05070025 " CITY OF CUPERTINO wiyS.i ". ::ep°e . ~. ._
BUILDING DIVISION PERMIT CONTRAGTOR''INFORMATI ON:'
< f..
BUILDING ADDRESS. PERMIT N
CURT FLETSCHER ROOFING INC 005070025
9T c;In Z5T)T)TTTr1Tr1N r'T ._. ._.._----_,-. _ —
OWNER'S NAME PERMIT ISSUE DATE
Adl UER _ _ "2 S4 M(1NTT('F.T,T,Q A$IE -. _ _ 117 /,x/-f?fCONTR
ZONE: SANRARY I) Cr1c;_ LNO.
(408) 267-2679_-
ARCHITECrTENGINEER: BUILDING PERMIT INFO
fi,BrL; ELECT PLUMB MEOCH
°00 LICENSED CONTRACTOR'S DECLARATION 'N
F I here m
by affirm at 1 am licensed under previsions /
n of Chapter 9(commencing Job Description�dl7/ I
pwith Section7fl(IU)nf0iviaion 3 of the easiness and Professions Code.and my license is
= LiicennseClass a� Lw a ������ REROOF W/COMP. SHINGLES
e r e Dale I am"ewr
'fly ARCHITECTS DECLARATION 7
m< I understand my Plans shall W used as public records
u
Fe e� q l
3 o G Licensed Professional
OWNER-BUILDER DELI-ARATIDN
nC 1 hereby al Gem rent 1 1 exempt from he Canin Con License Law for iW //
p o which reason (Section]1131 5, ,fib Business and Professions Code:Any ray or county
structure 4
$ which reywms issuance.permit ne construct,alup nn prove,de ermitt ore a sig any muemre 1 ' aA'7 cz n
pnormtts ensed pursu requites thovisio soff ft Contractor's mr=Laedsulemcm T ti -
<
(commencing incingwithSesuammmcofDiviotuo oftheBruessand trulaw(sCode)9 Sq. Ft.Floor Area ValuaUOn
a. (rommene xempt therefrom 7tanddeDmsmnr ofdmgcd Business end on.An ions Code)or
.ye 3$ that he u exempt therefrom and dm basis for the alicged exemption.Any violation of
Section 7031.5 by any applicant for a permit objects the applicant o a civil Penalty of 3 5 23ttM 0 Occupancy Type
not mats than five hundred dollars(1508).
❑Ido owrcrof the pro pent',omyemploym wM wagesuthcir(See.7W.Bsadors
will Pr fework.ends he Contractor's not mandcdorawdfor salt(Sec.in a�a, ime,of
and Professions Code:The Cont emon,and law dohs not apply lf an owner of Required Inspections
progeny,who builds vi improves thereon,and who does n notembe himself orhrough his
own employees,providedmrovem improvements arcne years fcererfem.theo net..
however,me buddogoropro proved;that wormot Wild or I will have th<WNen of proving mat he did not Wild or improve for purpose of
sale.).
❑1,as owner of the propeny.am exclusively conour ing with licensed constructors to
construct the project(Sec.7(144.Business and Professions Code.)The Conoacmr's Li-
come,law dohs not apply us in owner of prefatory who builds or improves thereon,and
who contracts for such projects with a contraction(s)Licensed pursuant m the Conoactors
License law.
❑I am exempt under Sec. .B A P C for tan mazon
Owner Dal
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of poUtiry one of the following dularasions.
l]1 have and will maintain aCe ulicnie of Consent to self-insure for Worker's Compen-
sxuon,as provided for by Semen 3700 of the labor Codc.for me performance of the
work for which mu prrmrt is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Code.for the performance of the work for which this permn is issued.
My Worker C,ompan adon lagunce n cr and Policy number arc
Cvncr. L TT1Iii??��--((HH�� Ir'U Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not he completed if the permit Is forgo,hundred dollars(9101)
or less)
1 ormly thin in me perr.miaiicc of me work for which this permit es issued,l shall not
employ any goon in any manner an as in become subject o be Workers'Compensation
Laws of California.Dv"
Applies•"
NOTICE 10 APPLICANT:If.after making thu Cerumcate of Exempsion,you should
become sabjctt to me Worker's Compensation Intervenors of tic labor Code,you must
Q z formwim comply with such provisions or this permit shall W deCmhG revoked
z CONSTRUCTION LENDING AGENCY
'T+ I hereby affirm that None is a construction lending agency for me Performance of
a the wart for which ion permit n issued(Sec.3097.Ov.C.)
!y A Unders Nam^
Z)z Undcrs Add¢, -
rJ Q 1 ccnify that 1 have read this application and sale that the above information is
correct.I agree in comply with all city and county oNreances and fare laws relaong m
Q U budding construction,and hereby authorise represenauses of his City to enter upon be .
above-mcts oncd property for iiupecuo t purposes
C (We)agree to save,mdemm fy and keep harmless he City of Cupertino against
F.,N babdnics,judgments,costs and expenses;which mayor any way we=against mid City
V Z in consequence of he granting of this perms.
^ APPLICANT UNDE STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dated
SOURCF<JIEGUTAPUNS. _
CC//�' !l,��--��LL {{nn'� Re-roofs
rmNC Q
Silp awn,of A6piipntnclor Date
HAZARDOUS MATERIALS DISCLOSURE ^Type Of Roof
Will tW applicant or futum budding occupant Amt m-loom le M sous material
as damned by the,Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.radon 255324)+ All roofs shall be inspected prior to any roofing material being installed.
Yes NO
Will the applicant or future building occupant use equipment or Jcvires which If a roof is installed without first obtaining an inspection,I agree to remove
#-iE harardous air contaminants as&rjncd by he Bay Area Air Quality Managcmcnt all new materials for inspection.
Dts mss
❑Yes S�No
1 have mad he hanodous materials requirements under Chapter 6.95 ofhe Califor-
Los Health&Safety Code,Secumts 25X15.25533 and 255341 understand thaffhc Wilding
deer not eurently have a IC an4 that it n my ecaponsubdoy as soli ly dC eecupant of me // J
tequtmmen,?r hmti mtlpnorwesmanmnr.ceroGrmc.1'Occupancy. Signature ofApplcant Date
.ecni
c Datc
Owner of aushonynJ h-) 6 c All roof coverings to be Class"B"or better
1 CITY OF CUPERTINO
REROOF dS ?' 7
�CUPERTINO PERMIT APPLICATION FORM
APN # J`P� Z 2 Date:
Building Address:
Owner's Name: '' rr Phone#:
I) 4ve q�3�or6�
ontracIt° 1 Phone#: License#: /
L i r} f C--1541 of Yo T—,267 -6 (6
Contact: Phone#: Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
• Built-Up Roof ❑ Built-Up roof
• Asphalt Shingles V Asphalt Shingles
ly Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cupertino's Tear Off Policy: [
J Description:II ''� I
V„AIJ LL!- l wlaj /Z - O�y wjoS 6 3"1 .S�(i' e/
Residential V . . Commercial
Fire Zone: Yes E] No ❑ Confirmed with Planning Dot. if �l
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
Qty. if
Applicable Fee M Fee Description Fee Group
( BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING J
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM
Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
� I I