04070082CITY OF CUPERTINO
i'%`=''=�" '� " -?
BUILDING DIVISION PERMIT
CONTRA O-TORIINFORMATIbN '�
' , ,,i~Y a„ ;c" i^
BUILDING ADDRESS:
R E ROOFING & CONSTRUCTION
PPffii�.'�l0'04070082
2162
OWNER'S NAME:
PERMIT ISSUE DATE
JOHN HIGASHIUCHI
NE:
SANITARY NO, CONTROL NO.
(408)925-9995
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 lemby affirm Jul I am licensed under provisions of Chapter 9 (Commencing
P
with Sectio ] BofDivision]af Ne Busimasark Professions Code. end mylicense is
�i«I°e�rc°Y1'�3
REROOF W/CDX & ASHPHALT COMP.
Lie.#
C
Dao: Contract.,
ARCHITECTS DECLARATIO
Iundcrstan le ellMusea d_
Lccnscd Pmfcssonal
..BR -BUILDER DECLARATION
1 hereby o(See that 1 exempt from Nc Cminaterl's License Law for the
moron. (Section ] 1. Busi.... nd Prnfcwions Code: Any city m
which myuiru a permit m cures t, altar, improve, demolish, math any ualme
which re omm
file taximete
pdof m its i the lW for such pttmiuo Btu riga,(summcm
alsopursuant
Sq. FL Floor Area
Valuation
ensed p,
in visimis of License
Nat witpursuantmtheprovisionsofthe
L
ndProflaonsCoatt9
eBusinesssand
(commencingatheisempt Section R0Xnand of Division r of lW of
f alleged ciiu on. Any lmonde)
' Net he u exempt therefrom and the bus for the alleged caemption. Any violation of
3-%(PN3,afn8u.0 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penally of
nm mart Nm five hundred dollars (SSW).
Ej I, u owrmr of,M ptopcny, m my employeq with wage a deir role compensation,
Required Inspections
will do firework. and the swctum is not intended conferred hostile (Sec. 7061. Business
and Professions Code: The Contractor's Liceme Law docs not apply to an owner of
propeny who buildsor honor sMerton, and whodoessuch work himselforthrough his
own employees, provided that such impmvemenu art not intended oroRered for salt. It.
however. the building or improvement is sold within one your of compleuan, on, owner -
builder will have the burden of proving that he did Out Wild or improve for purpose of
�I1 av
sok.).
V\\Wlln f1
(•�
❑ st u owner of Ne exclusively contracting with ntr m
(f0
:ittno Con tun's
Sec. 70y. , Bsie and
construct a the project (Sec. ]oda, Business and Professions Code) The C theme, n
cense Law does not apply tomowner ofproperty who Wilds orimprovu Nereogmd,
J q�
JUL
who wnuacu (of such projectswiNaconuacmr(s7licenxa punuam to the Canuactor's
4 Os#
2O
License Law.
I amn exempt under Sec , B $ P C far this rtuon
Y
Owner Data
WORKER'S COMPENSATIONDECLARATION
1 hereby from us&, penalty of p 0.1 ane of use following declarstima:
1 have and will maintain aCernfieam ofConsenuo self-insunt for Worker'sCooper.
sation. as provided for by Section J]W of the labor Codc, for the performance of thc
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance, as required by Section
PW of the Labor Cade. for the performance of the work for which this .it is issued.
My Workers. Insurance carrier and Policy number am:
�Coa/m�pTensation
mer. S t a^ a� F✓I-sD Policy.TjR:�S 'I—IOK�o�6
CERTIFICATE OF EXEMP IONFROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not W completed if tW permit isfmonchundma dollars (Sta))
or Ica.)
I certify that in the performance of use work for which this permit s issued, 1 shall not
,
employ any person in my mancer sou to become subject to the Workett Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Con licam of Exemption, you should
become subject in the Worker's Compensation previsions of the IaWr Coke, you in=
fpMwah Comply with such provisions or this permit that he deemed revoked.
CONSTRUCTION LENDING AGENCY
I bemhy Nm there is too Cm agency for the performance of
3
than
(Sec.
work for which this permit is issued (Sec. JU99, Civ. C.)
' s .
La
Leaders Namc
1<nderi Address
I certify that i have mad this application and sum that the above information is
'
' correct. I agree to comply with all city and county ordinances and state laws muting to
building Construction. and herehy authonm representatives of this city to enter upon the
above-mentioned property for inspection purpose&
nameless thc City of Cupertino against
(We) agree m an. indemnify and keepme
j liebilitics.judgmens. Cosa and expenses which may in my way accom agatrm said City
in conscqucncc of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date / J
S09RCE RE LAT[
^
j
Re -roofs
Type of Roof
Signatum of ApplicanVCon tar Date '
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding Occupant store or handle hunaou minimal
as defined by Nc Cupertino Municipal Code. Chapter 9. 12. and the Health and Safety
Code. Section 25533(&)?
All roofs shall be inspected prior to any roofing material being installed.
El Yet ®No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or (wits which
mit havardnus aim conwninans as defined by the Bay Area Air Quality Management
all new materials for inspection.
Dig❑Yes qts
(have mad the hvaNnus materialsmquimmcnts unJcr Chepmrfi95 of NC Califar-
nu Health&Safety Code, Sections 25505.35537 it 25534.1 understand NetiflW Wilding
Dora rot Currently haw a vnank N& it is my responsibility to notify the occupant of the
,d
regmmn awticbt�srWmetprtar aneconcemficine roecyPTy.
-7,K!5
C
Signature ofApplic'II Date
-
All roof coverings to be Class "B" or better
Own& coauth.w agcol pate
is
a", --
CITY OF
CUPERTINO
CITY OF CUPERTINO 2
REROOF
PERMIT APPLICATION FORM
APN # i ,v
Bldg Permit Fees
Date: n I I U
ENERGY
Energy
I
Building Address: 2-1LZ 2
J`
Seismic Fee Res
Owner's Name: �O �
1 1 AY`5-H I u b 1
j
Phone #: 2-55-9140
Contractor: n Phone #:
C. CpvsTnu.c�l�
�}U$— License #: a
�2�`��
[�OQ�IN 5 �tJ _
626�9i a I
Contact: Phone #:.
Cupertino Business License #:
�
`�32o
Business License
2p
Type of Roof Covering:
Existing: Proposed:
❑ Built -Up Roof ❑
Built -Up roof
❑ Asphalt Shingles ><
Asphalt Shingles
X Wood Shakes ❑
Wood Shakes
❑ Wood Shingles ❑
Wood Shingles
❑ Other (Specify) ❑
Other (Specify)
Number of existing coverings Z ❑
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: �Eµ LlkiyfiutJ Z IrM o,-3 c�
�ooY- L5 LAAr-C ova- - S lttNcr,rS t
1 NSl7A'UU 2" J U #- As-rm 1 l;;a
A511INa Lu to P,
Residential Commercial ❑
Fire Zone: Yes ❑ No
Confirmed with t. if
there are re frictions:
Cost of Project. W Type of nst ti
Occup cy
Qty. if ,
Aon 'cable Fee ID
Fee Deccrintinn
Fee C;rnnn
BPERMFEE
Bldg Permit Fees
BUILDING
ENERGY
Energy
BUILDING
BSEISMICRE
Seismic Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING