06050128 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CCilkt'C12AC !(112TT.Et A"X'IfJN
BUILDING ADDRESS: R E ROOFING & CONSTRUCTIO PETWO'06050128
7593 DUMAS DR
OWNER'S NAME: PERMI7115SUE DATE
SHEN JEFF Y AND JANE S 15230 CLYDELLE AV 2006
E; SANITARY NO. CONTROL NO.
(408) 626-9320
ARCHITECT/ENGINEER: BUILDING PERMRINFO
BO ELO PLUMS
MECH
O
pop LICENSED CONTRACTOR'S DECLARATION Ib Description
Nithfall
E 1 hereby @Mem that I am licensed uemr proOeSCrIP
visions of Chapter 9(commencing
wSection 70011)af 'Water 3af de Business roti Pra(esium Code.and mylicenha is
mmeanderre r( 5 REMOVE EXISTING 1 LAYER OF WOOD SHAKE. INSTALL
jpz LI.. s Lm.Q -� ��
Dau: contmmr 1211 CDX 30LB ASTM FELT AND LIGHTWEIGHT TILE
ARCHTTECI'S DECLARATION
f�� I understand my plans shell he used an public recnNs EAGLELITE
iud Licensed Pmfassiaet
b OWNER-BUILDER DECLARATION
f I hereby affirm that 1 am exempt from the Conuamors License Law for the
j O e following mason.(Section 7031.5,Business and Profasduns Code:Any city or county
which requires a permit to emuncL floor,improve,demagish,or repair any structure
zy prior N its issuance,also require the applicmtforsuch permit to file a signed summer,
that he is licensed pummt to the pmvisiorm of Ne Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
e� (commendnQ with Sectlon 7000)ofDivtsian7o(the Buunemand Prafruinv Code) Cy 1600Q
ERE Nat he ts exemft
mpt theorn and the basis for the alleged exemption.Any loNdon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
act mom than five hundred dollars($500),
❑1,an owner of the property,or my employees with wages an their=Is compensation,
will do the work,and the smuctureia not intended or offered for sale(Sec.7044,Business 215925027 . 08
and ProfemloM Cee 's m anm s:The CommemLicense Law dean apply an owner of Required Inspections
property who builds ar improm Nemen,and who does such work ho max or through his
awn employers,provided
ori that men Improvements arc not year
ofc mpleticonflicted tormN If,
however,the building thus orimprovemmt la hath within on yam or completion,the ower-
builder will have Ne burden of proving Nat he ale et holm or improve for purpose of
ole.). /
❑I,as ower of ct property.,Business s velymal cofessors with:)The C mmramon .
corona Ne pmnot (Sec.7041,worand Prony wh lose Code:)Theves Immune.U. �O
come law dura not appy e ts ower of property who builds or improve thereon,and,
who seracu for such projects with aconuamrtU licenced pursuant to the Connemr's
Licca law.
❑1 am mempt under gee. .B d:P C(or this mann
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hemby air=under penalty of perjury rte of the following decimations:
I have and will murrain aCeflifcast of Cmaenl m self-lase for Worker's Compen-
"'on,as provided for by Section 3700 of the labor Code,for the performance of the
W
for which this permit is issued.
1 have roti will maintain Worker's Compensation Inmmnce,u required by Session '
of the Labor Code,far lM per(ormaneeofea work forwhmh this permit u issued. '
My Worker'yyCCo^mapen�s-a'tion reran=artier and Policy number are:
Cartier. Ly r,flI.— ft h( Policy No.:� I—I
CERTIFICATEPION FROM WORKERS
COMPENSATION INSURANCE r
(DtNsection need not be completed If the permit 4 forme hundred dollar($1010
or max)
I certify that in Ne performance of the wank for which this permit is issued,I shall not
employ any person in my manner as m became,subject to the Warlmrs'Compensation
Laws of California.Dam
Applirmt
NOTICE TO APPLICANT:IL after making NB Cenificam of Exemption,you should
become subject to the Workers Compensation provisions of Ne labor Code,you am ,
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
.ztCONSTRUCTION LENDING AGENCY
0
f" thereby alGrm that Nem is a constrocunn leading gency for the performance of
gr'..>i Ne work fur which Ws permit is issued(Sm.7097.Civ.C.)
W� Q Undoes Name ,
z Lenders Address
U Q 1 certify that 1 have read this application and sum that the shove Information In
n.(r•'- comet.I agree to comply with all city and county ordinances and sum laws relating to
C:)O building convection,and hereby mehorim representatives of this city to enter upon Ne
O
above mentioned prepeny for inspection purposes.
(We,)agree to save,indemnify ad keep hamlets the City of Cupertino against
aE"•i y liabilities,judgments.costs and expenses which may In my way acmmc against mid City
U 9oeneeatthERSTA DSA1s y S'����
^ Ai E1D5 WILL OMPL VITH ALL/NONI-'POINT Issued b Date
SOUR E ! II1p10
Re-roofs -�,
rcofApplicanUCon r Dem
DOUS MATERIALS DISCLOSURE Type of Roof
Wills a app leant or future building occupantsmrc or handle hasardot material
as de0ned by tis:Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Snellen 2553x,)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea No
W01 the applb:mt or fume building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous urconuminanwas Bncd by Ne Bay Area Air Quality Managcmant all new materials for inspection.
`mict7 `
❑Yea
(3 No
I have mat Ne hmardmamam mis requirements under Chapmr6.95 ofthe Califon
nix Hephh&Safer Wce25505.25577mdM34.1uaam dthaif&Wilding
does not cu ha m, m,that It is my mrpumihility,m floury the ocC.Pmt of the
ave mast It mice of.camlicavaof T' 6 Signature of Applicant Date
mNarir<degcnt l Dam All roof coverings to be Class oBo or better
Community Development
10300 Torre Avenue
? / Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
4JUPEI�TINO
Building De artment
JOB ADDRESS: PERMIT#
� �tSScID' Z
OWNER'S NAME: & PHONE # q�
GENERAL CONTRACTOR: ,P— e i.c�ofw T-rkL� FAX #
I am not using any subcontractors: S 1 to `olo
T �t-
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
!m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: B1k: Lot :
APN 35925027 . 00
DATE ISSUED. . . . . . . : 05/16/2006
RECEIPT # . . . . . . . . . : 34418
REFERENCE ID # . . . : 06050128
SITE ADDRESS . . . . . : 7593 DUMAS DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SHEN JEFF Y AND JANE S
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : RE ROOFING
CONTRACTOR . . . . . . . : PROCTOR, PAUL LIC # 20615
COMPANY . . . . . . . . . . : R E ROOFING & CONSTRUCTION INC
ADDRESS . . . . . . . . . . : 15230 CLYDELLE AVENUE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95124
TELEPHONE . . . . . . . . : (408) 626-9320
*EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 18 , 000 . 00 255 . 96 0 . 00 255 . 96 0 . 00
BSEISMICRE VALUATION 18 , 000 . 00 1 . 80 0 . 00 1 . 80 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 257 . 76 0 . 00 257 . 76 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 257 . 76 9988
TOTAL RECEIPT 257 . 76
•
WOO
CITY OF CUPERTINO
`11 im REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# � �,-�•� Date:
Building Address:
Owner's Name: Phone#:
Contractor: /t) ` License#:
Contact: /pR�Iv11 Cupertino Bu eess Licynse#:
,10 i S I 6�jj
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
/5�.WoodShakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles ,,,,/rr
❑ Other(Specify) Other(Specify) LT•
Number of existing coverings *1 Provide I.C.B.O. Report# LM43
❑ To be Removed 1 ❑ Provide Mfgr.Installation Specs.
• I Have Read,Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: 'j �Mtsv� I NVI tJ ( LA"1 e& 0*- WUUYJ �t Lf INSTALL 1J teti 1 2't Cb�i
a �t lksTM ► v�-T a rrW0 K n
Residential?y Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning D_pt. if
there are an restrictions: E
Cost of Project: W Type of Con Occupa c group:
Qty, if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Eneriy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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