01070018 (2) 'CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22141 WALLACE DR DONE RIGHT ROOFING & GUT ER01070018
OWNER'S NAMEAPP LI TION.UB DATE
NEIL HAYES 1129 LONG FELLOW AVE 07 09f2001
PHONE: (408) 377-8777 SANITARY NO. CONTROL NO
l
❑ Z ARCHITECT/ENGINEER: UILDING PERMIT INFO
lam O B ELECT PLUMB MECH
Z LICENSED CONTRACTOR'S DECLARATION of Chirpier
Job Descript' n
0 Zy 0 1 Hereby alhnn mm 1 ten licensed under provisions of CM1aptcr 9lchmmencing REROOF. COMP TO COMP.
re,tic,-nim Scction]f100)of DivisionJofthe Business anJ Pmfessiuns Caae.and my license
1inmuTo a fR GZ
e Liens Lic,p
w 3 u. m Contra"
ARCHITECT'S DECLARA ION
nand my plans Shull he med as public record,
w <0 Licensed PmPonsi...I
OWNER-RUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License law for the I
F following mason.(Section 7031.5.Business and Professions Code:Any city or corny $19000
E S p which requires a penmt n)nmamct.alta improve,demolish,or ocia"any awnure
i 3 _ -Prior to its issoancaakat outs've,Nmpplicant fa such pemdt mule.dgrcdsmmmem. - --- --
thmhei9littnieapursuenitothepmvtzionsnfWeConoacmr'sLicense taw(Chapmr9 , ..-.3,2U&)455or�.peu v Valuation
(ci,mmencing with$<etion,]Il(10)nf DivisionJor tM1<Business and Prof<ssionz Cale) r.tI .A.. :1.}."� .
or that he is<xempt theterrom and the basis for the alleged exemp41o6.Any violation
-of Section]036.5 by any aPPllcaot for a permit subjects the applicant on a civil penalty
Of our are than eve hundred dollars(S5Ws 3 0 5APN PgUq�Ig Occupancy Type
GLas owner of the prnpenr.or my employees with wages as their sole compensation. 307 — INSULATION
still do the work;and the structure is not intended or offered for sale(Se:ra7tw, 601 - ROOF TEAS (p�FeR Ins ec[ions"'
Business and Professions Cale:The Contractor's License Law does not apply to an CI p
Owner of property Who builds or improves thereon,and who does such work himself 602 - ROOF PLYWOOD NAIL
or through his pl Yc s.powuled that ch aripmounment,me Out intended or
oR d'f I Ito - th b Id g p ne sold m Y r 603 ROOF__BATTENS
completion,
Ili bid III' hnJ fp ighth A'd th 'IJ
improve
rrntpne r I ,) 604 - ROOF IN-PROGRESS
❑1 fth P Pent' xl elYc nmRngwth licensedent mart
construct th p reject(S 7044Business d P fe. ons Cab)Th C tncsm
LicenseLad t apply t f p pony h bu'Id. p -th neon.
_mrd.who coutueb,10 -Bch Pruleus w th a emanscums)f nsed pursuant to the.
Contranars License Law Q/
nt exempt under Scc. r,B'&PC fe"his rcasmn
❑le
c own c, Date ..
WORKER'S COMPENSATION DECLARATION
I hereby a?nn under penalty of perjury,oric of the following decorations:
❑ 1 have and will team am o'Certilicaie of Consent to se f insure for Worker's
Compensation, as provided for by Section 37W of the Labor Cale, for the
petfonompeoftheworkfurwhich this,,.tIs u,t l
❑1 nave antl will maintain worker's Compcnsoiion Irsiumnc<,.m required by Section
3700 of she Wbur,Code far me performance I the work for which this permt is
sxl Mr'ern pc m Insd ace ca dPol y bet
is
a9s5.)/ � _.._
Ce .',CEFICATIIO
IONUoridi i NFROMMURKER51 '�.1_ 1•. 1'.1_f,.l ,,. s.+c'; :H1.:, •'y': i
T 7 ,_COMPENSATION INSURANCE t' _,._. -.... _ .. __.. ._ ...
tl '('inis'idction nccd"motbea.mpleted ILthe peanuts future hundreddollars _ -- -_`-' .. .
(SIW)mlesod _
1 Gen fy that in he performance f th 'work for which this permit ie issucd.'lLows li
fossil
net empldY.anY.person to any manner vo ax m hecome sub)ect to
Crmpen,mi ,the Workers'
on r Calif m a.Date
Applicant - _ _ _ .. . ... .. . . .... .. _
,NOTICETOAPPLICASf If ft rmakmg ImitCeinficalentExemption:you should -
Qpe on hjccuutheW k C mpen t p - sof theLadCode....must
forth .the comply withhprovisionso th pc n hall be deemed revoked. I
... .. _ ..._ _ _ - .. .-
V] `A' T'V'" " "'CONSTRUCTION LENDING AGENCY .. I.
C ; 1 h<rchyaffirm thin there is a construction lending ogency for the performance t
L,Q oft, work for which this permit is issued(Sec.30W.Civ.C)"
Lender's NSme'
D,Z Lender's Adtlress', u•
V � 1 cenlfy that 1 have read thi,application and mate that the above inronmion is
correct,I agree to comply with all city and county mcbmar eats and state laws relating
0t tobuildingeummielinn.antl liercbv umhurize reprcsemmives of chis city renter upon
}'W the abnvemerro.red pruperq fm inspection morrows
L (We)agree to.vase.indemnify and keep harpresi_the City of Cupertino against
to li bit j i ic.!, c L d pence y In any Y a'crue again,,said
.. U.Z c 4 e''ce pkAry B'nt ND In Poon
LIC \ r,{p`byFL}tONS.DSACDWILLCOMPLYWITHALLNON-POINT Issued by: Date O
.OURC U )NS t � _
Si y e, plue.WCounichur Date Re-roofs
fLAZARDOUS MA ERIALS DISCLOSURE
w'u m ppli t r t' Hadar s e P t rc n hwlle naaardnm maten:a Type of Roof
'as defined by 2 Cupen M <tpol CsNe Chapter 9.1'_ tithe Health and Safety -•�; , '. 1 ,^• yrs-„ ..
Corte:s glomom 255]2( ) - p m J1
'pYes .CJNn , t?''-' t 1'rt k ._-All roofs shall be inspected.prior.to any.roofing.material being installed. _. . ..
:Will the applicant or fuwrc huildlns oecnp,mi no,e,tupmemt rdevice,which If a roof is installed without first obtaining an inspection, I'agree'to remove
cm it hareNous air contumimanu as defined by the Bay Arca Air Quality Jlenagemem
D"hier. all new materials for inspection. Applicant understands and will comply with.
- ❑vga: oNn' -'. -- ' all n -po In siownce regulations: .
r "1 have read the h ouv materials rcquirements under Chapter 6.95'of the
Icup
Iia Heat &Sat Codc.Sections 35505.ZSSJ3 and 3551].1 undersmnd tom _buihh dylime a tenant;Cher it is my iesponsibility m m ify thea a ocs h rent ms which must he met prior m Issuance ofa Certificate of
Pay
s
gnature.of Applicant Dale
/ownernfanmprRWagent Date All roof coverings to be Class "B"or better
OFFICE. . . ..