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CITYBUILDING
CONTRACTOR INFORMATION:
NNO PERMIT
DIVISION
BUILDING ADDRESS:
PERMIT NO. 1
11530 UPLAND WY
OLD COUNTRY ROOFING
01110010
OWNER'S NAME:
BUSCH JOHN R AND WENDY L
387 UMBARGER RD #B
APPLICATION SUB DATE
11/02/2001
PHONE:
(408)362-1111
SANITARY NO. CONTROL NO.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I herchy affrin that 1 am licensed under provisions of Chapter 9l commencing
with Section 7") of Division 3 of the Business and Professions Code. and my license
REROOF .
iS"c^uafort`t,e !0 73
T/O SHAKE,S ADD MONIER CEDARLITE
Lica
Date l� c..mcu
SHAKE TILE. ICBG ER 2656.
ARCHITECT'S DECLARATIO
1 undamand my plans shall h .,ad as public record,
Licensed Professional
OWNER BUILDER DECLARATION
1 hereby aTnn that I am esnnpt fmm the Ccmmenn's License Law far the
following muon. (Semon 7031.5. Business and Professions Code: Any city or county
which requirts a permit m common. alter, improve. demolish, or repair any structure
_prior.tons iouarcn.IsorequirtstMapplkant forsuch permit to fileasigrrcd statement.
- -� - - --------------- ------ --.. ___.. ___
that hd A,lianted pumibnt to thb priivisions of the Contractor's License Law (Chapter 9
Section 4000) Division 3 the Bueincsn Prpfxlions Code)
9 IOOC'A[Ca'nw 1
j�}� it..l jj\, F �,'v �•:
$'Z 8 .1 ation
(motorman, with, of of an!
or that he ii czempt tM1cmfibm and the basis for the alleged exemption. AAny violation
e _'t"Fi 1.'+1 1_v 3". ht
-of Scaion 7031:5 by any applicant for a permit subjects the applicant to a civil peruhy-
lornoemorctnanevenandrcaaonata(ssoo).
,- 36 tgnb®ID
-.`., '• Occupancy Type
❑ 1, owner of the . or my employees with wages etch sole a
3 05 - FRAME Required Ins ections" 1` •� -
Q '
le (S 70,Tn.
will do the'woro;esndNYstre: The s trot ibmruffd'oneBLaw doe sale (sec. to a,
d andthe a
rBus prProfessions License Law not apply tam
Care: Coes
builds daemon. s such
owner rproperty wn h la pm.eaenercon.anewnaa :ace orkhmself
307__— INSULATION ' I
of 0 sh h' empl y e'. p J d that such improvements o t'ntenJ a or
.. ..___ ._.
g arurdenomm rte year of
'mfr ed_f - I If ho a er eh Wilding t s Id lh
_......_ _a.. ....._..
601 - ROOF TEAR OFFr__,•. .. ,. •'....
ample far the s salts.). have the burden of pmnng that he did not build or
Improve Duro e °
602 - ROOF PLYWOOD NAIL
withlicensedennimcuosm
04asowner,pof themjm D(Sm.
;__
- ^.. - I'Ys•I, ;•.Gt`
ROOF' BATTENS
lam Business and Professions
Busters and Profusion Cade:) The Comraaon,
conmm� the project Iappl
6 04 - ROOF IN -PROGRESS- - '' `'' it
to a at improves thereon,
License law docs rrot apply man owner of proontr who
).Ain
..and foe such Projecu.with.a.canerumr(x).licensed Pursuant.w the
.-_. ..... __. ___ _.____._ ---- ..._ __. _ .. .._. _.. ......
memos Licas
Contractors Liccnde Law.
❑lam exempt under Sec.' ' '•1 •' ''�.B�&PCfor this rcawn
-' I•.. .;I`.:("1
Own Date -.' .• .
' WORKER'5 COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
�� �s C
ar-~ G
❑ 1 have end will maintain 'a Certificate of Conant to self -insure for Worker's
Camperosatiq°.. provided ro, by Section '37W of the Labor Code, for the
Performance of the work for which this permit is issued.. v
DEC 0 4 ZO 01
II have and will W Section
of
the pefformar
57o0'of da, Laba Cade Bar armit rmit1
the- work' for which thiiss/p
whe"M V•orYA.c oCosP to 11
1{
+e,.
Via'
` I'�. I �.: l�'st ftli_� I ii�S ssf ,
�CERTIFlCATION OF E%EMPTION FROM WORIf.ER$•�-, ..
'..'
•V
INSURANCB,:"` .• •
. _ COMPENS .... •h.rr- . ..Ff,_ ,
nscduon
__.__....___._..-__.._.-_.__-______�_. __ _ ___ __.._______ ___ ___.__.—__ .
`e (TM1 nceJ'n°i be mmAT10N
i1`- ` plated if the permie is for one hundred dollnm
^Iii'• ... a ..: .t .,. _ .'i P. �•'
IS I W) our lcss.)t. .,. .. n' .. ..
._. ._.._e.. ..-,.-....-...-_._� -
---•`—_--•- T•• �_---'- _(
'tI'cenifythat in the, pekoem°nce of ehc work fir whieA'ehii permit is isstieJ, 1'
�sNdll�nto in ma sit to become io'the Workers'
;, C"•.� ..+I;. . ,: T::i's
"
employ anyperson any ei us subject
Compen...am Laws of Califomie.
'Applicant
NOTICE TO APPLICANT: IL ager making this CcniOcae of Excmpeion. you should
`
become svhjeci m Inc Worker's Compensation Droviaions of eM1e Canbr Codc, you man
foehwnh''am", wit, inch provisions or chis permit shall M deemed rtvoked.
Jl.rI IONLENDINGIAGENCY'"""
Sem
" Tho rte that isa
I hereby Shute this chert its cooiwaiar Ichaing agency for the perfo
I I
; ... ,. ... •. �. .. .u... ...�
�..
Lead kms which thispe it. '. seed (Sec'J(N7 Co.C)c - ,'" -,,
,
_.-_ _�. .._. _.. _. ._..__.. ___ _.. .. _ .. _..___ .. ..._.. ... ..._..._...
-Lend ryN-e ...
Lands Addrae " � _
•. _. ._ _. ,..
_ .. .. _
1 certify that I have mad this application and state that above information is
_
"' agree to comply and enure ordinances and state laws relating
orrmsn p y with all cry g
tobuildingcontimadorarily maim of chit city intoner upon
c
sM bo e) toe for inspection uposemativds
ndf Pod purposes.
'
(We) gmenomain mthean City pCpen o'eg se
to five:
-- -- -
and exlyandkephamJ
liabilities, e judgments. nes, eo t nd pe us li eh Y n any Y It in t id
Cr consequenceafm g _t g fabs p' t' .
MI'LICApT UND SAND\WI OMPLR N�ITH ALL NO Po
"-
-' Issued b Date
y'
SOURCE REGL . NS. (�2/ O /
Sigmimm of Applicof Applican (Cant <tnr "'" "'-" ".-'ra. •"'"goal—''
1
Re -roofs--- ---
v ,HAYAr MATERIALS DISCLOSURE
me
pCuTs or fumrc ipalingacupaotstwe h ale Hearaws
Type Of Roof. .. ..: .- --. - —_-•: _' - _ - --
Sanl
as ediklby
C defined by t25 Cupcn o Municipal Cade Chapte 9.12. atltl to Health d Sefcry
.t
Cod Sen 25572( )7 t s t It SI s 4 (•�lj,
1
1'••r F i Y . La > {1 a 1 tt yr. is `.� 1 I .i' t}, r'; a
_-
_-All roofs.shall,be inspected.prior to.any roofingmaterial. being installed__.... .
win the applinm or future building occupant use equipmem or devices which
If aroof is installed without first obtaining an inspection, 1 agree.to remove
cam hnmrd r cat u arts defined by the Bay Area Air Quality ty Managem t
Distinct? /
all new materials for inspection; Applicant and will, comply with
ave : } '" °°
.understands
all on' -point source regulations .; . '
'f I It read the hazardous materials relairrenneau under Chapter 6.95 of the
cal fita Heildt & Salary Code Sm,imus 25505 25533 and 25334 1 t nderstand that
'if eM1 Wildia,roes note tlY have a nomm. that itis my rePo blot mnotifY,the
-
0- d l
oc'Cupam of the anis whish m'. bdmci poor to issuance of a ni0 are'of
IIFFF.///
Occuputc " '.
• I- �I 2 �
Signature. ofAppli-- nt. _ - _._ .- Date
All roof coverings to be Class "B" or better
owner ar aamorizm gist"r• ;'.; "1 ', -• am