051000592 C
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CITY OF CUPERTINO
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BUILDINCJDIVISION PERMIT
,GONTRAG�TORINk'ORMATION:
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BDILDINGADDRESS:
ROOFCO OF SILICON VALLEY
PERMITNO.05100059
2112
OWNER'S NAME:
PERMIT MUE DATE
CHIN HSU
3801A CHARTER
2005
ONE:
SANITARY NO. CONTROL NO.
(408)795-3335
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
p
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
'a, 'Now,
with Seetion 7") of Division 3 of the Business Professions Code, rimy license is
in full force and cff t. �_
y
REROOF-FLAT PORTIONS W/L r
u«nae el Lie..
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1 understand my plans shall M used as public records
NUV- 1005
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 License law for the
exempt from the fessin
y t -e1
Co
following muoa (Section IDnstr Business and Professions Code: Any city or county
reaso 1.
which acquires a permit ahcn improve, demolish, ere pati any structure
cores
.p b- .9.�
!- : to �p 1
re the
prior m its issuance, also requires the applicant for such permit to files signed sutemem
u,
Sq. FL Floor Area mPss�yl lr Valuati��500
Noshe is wit pursusat to the ivicmof NcConusines and
Professions Code] of
eivisio the Cook) or
mecing of Division
(commencing
pt tramfoonon
add the or the aged exempt on. Any
' Nat beefs exempt therefrom and Ne bazis for the alb god exemption. Any violation of
APN Number Occupancy Type
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
act more than five hundred dollars ($500).
32653032.00 -
❑ I. as owner ofthe prOporty, or my employees with wages as their sole compensation,
Required Inspections
will do the work. and the swcture is not intended or offered for sale (See .7 4. Business
and Professions Code: The Conuanor's License law does nor apply to an owner of
property who builds or improves themon, and who docs such work himself ar Nmugh his
own employees, provided that such improvements are not intended cautioned for sale. If,
a
however. the building or improvement is said within ane year of completion, the Owner,
builder will ban the burden of proving that M did not build or improve for purpose of
sale.).
1, as owner of the property, am exclusively contracting with licensed contractors to
constmm the project (Sec. 7044, Business and Professions Code:) The Convacmr's Li.
cense law does not apply to an owner of proyerty.who builds or improves thereon, and
who contracts for such pmjecu with a corn acmr(s) licensed pursuant to IM Contractor's
License Law.
❑ I am exempt under Sec. ,B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self -insure for Worker's Compere
so ium, as pawned for by Section 37M of the Lane, Code, far the performance of the
work for which this wmat is issued.
❑ 1 have and will maintain Wmker's Compensation Insurance, az rtyuirod by Section
3100 of the Labor Code, for the Performance of the work for which this pcordE is issued.
-
MyWorIt I CTo�m{pe�sa In antt am rand Policy�nuummber,a-m,:�
Cartier. 71 1 \ C '�(,Micy No.: 11f.�L
-- CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed ifsM Permit a forone hundred dollars(SIM)
.
or leas.)
1 certify thus in the Performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to Mcome subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cer ificase of Exemption, you should
become subject to the Worker's Compensation provisions of fee labor Code, you must
' forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nam therem is is construction lending agency for the performance of
' Newark for which this permit is issued
ued (Sec. 31197, Civ. C.)
Lender's Name
,
Leader's Address
j 1 certify that I have read this application and state that the aborx information is
' comet. I agree to comply with all city and county aNinanas and sum laws relating to
building construction, and hereby mnhorine rcpresematives of this city so enter upon the
I above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way seem, against said City
in consequcncc aflM a ti go his permih
�L
i APPL A S PLY wl H N N -POINT
Issued by: Date (y/ L -0d-
S E I
Re -roofs
Type of Roof '
pylic Dom
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ser (marc buddin acupem store or handle havaAous material
as dcfinctl by the Cupertino Muni ode. Chapter 9.12, and the HcaIN and Safety
Uipa
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or (n, building Occupant use equipment or devices which
mit hazardous air contaminants as diehard by the Bay Area Air Quality Management
all new materials fTiection.
District?
Yes
I have mad the havallousmamrials requircmenu under Chapter 6.95 ofthe Califor-1d
nice HcalN&SafcsyC,Seed 255115, 2333 and 25534.1 Ondcrsund thatif Nc building
4gnat
n
d sent sere nmly a yr ihililYmnuuly sM atop lot Ne
"" p '" ntE"m ` p
o pelican Date
All roof coverings to be Class "B" or better
w er t ge I Dae
CITY OF
�UPEkTINO
E
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
.:...
noff
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
I am not using any subcontractors:
Signature Date
Please check avvlicable subcontractors and comvlete the followine information:
Date
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
Date
4
•
'CUPERTIN0
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
APN #
Bldg Permit Fees
Date:
�
Building Address:
Energy
Owner's Name:
BSEISMICRE
Phone #:
PAN Su
BSEISMICOM
qq to —25cx'
Contractor: ,
BPLANCHK
License #:
O-3
BUSLIC
Business License
Contact:
Cupertino Business License #:
S
Type of Roof
Covering:
Existing pos Pro :
G✓ Built -Up Roof
Built -Up roof
❑ Asphalt Shingles
❑ Asphalt Shingles
O Wood Shakes
❑ Wood Shakes
❑ Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
❑ Other (Specify)
Nu*er of existing coverings
❑ Provide I.C.B.O. Report #
C3 To be Removed
❑ Provide Mfgr. Installation Specs.
Have Read, Understand and Will Comply With Cu ertino's
Tear Off Policy:
Job Description: 7tiF SLATOlr1S
�/yl LtTA\ \vSC� 17 CSI (S Ni'� �j
Residential EEr ommercial ❑
Fire Zone: Yes ❑ No ES
Confirmed with Planning Det. if
there are an restrictions: LJ
Cost of Project: Type of Construction:
Occupancy group:
,*a Svo — -TDwn+AcSuSP—
Qty. if
Anol icable
Fee ID
Fee Deserintinn
PPP (-.rnl,n
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
CAMS - Ng 3
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