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'CITY OF CUPERTINO
PERMITCONTRACTOR
INFORMATION
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BUILDING DIVISION
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BUILDINGADDRESS:
ALL SEASONS ROOFING SERVIC
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OWNER'S NAME:
PERMITL$UEDATE
CHRISTINE BUTCHER
179n qmTTT4 Aww
ONE:
SANITARY - C NOL NO. --
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSEDCONTRACTOR'SD LARATION
1 hereby Orem Nal I am licensed under P ou of Clmpser 9 (rommcxing
Job Descri do
P
wish Scmion7l )of Division3ofthceusituss Professions Code, end my license is
mar �:®
in full r(y. defy 6 9Q
LicenxAai t � � Lk. g
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REROOF W/'FIRE FREE SHAKE e lL
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ARCHITECTSunDECLARN
Tj,k dmydmN.mdlbeuudopublic A''f1]��Oattrds
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— — - --_----_- - --NOV 2004-- _
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Licensed Prefectional
OWNER -BUILDER DECLARATION
1 hcrchy affirm that 1 am exempt from tW ATIONls License Law fur sM1e
U I �®
following rtam0. (Section 7031.5. Burd.and Prefossum Code: Any city or county
'
construct, altar, improve, demolish. or repair any structure
which requires a permit in m
! pmormitsi.... cc,amo mquims tW applicam for such psrmiuo Bic aligned smmmant
Contractor's Lw<nac Law Chepux9
Sq. Ft. Floor Area
Valuat on
Net be is lianud pursuant m the proviamm of the
t (commencing with Section 7") of Division 3 of the Business and Professions Case)or
that he u exempt therefrom and the bum for IN alleged exemption. My violation of
3 14NQ4&ftr0 0
Occupancy Type
Section 7031.5 by airy appliant for a permit subjects do applicants to a civil penalty of
not mem than firs hundred della. (S!iM).
,
0 1, u owner of she Property. m my employ= with wages as their sok rompeuation,
- -
Required Inspections
willdo Neworkand Ne structure is not intended or offered for mile (Sec. 7044, Buormsa
and Pmfessiou Code: The Contractor's License law d= not apply m an owner of
Property who Wildirmimproves thereon, endwhe d=ouch work himulfar through his
own employca, provided Nat such improvements and notin¢Med oroRertd formic. IL
however. the building or improvement is said within ON year of completion. the owner -
Wilder will have the Wrden of proving Nat he did nm Wild or improve for purprec of
rale.).
0 1. as owner of Ute property, em exclusively contracting with licensed crommctent to
construct she projen (Sec. 7044, Business and Profession Code:) The ConuacNYs U.
cause law d= not apply to in owner of property who Wilds or improve Nemoe, and
who eontmcts for such proj"m with a eonuaemr(s) licensed pursuant w Use ComereNYs
-
Lies.law.
0 l am exempt under Sec. , B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby eRmr under Formally of perjury one of me following declarations:
I hue and will mountain a Certificate of Consent to self -insure for WmkcCsComyan-
.,ran, as provided for by Section 3700 of me labor Coda. fm Ne parfommn¢ of Ne
work for which this permit is issued.
0 1 have and will maintain Worker's Compertsation Insurvtce. as required by Second
-
3700 or Nc labor Came. for the peRormancc of me work forwhich this permit is issued
My Workers Compeuetion Inmmmce carrier end Policy number arc:
' .S'1o,IL .'f Z licyN., 1 ?0 $S
CERTIFICATE OFEKEp ONFROMWORKERS'
COMPEL ON INSURANCE
, t -
(Tom section need not W complemd HUN permit is forage hundred dollars (SIM)
ser us-)
I ecnify that in the performance of the work for which this Permit is ismcd, 1 shall not
employ any perm. in any manner m as m become subject a. me Workers' Compewuon
Laws of California. Dau
Applicant
NOTICE TO APPLICANT. If, after making Nis Ccnifmase of Exemption, you should
become subject in Ne Worker's Compertmuon previsions of Bre IaGn Code, you mum
ended! comply with such provisions or this Permit shall he deemed ieml ed.
j CONSTRUCTION LENDING AGENCY
t herebyName oRrm Net Ncrt is econmmctinn lendingagcrsey for the performancc of
Ne work fur which this permit u issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Add.
Lmilm'
j I ecnify Nat 1 Bove read this application end sum Net the seem informed.. is
correct. 1 agree to comply with all city and county aNiromms and sou laws misting to
building conduction, and hereby author ire icprucntalou of this city so case, upon Ne
alms-mentioned prep
rly ex
purpo
for tu,mu
(We) agree to save, indemnify and keep harmless me City of Cupertino against
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j cost at which may in my way accrue agairtstsaid City
inliliuuccomo thecostsi,itf tcnscswhich
of ingot this Per mit.
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APPLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY LL NON -POINT
UNDERSTANDS
SOURCE REGULATIONS � s/
Issued by: Date
1 /`^'!v/ �JG/V
ll
Re -roofs
Type of Roof
—°y
rgnanu A plicanUConuacmr Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupied store or handle harudous material
uefined by the Contour, Municipal Cade. Chapter 9.12, and Use Health and Safety
ode. Section 25532(4)7
❑tied
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or (ti=re building Occupant use cyuipmcnt or devices which
If a roof is installed without first obtaining an inspection, agree to remove iection, I
P
ran,
emit air conmminanu as defined by the Bay Area Air Quidity Management
Disuin?
all new materials for inspection.
0 Yes
ihavemadNehna msm=dalsmquim=nuunderC pmr6.95ofthe Califof-
nia Health&SafetyCode,Scctiom25(5,25533am125534.1undemmnd Notifine hail'
dose nol currently haw a comes. that it u my redpmumildy in notify the occupant of
num, ts �m bemetPoortoin.of.Ce' a erOcanPON)'
��'°"d re�
Signature of Applicant Date
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coAll roof coverings to be Class "B" or better
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owner or mthori> a agentD au
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CITY OF
CUPERTINO
CITY OF CUPERTINO
REROOF 0 �f j
PERMIT APPLICATION FORM
b600?
APN #,3 0 `2-7
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Bld Permit Fees
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Date: 10 1 1
Building Address:
Energy
Owner's Name:
Phone #:
qo� a -S5 - 0 (o Lt 2 -
Contractor:
Phone #y
License #:
Seismic Commercial
BUILDING
BPLANCHK
Contact:
Phone #• X-501
-- - ZAy55
(
Cupertino Business License #:
a- \0 3S
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qoU�
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
❑ Asphalt Shingles
❑ Asphalt Shingles
❑ Wood Shakes
❑ Wood Shingles
❑ Wood Shakes
❑ Wood Shingles jrC(�j0#
Other (Specify) tibm l otNor l�
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 Cu ertino's Tear Off Policy: ❑
Job Description: (Len('nO VC. D . \ 12
CeNv\v_')0 Coo t,„ns-Nrn \\ \)L,\ L�r j C -e IV Ce
SY�nkc h'lo.�tic-� c..
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑
Confirmed with Planning Dept. if
there are anrestrictions: LJ
Cost of Projec$� —1,0<j5,g- Type of Construction: Occupancy group:
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An6licable / Fee ID
Fee De.wrintinn
FPP r.,,,n
BPERMFEE
Bld Permit Fees
BUILDING
BENERGY
Energy
BUILDING
BSEISMICRE
Seismic Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING
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