...pcnnin is i.vwed Ise,.31197,civ.CJ
L Q Isndcr's Nano
7 Z. 1<ndet,nehlress
V p 1 vcm y that l boo,read this upplicatian and%toe Beal the ahove information is
loaned.I ages,or m.. fly with all tray; I.wan I,aid lnunce,1 1"ale laws relming
p [) ,,building eorotrawie.,and hereby aumodae representatives of this city to enter upon
} the above mention(]progeny for in,pection purposes.
H L
(We)agree to wvc.imanaryand keep harmlev,the Cryof Custom against
Uri) hathdonev,judgmcnl,,a I,and axlen,c,%Inch may in any way accrue against.said
Cis in c we'e el he
if do,
Solid
UNDERSTANDS AN`DWILL Permit.
COMPLY WITH ALL NON-POINT Issued by: Date / '�•�
-nrhi (a��ler,
sign—:,Iam,dnphhettmteamm( Daae Re-
roofs
HAZARDOUS MATER1AIS DISCLOSURE
Will the appfcam nr In bre Ivdaimg amtpant q:ac or handle hvnnlaa,arterial Type of Roof
as defined by the Ca,setz M "ipul Calc.Chapter 0.12,anJ the Health and Safely
Code,Swoon 25532(.1'!
O Ye, )No All roofs shall be inspected prior to any roofing material being installed
Wilt the applicant or future building arcupant use equipment or device,which If it roof is installed without first obtaining an inspection, 1 agree to remove
,v
1amloas an luntun:in:m,w defined by the Hay Arca Air Quality Manu career
,it...let'! all new materials for inspection. Applicant understands and will comply with
0Yc' N. all non-point source regulations.
1 have mud Ire haranmu,:onen.1,nc,mmnRnl,under Chapter 6.95 or the
CnliI ria ifill It ge Safely Calc,Seddon,255115,:55;11 and 25514.I model,it
IM1tn - 1`�,k
iflhe building de,nol currently ly have a mue.Ihal it i. n,or,pm.iMda,h.natlty lbs -�_� �.4� ��l on
cu,na at the aqui menti which mot he mel prior it,n...acc of a Certiliwle Pel l
Oc,aphae1w - t a Signature of Applicant Date
mod!a"- -� _ee All roof coverings to be Class "B" or better
owner or�nmodaed ager Otte
OFFICE