08090078 CITY OF CUPERTINO ms '
BUILDE',G DIVI510N PERMIT ItONTRACTgR INFORMAT�0l
BUILDIyCyAgDR�$vf;BB RD TBD - TO BE DETERMINED 08090078
OWNEER'SS 22NSSA��IIME: 11 PERMrf LSSLIEDATE
WASSON ROGER E AND LILLIAN H 09/15/2008
ONE SANITARY NO. CONTROL NO,
ARCHITECT GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
woo LICENSED CONrI AC1OBS DECLARATION Job Description
1 bembY�m that I w Iicnxd under provision of Chapter 9(commencing P
with section70 Mp of Division J of Ne Business and Profaxiov Calc.add my license is RE-RF T/0 CMP& INSTL CERT PRES SHNGLS CLSA 1950SQ
s
in full for¢and effort
j'rOA� License Clam Lic.0
Dao: Contractor
ARCHITECTS DECLARATION
1 uMcrmanJ my PI....soil W used as Public reoda
Mo
y o Lrencd Professional
3
OWN ER-BUILDER m Ce CmuraON
aC O E I hrtso .(Bre that 11. exempt from the Coevecmra license t4tw far IK
COC fallowing massa.(Sectio 7031.5, t.aircss and Profession Calc:Any city or roomy
which mgsima•penile ac mires e4 aim.impose,demolish.t err repair any mvetum
PriorIris ccomipaisomgn the thovisio of forthesochpemi's Latco rile aaiaw(chaCmd ment
(chapter
ss< Nm he is rmncd Porsoant to the of Division
of of c Buacuxs Idcente Law(C ode)9 $q.F[.Floor Area $29500
Valuation
(coy F$ Mat he olxempt Berm.75nd the
Diub for of lk eg Business and Praon.Any
Cede)a
Q Net io u 31.5 b tmy fourngpfi and Ne Per for be alleged exemption.to Any l lemma of
Section]Mand!.tory aPPlica.t far.Permit sobjects Ne applicant to a civil perWtY of Number Occupancy e
rot roam NO Rae huMrM dalWs(5550I. 36211061 . P YTYP
❑1,as aa.of Ne propvty,or my employers with wag.as their sole compenntion.
will do the wart.and the suueruse 6 rat+nuMed or offered for ale(Sec.too,Business
and Pmfrsvon Code:The Contractors Lina Law Maes nae apply to an owner of Required Inspections
propenywho Wildaoimprom Mrreon,and whods.suchwokh+mxifo Muough his
own employees,provided Nn such improvements are not intended oro@md forsaln IL
however.Ne building o impromnent is sold within arc year of eamplation.Nm owner.
Wilder will haw ft Muds of proving Nat M did not Mid o improve for purpose of
sale.).
P4L.avcer of the Property w amInively...muscling with IiravN contactors to
covtvet the project fsec.7014.Businm not Profession Cods)The Contractors U.
max Law don not apply Was amoer of poperty who Wilda or impmm therms,sod
who contractsferment Projects with ae.ntractor(s)licensed pursuant to dm Com ewrs
Lace.law.
❑1and cm /dfig ,B&P C Ice this reason
Owner t�(r_/. KI d L Dau 9�is�a
KERS COMPENSATION DEC
lAMT10N
1 bercby of hem under Penalty of perjury arc of the following decimations
40 1 ham and will maintain a Certificate of Cannot to self-Ware for Workers Continue.
We...provided far by Section 3700 of the Labor Code.far Ne perfamoo of the
work for which this pannit is issued.
❑1 have and will maintain Workers Csmpevatisn Ivursnr,as acquired by Sodom
3700.(ft Laino Code.far Mu performan¢of Mx wars for which this Permit is issued. '
My Workers Compensation Insurance carrier and Policy number ar:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Miexnlo need not W completed if tte Permit Is forum hundred dollars($100)
or Wm)
1 certify Mut In Ne perfommuce of the rack far which this permit is issued,I Mail nor
cmplW any Karen in my memo,,[[ as boome subject to the Workers'Comperamem
l,ws of CaliWmtypatOS J
Appll.nt `ami r ,.
NOTICE TOO PPLICANTT If.after making this Ccrtifinu of Eaempdon,you ahold
become subject he the Workers Compevdtian provisions of sic Lamm Cade.you mum
.J O forthwith empty with such Mviamv or Nu Permit"I W turned rwkcd.
„zi y CONSIRUCfION LENDING AGENCY
t'� )herby slim Nat does is contraction landing agency for the perfurnmer of
Ci Ne work fa which this pemit is Word(Sec 3097,Civ,C.)
W Q )ambos Num
.a7 z Landers Addrm
U Q 1 certify that 1 have rod Ws Wiiemian and sum Nm the show Womatio is
Ig, omca 1 agre to comply with all city and cooay ardinamvad sou 1.dating to
.17 Wilding construction.and hereby named.representatives of Nu city to cnurupe.sic
a Ww-meatia.ed property for calard an pmiwea
(We)ogre de sew.Ndemnify and ylep harmless Ila City of CuPsnlo agaiiut
Z OaNRdequeneofineewand.pcv.which may in anY w,yamuc agaivtsaid City
U,'� A APPLICANT
of sic granting S this Perm+t.
�^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date.
SOUR ONS.
'Of&'R Re-roofs
Signature Of AppileanUContractor D,te
HAZ.VtDOUS MATERIALS DISCLOSURE Type of Roof
Will Mc applicant or future Wilding accmpant mar.handle Wooden material
as dclined by the Copenim Municipal Code.Chapmr 9.12,and Me Healthand Safety
code,Section 25532(,)t
❑Y. 1111q. All roofs shall be inspected prior to any roofing material being installed.
pplinnt or fuwm building acupant tax equipment or Mend...which g an P
If a roof is installed without first obtaining inspection,I agree to remove
Wtll Nc a
ill hoiardnn aif cmumivnu so dcOncd by Ne Bay Area Air Quality M,nagcmm, all new materials for inspection.
Ov.
I have rad the hvardwts msurials requirmern under Chapter 6.95 of the Caiifer-
d Health&SsfetyCade,Sredau25505.25533un+25534.1underma BMte Wilding
does not currently la terms.Nmv
naat it u my poibility m maty Ne=upset of Me '
rquir ow and poor tolnuanceofaCcdl,.mofOcge
D.te Signature of Applicant
Owner oriuNari.cd age., Date
Lest E All roof coverings to be Class'%a."or better
CITY OF CUPERTINO
• 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN 36211061 . 00
DATE ISSUED. . . . . . . : 09/15/2008
RECEIPT # . . . . . . . . . : BS000006081
REFERENCE ID # . . . : 08090078
SITE ADDRESS . . . . . : 1184 BUBB RD
SUBDIVISION . . . . . . :
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : WASSON ROGER E AND LILLIAN H
ADDRESS . . . . . . . . . . : 1184 BUBB RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4966
RECEIVED FROM . . . . : ROGER E WASSON
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 29, 500 . 00 3 . 00 0 . 00 3 . 00 0 . 00
1REROOFRES SQ FEET 14 . 00 182 . 00 0 . 00 182 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT : 185 . 00 0 . 00 185 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 185 . 00 #132
---------------
TOTAL RECEIPT 185 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
Deo �0�7�
CITY OF CUPERTINO
am REROOF
•CUPEkTINO PERMIT APPLICATION
APN # <� .q - I► - o6 I - 00 C�O Date:
Building Address: 11 ce4 i3u66 ?d. C„r e in o CA n Sol .-
Owner's Name: Phone #:
�oc�g� � �� ll�a..l W4SSorr, �$ - z53- S6k'�
Contractor: I Phone
t'#:
I7o�eKst ,1� cu�cfo/1 E a �- Gkk- 0747
Fax#:
Cupertino Business License #: Contractor License #:
_�a4S-7
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
0' Asphalt Shingles ,z Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
o Wood Shingles ❑ Wood-Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings z ❑ Provide I.C.B.O. Report# / 3 $9
,.a- To be Removed ❑ Provide Mfgr. Installation Specs.
sh'�.,gles
Job Description: A 66 nc e y S�
Residential El Commercial
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions:
applicable, include in plan set.& the sheet index.
Valuation:
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Signature
Revised 6/16/08
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