05070023 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR,INFORMATION:':
BUILDING ADDRESS: POAMIT NO
CURT FLETSCHER ROOFING INC 05070023
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OWNER'S NAME: PERMIT ISSUEDATE
RAVT (-OP_AL "AF4 MnMTTC'FT,T.n 4.22 . _ _ - A'7 / � /� G
ONE SANITARY NO CONTROL NO
(408) 267-2679 - — ---
ARCHITECTrENGINEER. BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
S 0
u-5 LICENSED CONTRACmR'SDECons of CON
n u¢C 1 ..70 affirm trim I am raved undo Pmvnions of Chapter 9(commencing is Job Description xmby$¢U6 wMllfmcc d.fferDivision3of the BUanrsxaM Professwn Code.andmyhcens is
c� in ran three aria ercen.
Sr,? Lmensc tins �'.� Lies. sex 6, �6 REROOF W/COMP. SHINGLES
n=2 Dam ')-a_-� Confirm - �-
ARCHITECT'SDECLARATION
I undcrsianJ my plans shall W Sau as public recnNS
D w U
,0 Licensed Professional
3 OWNER-BUILDER DECLARATION
I I Wreby allure that 1 am amni from me Co irmar ofs License Law far the p
0 o following mason.(Section 713 L5,Business and Profecsims Cod,Any city or county
$ which requires a permit to convect,almr,impmve,demolish,or repair any structure �l yKp!I M,R'w 0 C n'7 n n
prior tit its issuance,also tegwres the applicant for such Permit to file a signed summer s 1
< that he is littm pursuant cd pursuano the provision of the Common's license law(Chapter 9 Sq.Ft.Floor Area g/J Valuation
YFc (cianomming with Section 7")of Dnmon 3 of fa,BUivarai rid Proression Coda)im
y 3
that he H exempt tWrefrom and du basis far the alleged eumptom.Any violation of 41
Sects n 7031.5 by any applicant for a Permit subjects the applicant to a end Penalty of 3 54"P2'pI$1ih] M 0 OcEif ane Type
not mare man five hundred dollars($50o). P Y YP
❑1,u owner of the pmpmy,sir my employcu wire wage u tW it sole compcnudon,
will do the work,and the stmcmre is an,intended or offered for sale(Sec.7014.Bustraus
and Profusion Cadc:The Contractors License Law don not apply to an owhor of Required Inspections
property who builds or improves thereon.and who does such work himself or through his
Own employees,provided that such impmwmenu are not intended aroffemd forsale.IL
however,the Wilding or improvement is Said within am year of compkuon,one wmcr-
Wddcr will haw the burden of Pmvmg that he did net Wild or impmve for purpose of
sale I.
❑1,as owner of the prapeny,am exclusively contracting with licensed conumu s to
convect one Pmjcn(Sec 7044.Bnmeas and Profession Code:)The Contramos's U.
rise Law does not apply m an owner of property who Wilds m improves thereo,and
who concocts for such pmjccu wM a contractor(s)Immued pormain to the eommuctoes
License law.
❑1 am exempt under Sec B k P C for this moon
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of the fallowing declarations:
I have and will maintain aCcoufiene of Coiucnl to self-imam for WoftesCompen-
sauon,as provided for by Section 3700 of the labor Code.for the Performance of the
work for which this Permit is usuad.
❑1 now and will mainum Workers Compenadon Insurance,u sgm cd by Section
3700 or the Iatur Code.for the performance of the work for which this Permit is Wool.
My WOrkm` am nsau nlnsuran ca later and Polity number am:
Comer. o =a Policy No.._46G,O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
M.Section need not W completed if the permit is far ane hundred dollars($100)
sir Ices)
1 certify mm m the performance or the work for which ran Permit u issued.I shall not
employ any person to any mannerso as m become subject to the Workui Comp otandon
Laws of Califorma.Da-
Applicant
NOTICE TO APPLICANT:If.after making this Ccmficale of Exemption,you should
become subject to be Worker's Compensation pmvimons of the Labor Com.you must
.J z faMwith comply wM such Pmvtsmn or mil Permit hall W daemcd revoked.
' M CONSTRUCr10N LENDING AGENCY
4 I hereby affirm that there is a construction lending agency for me Performance of
t>!i the work fur which this permit is issued(Sec.3097,Co,C.)
D. z LenEses ANdaic« -
V 0 1 candy that 1 have read this application end Sam that the about information is
D. F coned 1 agree 10 comply with all city and county ordim es and suit laws relating to
O V building convection,and hereby stardom rapresnteosms of this city to enter upon the
,ra &Wyemenioned property for impaction purposes.
(We)agree fo saw,indemnify and keep harmless the City of Cupertino against
f'fA liabilities,judgments,costs and expenses which may in my way accrue against said City
V z A consequence LICANTUNDERrSTANDStAND rWILL COMPLY WITH ALL NOWPOINT Issued by:
Date-7--r—r SOUREGU,ATIONS. Q Re-roofs
Signatuc6 AppmvCnlremr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicant or furore Wilding Occupant nom or handle h okolou malarial
M dented by tW Cupertino Municipal Code.Chapter 9 12.and the Health and Safety
t"Code 0Yns2ss32(a)7 Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant sir r building pce.inuo us.equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I'l,cl,hazardous air conuminsms as defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yea TO'
J I have mad the haardous materoleregmmmcns un,kr Chapter 695 atone Califon
nia Health A SafctyCade,Secumm 25505,25533 and 255341 understand um,f the Wilding
does not currently haw mnanc that u rs my rcsppmthiiny m nnuly the Occupant of NC TTTT- / J
mild uwh¢hm Wmetoor uissuance oracesufcate oroccupancy Signature ofA nI Date
5 P
Owner or aatno11:j ,m Dam All roof coverings to be Class"B"or better
autrzu CITY OF CUPERTINO �S� Z>o Z Z RE ROOF �
�CU14nZf 1N0 PERMIT APPLICATION FORM
APN 11 �_ _s' _Z Q2 Z _. Date: 1—
Building Address: f r l
/-5-5740 A Jif Vl
O er' tame: Phone #:
o�Dr� v0 & ;,1,s'7-S�l6
ntr to . Phone#: License #:
C tact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles 'Q' Asphalt Shingles
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:
�Job Description: II -I n I
6�CP ,Mn�re Srio & - 7n)TU/I 5 01 n�� Aloa�— 116vr/) 4S/tinc���J
Residential Sz Commercial ] 1
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dot. if 1
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
/Y76o
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
/ BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License_ BUILDING_