03090001 1
,CITY OF CUPERTINO mM^u^ '� '%-' li��"` '- '* `
BUILDING DIVISION PERMIT CONTRACT RINFORMATION fk
OUILDING AD.DRESS: AMERI-CAL ROOFING PEB"'.103090001
R'S NAME' 35369 ARDO CT PERMIT ISSUE DATE
NE: SANITARY NO. ONTROL NO.
(408) 792-5582 C
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
.0, LICENSED CONTRACTOR'S DECLARATION JbDescription
1 a 1 hereby affirm IMo
I I am licensed under previsions of Chaplet 9(commencing
withSectionTorr Criv.1 viaonyorMBa eSzos�ti�g.a^dmylice^xis RE-ROOF-INSTALL COMPOSITION �l,v��wE®
In full foresano of d.
License Cl Ctoo
DaIe9-�-�-✓ Cumrec -Ci
iF ARCHITECTSD RATION SHINGLE OVER EXISTING COMP .
e4�q I un horYMd my plans shall he used as public records SEP 16 2003
yW
eGG Licensed Pnsfcumnal
2 3 OWNER-BUILDER DECLARATION BUILDING
I hereby (Scc un 11. exempt from the Contractor's License Law for the
.00 following rcpeon.Permit
t 703 1.5, i,alter.and improve,
demolish.
e ape Cale:Any tiny m county
S$ which reyuiru a e,alto re sures the applicant
improve,h ramie t or repair any mmmurc
i y that hor n its licensed
pursuant
to the prevision Of for xch permitm ice se Laved statement
2x"< (emhc lading sed pSectio 7 the previsions or the the
ad Pwrtaw(Chaper9 Sq. F[. Floor Area ValuaN(/4,C00
d€� (cat he is xempt Section lad d dueof Division r the
al Bminua pt on.Any
Cale)of 4�
Net io is exempt thcrtfmm and Jit aper for be alleged exemption.Any l violation of
net non Cham five
any applicant for apermit subjects the applicant to+civil Pemlty of 3Wj1'j`dpb )grO0 Occupancy Type
- not more Nan Ove hundrtd dollars(g500h --
I,st ownerof the property,or my employees with wegu u their tole compensation,
will do the work.and the awcmle is not intended oraffercd for sale(Sim.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of 305 - FRAME q p
property who builds or improve+thereon,and whodoes such work himself orthrough his
own cmployes,provided that such improvements ate not Intended oro0ered for ole If. 307 - INSULATION
however,the building or improvement is mid within one year of completion.the owner-
builder will have the human of proving that he did not Wild or improve for purpose of 601 - ROOF TEAR OFF
sal..).
❑ I.as owner of thy,
epropenamexclusivelycontractingwithlicensedmnuactaata 602 - ROOF PLYWOOD NAIL
colo.,,the project(sec.7044,Business and Profeatiom Code:)The Cmtncxri Ll- 603 - ROOF BATTENS.
come law does act apply to an ownu or Portrait who builds or improves damson.and, 604 - ROOF IN-PROGRESS
Who canmcts for such projects with a contractor(s)licensed pursuanno the Contractor'.
cense Law.
1 am eaempl under See. B k P C for his reason
r Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pe.It,of perjury one of the following declalatims: ,
I nave and will maintsin a Cenificam of ContendIo self insure for Wmker'e Camper.
titian,as provided for by section 3703 of the labor Code,for the Performance of the .. -
work for which this permit is issued. ,
❑I have and will maintain Worker's Compensation Insurance,as required by Section - .'..._..
37M of the Labor Code,for IM Performance of the work for which Nis permit is issued.
My Worker's Campemation Insurance carrier and Polity number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin section need not x completed little permit is forome hundred dollms($100)
nr leu.)
I certify Nm in He performance of the work for which this Permit is issued,I Nall nut
employmy; rmmynaiTraj u�beeomewbkeLto dx Wurkcn Compew0o^
Iawa of Califo I o _
A jell rad
N E TO APPLICANT:If,atom making thin ins or of Excerption,tem you should
omit subject x the Workers Coons to this
pro ions of de labor Cale,you most
�z fonhwilh comply with such Previsions m this permh shall he deemed rtvakctl.
zO CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is convection lending agency for the performance of
Yr 9 the work for which this Permit is issued(Sm.3097,Civ.C.)
YLenders Name
3. z Lenders Add.
J Q I cenify that I have read this application and sate than the be.information is
correct.I agree to comply with all city and county oh inarms and state laws relating to
'U building convection,and hereby aunhOfiM rcpresenlaniwa of this city to enter upon the
Wabove-mentioned property for inspection purposes.
04 WC)agree to save,indemnify and keep harmless the City or Cupertino against
r Lo) Ilebilitiu,judgmenu,cosuandeepensca which may In anywayamnre agalnlseid City
:),'Z in eonequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR EREG LATI N7—
Re-roofs
Si on,of Applinracmr Data
HAZA
HAZARDOUS ATERIALS DISCLOSURE Type of Roof
Will de applicant or future building occupant amrc or handle ha'raNam material
efined by do Cupertino Municipal Code.Chapter 9.12,and the Hcalth and Safety
. 0 on 25532(aI? / All roofs shall be inspected prior to any roofing material being installed.
❑Yes ONu
Will the applicant or mare building mcaPanl ax equipment or dcvmes which If a roof is installed without first obtaining an inspection, I agree to remove
11 Mvardnus air moduromu u ddincd by the Bay Area Air Quality Management all new materials for inspection.
mitt?
❑Yes a
1 have read the havadd nsmateAar requirements under Chapor6.95 of de Califary
nla Hcalth&safenyCadc.Seeduru25505.25533 n 25534.lunde dWtirde Wildias � •�()-Z�C�3
dms not curtenlly haw a octant that it r my responihility o maty the rmuPenl of dmA-A
requfremenls wN<h m
as m P miattr,ne acenilicaoor Occupancy. Signatureof Applicant Date
1 L o3
er or am.....
a i ed agent Dale All roof coverings to be Class"B" or better
CITY OF CUPERTINO
REROOF e� 3Oy"I
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
9- 0-L- 0 :3
Building Address. s �I
D� p-
Owner's Name: Phone#c (R 0B)
Contractor:n Phone#: t Sl" License#:
R)menr,, —CA a4,itiel 05s —sss8z S2S 9 '78
Contact: Phone#: C91%) Cupertino Business License#:
Atuo'A N S qlS - 3396
Type of Roof Covering:
Existing: Proposed:
❑ uilt-Up Roof ❑ Built-Up roof
Gy 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 CoWly With Cu ertino's Tear Off Policy:
Job Description: p C014rS ant ovcr e_,<,s jNc
Residentia Commercial ❑
Fire Zone: Yes E] No Confirmed with Planning Dept. if
there are any restri s. LJ
Cost of e Type of Constructi Occupancy gro
r-
Qty:
i
A li a 1 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