04110052 CI'i Y OF CUPERTINO `ui4r` "' +E.' '* � �s '
Buu.nlNc D1vISION pRR z C®NTRACTnRINFORM' ;aI :%a '
BUILDING ADDRESS: PERMIT NO.
LEGACY ROOFING & WATERPR00 ING 04110052
M _ PERMIT ISSUE DATE _
N SANITARY JQl ROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECfI
app LICENSED CONTRACTOR'S DECLARATION Job Description
til F❑ I hm Nn
ereby affirm 1 am licensed under provisions of Chapter 9(commencing -
iW with Section 7000),dDiAdmin Sof Na Business add and Profession.Codc.and my license is
m<n• in full foreeand effect.
Licemaclazs `" Lie.H S.n'abri. REROOF W/ SHINGLES
Zip Dae fel Connector r.
ARCHITECTS DECLARATION 1 LAYER 30 # FELT AND 30 YR. DIM. SHING
"yl w understand undcanJ rose plans sbavu^x ftp oris
3 a.
u.t; Licensed Professional
.ct� OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from Ne Contractor's License Law for the
a O following reason.(Seeing 7031.5,Business and Profs ions CMR:Any city or county
a-_fl! which requires a permit to a
comanager.then,improve,demolish,or¢pair any sho um
prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant In the pavisionsof ftContractor's License law lChapler9 Sq.Ft.Floor Area Valuation
,FG (commencing with Section 7001N)or Division 3 of the Business and Professions Cook)of $7000
i $ Nat he Is exempt themefam and Ne basis for be alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil family of APN Number Occupancy Type
not more Nan fisc hundred dollars MOB. .
El I,as owner of the property.or my employees with wages as New vele compensation,
veil 4.pr bework.andth Tire Contra nori License
Law does
s not apply loan,owner
,p,a ra,,,aw,,,,a, �®
ss
and Professions andel The Contractor's License Law docs not apply 7 an owner of {�j ' s�p�pWVt®/dr/iq}{yyYlttyLl{'{yfmti�
property who builds or improves themon,and who does such work himself or through his
own employers,pavided that such improvements are not intended m offered for sale.If.
however,the Wilding or improvement is sold within one year of completion.Ne owner-
builder will hire the burden of proving that he did not Wild or improve far purpose of
sale.) JAN �) 1005
❑1,as owner of Ne property.am exclusively contracting with licensed contractors N
Moores the pajecl(Sea 7Oaa,Business and Professions Code:)The Commuter's Li- fy�f�
c ate law duct not apply a an owner of property who builds on impawt thenen.and p)7 A [I �I ®�
who comncar fog such pmjccu with a comncar(s)licensed pursuant to Ne Comnctoh 1lrAfSyJp(ft1IVf9I Lpp^r'
License Law.
❑lam exempt antler Scc. ,B&PCfonhis..on
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of pejury one of the following declarations:
1 have and will maintain a Ceuificam of Consent on self-insum for Worker's Comped.
on,as provided for by Section 37M of the Labor Code.for Ne performance of the
work for which this permit is issued.
❑1 base and will maintain WWWx Compensation Insuranm,az required by Section
37W of NR labor Code,for the performance of d¢work for which this permit is issued.
My Worker's Compensation Insuana carrier and Policy number am:
carne: 7NIC fwsa4 Policy No.: 1Y'52_27 Soy
CERTIFICATE OF E%EMPTTON FROM WORKERS'
COMPENSATION INSURANCE -
(rho section need not heemod.cd if the pm en is for ou hundred dollars HHOo)
or less.)
1 certify Naz in Ric performanec of Inc work for which his permit is issued.l shall not
employ any peraon in any manner an az to become subject a the WorkersCompcaxtion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker'a Compensation previsions or the labor Code,you must
.JZ fenowith comply with such provisions or this n,moshal l be deemed mwked.
zCONSTRUCTION LENDING AGENCY
¢+ Ihereby offirm that them is a construction lending agency for tW Performance of
(3'
the work for which this permit is issued(ScC.3097,Civ.C.)
GQ Lender's Name
7 Z Lender's Address
U O 1 eenify that 1 have read this application and sum the the above information is
LT. F' comet.I agree to comply with all city and county ordinances and sure laws relating to
0U building convection.and hereby authnrie,mpresematives of this city to cnen upon the
above-Mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupcni no against
F'N liabilities.judgmcnu,costs and expenses which may in any way reacts agaimneivid City
U Z his peogrit.
APPLIC NTRUNDERSfAof dic NDSof tAND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCEFEPULATIONS. i
01C Re-roofs
Signature of Ap irgnUCmaromr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant more or handle hamrdous material
az defined by the Cupenido Municipal Chic.Changer 9.12.and Nc Health and Safety
Code,Section2532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea �ZNu
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hamndnus air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
rstrget"
❑secs No
r Ihave read he W.mous materials mgWfcmeno under Chane,6.95 of be Calif., /
L
SafctyCMc,Savons 255115.25533 anJ 2553d.l unJcrsund NmifNc Wildingrtcnd haw a enanL Natitis my mxponihilityw noulythe occupantofNcts wheIt be mel prior a issuangee Of a ceNfirale Of ageapanR Signature ofApplicant Date
Owner O�OtnO ,w gr• v�� o'rR5 All roof coverings to be Class "B" or better
CITY OF CUPERTINO
I� 2 of 3 PERMIT RECEIPT OPERATOR: conniew
COPY # 4
Sec : Twp : Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35907010 . 00
DATE ISSUED. . . . . . . : 11/09/2004
RECEIPT # . . . . . . . . . : 27708
REFERENCE ID # . . . : 04110052
SITE ADDRESS . . . . . : 10092 BIANCHI WAY (BLDG 6)
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : CUPERTINO COMMUNITY HOUSING DI
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : REDWOOD CITY CA, CA 94063-2751
RECEIVED FROM . . . . : RYAN LAUBACH
CONTRACTOR . . . . . . . : ROBERT LAUBACH LIC # 24091
COMPANY . . . . . . . . . . : LEGACY ROOFING & WATERPROOFING
ADDRESS . . . . . . . . . . : 860 FAULSTICH CT.
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 467-0150
ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
-- - -- --- - ---- - -- -- -- ------ ----- -----
BPERMFEE VALUATION 7, 000 . 00 137 . 16 0 . 00 137 . 16 0 . 00
BPLANCHK PERMIT FEE 137 . 16 183 . 04 0 . 00 183 . 04 0 . 00
BSEISMICOM VALUATION 7, 000 . 00 1 .47 0 . 00 1 . 47 0 . 00
TOTAL PERMIT 321 . 67 0 . 00 321 . 67 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
--305=== FRAME----------------------- ==307=== INSULATION=====_____________
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•
CITY OF CUPERTIN#
ZiaEREROOF
aUPERTINO PERMIT APPLICATION FORM
APN # ✓ Date:
3S v7
Building Address:
100212 2:uv,c1�' w IcX2 I
Owner's Name: Phone #:
C eA cn.v,
Contractor:p Phone#: License #:
to Fo
c e F:n LiDb• t6-7- of SJ 8026S6
Contact: Phone#: Cupertino Business License #:
Oct , Lwk-t, ,, 4og-2to-997
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
BC Asphalt Shingles & 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 Cu ertino's Tear Off Policy: ❑
ob Description:
'Z.ns{ntl 30 -fie 14 iw,d N. .- 30 sln:- 1f
Residential ❑ Commercial
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: Ll
Costo roject: Type of Construction: Occupancy group:
%7,00b
Qty. if l
A i ab e 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
27 7 "S'
r3zi . 67.