05040077 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORANFORMATION .;
BUILDING ADDRESS: PERMrf N0.
05040077
OW NER'S NAME: PERMTT ISSUE DATE
ONE: SANITARY OL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION s
eraC I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
=yiFu with Section 7")of Division S ofthc Business and Professions Code.and my license is '•-_ _���
in full force andXfcc
D�? License Chis c^. LK.. REROOF W/COMP . G
Dam Con. LA - CONTRACTOR: ROOF ROOFING
f ARCHTECCon. RATIOI.�N � ,-
9, 1 undersand my plans shall he used as public records
DyU ( '
3 LL Licensed Pmfumicrol
0n
aOWNER-BUILDER DECLARATION
.<l 1 hereby affirm that I am exempt from the Conlacsors License Law for the • �.-_"� .. .. ..
Y a c following reason.(Section 703 L5,Business and Pr0(es ione Cook:Any city or county
x m rtes which reyuire5 a permit to construct,alter,improve,demolish,or repair any Structure
Fiy poor In its issuance,also requires the applicantforsueh Permit o file a Signed statement -
< that he is licensed pursuant to the provisions of the Contractors License law(Chapter9 Sq.Ft. Floor Area ValllatllJA000
9Fo (commencing with Section 7")of Division 3 of din,B usiness and Professions Code)or ++��1V
y
that he IS exempt therefrom and the baso for the alleged exemption.Any violation of
Seeuon'/o31.5 by any.pplicvn forapermit subjects the applieml to a civil penalty of APN Number Occupancy Type
not mom than love hundred dollars($5W).
❑1,a owner of the property,or my employees with wages as their sole compensation, 36914030 . 00
will do the work,and the structure Is not intended or offered for sale(Sec.70,M.Business
and Pmfccuiam Code:The CpnuactoYs License Law does not apply On an owner of Required Inspections
Property who builds or improves thereon,and who domauch work himself or through his
own employees,provided that such impmvemenu are not inmMed or offered(orale.if,
however,the building or impmvemenf u sold within one)ear of completion,Ne cwser-
builder will has the hmden of proving that he did not build or improve for purpose of
sake.).
❑1,as he,of the property,am exclusively contacting with licensed contractors to
construct the project(Sec.7014,Business and Professions Cade)The Contractor's Li-
come law docs nos apply to an owner of propeny who builds or improves themon,ad.
who contracts for Such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
I am exempt under Sec. .B&PC for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 h:ve and will maintain a Certificate of Common to self-insure for Workofa Co nter-
ation,as provided for by Section 37M of the labor Code,for the performance of the
work for which this permit is issued.
�-Ihave and will remouin Workers Compenaturt laurance,as required by Section
3700 of On,Labor Code.for the performance of the work for which this permit is issued.
My Workces}Q mR{�aa6 Insurarra carrier and Policy number are:
carrier: '3 `nom `� C�—tY Policy No.:229 2W
CERTIFICATE OF EXEMPTIONFROM WORKERS' '
COMPENSATION INSURANCE
mos section need not w completed if she permit is Intone hundred dollars($100)
or less.)
I cenity that in she performance of the work for which this permit is issued.I shall not
employ any permn in any manner an as m become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become subject to the Worker's eompcaatien provisions of use labor Code,you must
.J Z forthwith comply with such prnviVins tar this Permit mall M deemed revoked.
z CONSTRUCTION LENDING AGENCY
Ihereby affirm that throe is a construction lending spray for the performance of
C'> the week fur which this pemu,is issued(See.3f A7,Civ.C.)
!y Unders Name
d Under's Address
C.)0 1 cenity that I have read this application and state that the above infmmadon IS
Iy Pcomer,1 agree to comply with all city and county ordinances and sum laws misting to
0 C.7 building conswnion.and hereby authorion representatives of this city to enter drum the
D•1 above-mcntiuned progeny for Inspection purposes.
py (We)agree to save,indemnify and keep harmless the City of Cupertino against
U z liacolnmquc cc of the grantingt
dexpens�mhich may in any way access against mid City (�&
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG LAT . 1)
Re-roofs
Signammof ApplieanV onuaetor Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof'
Will the applicant or future building occupant Son or handle hvardous material
a defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Semon 25su(a77 All roofs shall be inspected nor to an roofing material being❑Y ❑Nd P P Y g g installed.
Wm the applicant or mere wilding ntcdpant dm equipment or devices ween If a roof is installed without first obtaining an inspection,I agree to remove
it hanorous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
Disuic"
❑Yes ON.
I have read the haothims materials¢yuimmcnts under Chapter 6.95 of the Califer-
nix Health&Safety Code,Sections 25505,25533 and 25534.1 undersuml the if the building 7 /
does not currently have a monk that It Is my responsibility m notify Ile occupant of the
rtyuimmcnuw ' h sem missuancc.ofaCenircamorOccupancy Signature ofApfIlicant Date
� All roof coverings to be Class"B" or better
Owner tar awhmixed.gent Dam
r Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: _ PERMIT #
t� 366 Gnc� awlJ c--"- o.5 ° Y `' c' 7 ,7
OWNER'S NAME:,-ye-VF h Ck So r PHONE #95"b- 5-2o - 4(8,6
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
L.� Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
dwner/ Signature Date
CITY OF CUPERTINO .
tom' REROOF Ste'
CUPEkTINO PERMIT APPLICATION FORM
APN # > Date:
J d ley-os—
Building Address: (�
`U3
Owner's N e: Phone#:
ContractoF Phone #: License#:
2ovr `(ve ?&r-5'.t-? (-, 6Ir_)36r
Contact: Phone#: Cupertino Business License#:
d-� moots '2.65• C1� [�
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles IJZ Asphalt Shingles
,.O---Wood Shakes ❑ Wood Shakes .
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
No ber of existing coverings ❑ Provide I.C.B.O.Report#
To be Removed O Provide Mfg.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description: \ \ 1
Quo T� exritli - S1 .1c _ j t-l� y 30. ` coo^ , XL ,Jcuo oS
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: (� (� Type of Construction: Occupancy group:
IL�+GtX�� .
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
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