05030125 CITY OF CUPERTINO xix .r +, ' ter:
BUILDING DIVISION PERMIT CONTRACTO-WINFORMATION
,.-
BUILDING ADDRESS: ""T"65030125
OWNER'S NAME: PERMIT ISSUE DATE
DAVID BRETT OLIKER
ZONE: SANITARY 10. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOo LICENSED CONTRACTOR'S DECLARATION
F I beery,d".
Thal 1 w r¢mcd under provisions of Chapicr 9(commencing Job Description
<U wish Section 7")of Division 3 of Ore Business and Professions Code,and my license is
„ in full force and effect. REPAIR/REPLACE EXISTING PLYWOOD
y yR? Licenx ClanLin.•
pro Dart Contractor 2030 YR ASPHALT W/FELT
F try ARCHITECTS DECLARATION
1 undervand my plans shall he used as public records
J a.
3oG Licensed Pmressianal
3OWNER-BUILDER DECLARATION
IF I bertby mirm that 1 em exempt from Ne Conuacor's License Law for Be
m0 following reason.(Section
713 IS.Business and Pm@csimu Cade:Any city at county
yS� which requires a permit to ennsuueL arm,.improve,demolish,m repair any nsuctes
prior m its issuanm,also requires the applicant for such permit to file a signed statement
�E< that he is licensed pursuant to the provisions of she Commetur's License Law(chapter 9 Sq. Ft. Floor Area - Valua, o}p0
Fe (commencing wish Section 7000)of Division 3 of thc Business and Professions ewe)or
i $ that W Is exmpt Ocrefmm and de basis for she alleged exemption.Any violation of
Section 7031.5 by arty applicant fora permit objects the Ppfc um or a civil penalty of �� ppN Number Occupancy Type
not mom Nan five hundred dollars($5001. - [///\�
❑Lissowneroftheproperty,or myemployees with wagesutheirrole compenution, /I/ _3157I40I3 . 00
will do she work.and she swcwm is bar mutual or offered for'"m
(Sec.70a4,Busimss i
and Professions Cade:The Canuxtors License taw does not apply to an owner of I ,. �,','!�, Required Inspections
propeny who wildsor improves shcreon.and who dmssuch work himself or shmughis" I .
own employees,provided that such improvements amnot intended m offered for W..If.
however.to building or improvcmcnt is sold within one yur of mmplcuon,she owner- f-
Wildcr will have Ue burden of proving that he did not build or improve for purpose or
V
.as owmr of the property,am exclusively contracting wish Iimmcd commissars to
corse uct the project(Sec.7044,Business and Profession Code:)The Conuacw/ Li.
who Law does not apply tom Dinar of property who wilds m antmvv ICon=and
License actsfors hprojccu wish acantrutoKs)Iiccnsetl pursuant rode Conuaaora
License
alaqI cacm , nd BAPCfor sh' 2azan
Owner Data3 9 o>f
WO tERS COMPENSATION DECLARATION-
I hereby amrm under penalty of pcsjury one of the following declarations:
I have and will maintain a Certificate ofComent to self-insure for Workers Compen.
sation,u provided for by Smuon 37M of she labor Code,for Ne pedo...of de
work for which this Penni,is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the peorormanm of rhe work for which this permit is issued.
My Worker's Compensation Insurantt carrier and Policy number am: .
Cartier. Policy No.:
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(Tris section need not he completed if the permit is for one hundred dollars($100)
ar It
1 mrufy that in she performance of a work for which Nis permit is issued.I shall not
employ anypersonm m a5lubecome subject to the Workers fompewauon
Lawsof ifornia. at w
Applican y
NOTICE TO APPLICANT:If,after making this Cc kale of Exemption,you should
become object to the Workers Compensation provision of the lahor Code.you star
.,O raMwith comply with such provisions w this permit Oudlbe seemed!revoked.
z 'w CONSTRUCTION LENDING AGENCY
F+ .�.. I hereby affirm that there is a comirsed n lending agency for de performance of
1� thc work for which shls permit a issued(Sec.3097,Civ.C.)
1 A lanCefs Name -
= z lender's Address
V 0 1 certify that I have read this application and state that she above information is
Iy F cermet.I agree in comply wish all city and county on inarsms and sxte lows relating to /
OYJ building construction,and hereby somatic,repmscmatives of this city to enter upon the
Ifl ahom-mentioned property ror insrmuon purposes '
,C,r gy (We)agree to save.indemnify and keep hank the City of Cupcnino against
rq liabilitics.judgmcnu.costs and expanses which may in any way accrue against said City 1�
fJz in eansegmnce of due granting of this permit.
'—' A A UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date i--
UR E TIONS. , /
Re-roofs
gn
Suaturt ofApplic trAZARDOUS_ MATERIALS DISCLOSURE Data
HType of Roof
Will the applicant or future building Occupant store or handle havardous matenal
az defined by shc Curcrium Municipal Code.Chapter 9.12.and the Health and Safety
code.SecYcs tion 25532(a)7 dal All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant or future wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
;mit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
p Yes CMS
Ihavesadduehv i)usmawrialsmquimmenuunder Chaper6.95of Oc Califon
ria Health&Safety Code,Seeuom25 )5.25533 nd25534.lundersmndthmirshc building
itismy respmihilintyihmcanteotiorfyash3e ueuput of Na
/
Signature ofApplicant Dale¢ �
owner m out annd ascot Date All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
t ✓ Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPERTINO
Building Department
JOB ADDRESS: PERMIT #
"OL, - L�L w e o S'0 3 o Z S`
OWNER'S NAME o YQ `,j�c Q I: PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
C -3
Owner/Contractor Signature Date
CITY OF CUPERTINO
REROOF
CUPEI�TINO PERMIT APPLICATION FORM QSo
APN # Date:
35-7- Iy-o13 31-d35-
Building Address:
o4Q4 3 rvw i
Ar ,4 C14
Owner's Name: Phone#:
-7
Contractor: Phone#: yo8_q;ty-bg2g License#:
G Ca,, -7 y1 r-19->
Contact: Phone#: Cupertino Business License#:
j4w
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles G1—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: ❑
Job Description: o _y^ J y I- {
Ver ��I�. �4L1� ?�'�7j tr I l�./a�/1 "�"�l -Y Y 1/ R0.I W 1 J-
Residential 'Commercial ❑
Fire Zone: Yes ❑ No 9 Confirmed with Planning De t. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
X1.3
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