05040078 CITY OF CUPERTINO
BUILDING DIVISION PERMIT i�CONTRACTOR INFORMATION-
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BUILDING ADDRESS: PERMIT NO.05040078 5040078
OW NER'S NAME: PERMIT ISSUE DATE
NE:
SANITARY4:40 OL NO.
ARCHITECT'/ENGINEER: l BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION1
C 1 bcmby afrrm that 1 am licensed under provimins of Chapter 9(commencing Job Description
n<"t wiNScction]IXkBof Division Jmf the Business and!Profeainns Code,and mylicense is
5y uc�^lunR�6ndf +�uT' _Li<.a r4`7�G�= REROOF W/COMP.
IDam ,�5uv--contractor -�% � CONTRACTOR: ROOF ROOFING /�� n"'"
� ARCHRECI-S DECLARATIONf 2LU�
nU I uMersund my plans shall W used as public records
Licensed Professional
O1 OWNER-BUILDER DECLARATION Nu t ' t rl 7
i P 1 bemhy arrm Nn
fI am exempt from the Conuacmrs License w for the •• _=%❑�� ` `/
o D following mason.(Section 703 1.5,Business and Professions Code:Any city or county
$6� which requires a permit to construct,alien improve.demolish,m¢pair any suumme
prior m its issuance,also requires Ne applicant far such Permit m rile a signed statement
t?'< that he islicenudpursuan totheProvisions ofthe ContractuhUccoac aw(Cooper9 Sq.Ft. Floor Area - Valua[o�000
QFC (commencing with Section 7")of Division 3 of the Business and Professions Code)or
$
that he is exempt tkrefrom and the basis for the alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant to a civil pcnaltyof APN Number Occupancy Type
not mom than five hundred dollars(S50)).
01.asmvnerorthepropenyormyemployeeswwwagesastheir:omenmpensation, 36914030 . 00
will do the work,and Ne swetum is not intended or offered for sale(Sec.](I14,Business Required Inspections
and Professions Cade:The Contractor's License law does tat apply to an owner of q P
progeny who builds or improv theman.and whodoessuch work himself orduough his
awn employees.provided that such improvements arc not intended oroRered foraale.If.
however.the building or improvement is sold within one year of completion.Ne owner-
builda will have the burden of proving that he did not Wild or improve for purpose of
sale.).
( I.as owner of the progeny,am exclusively contracting with licensed contractors to
consrvct the project(Sec.7014,Business and Professions Cade:)The Contractor's Li.
cense law docs not apply in in owner of property who Wilds or improves themon,and
who comma for such projects with a contra tor(s)licenmd pursumt to the Contractor's
License law.
C14-1 exempt under sec. ,B @ P C for this mamn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury an of Ik following dedasation:
I loam and will maintain a Certifiam of Consent to self-insure for Workers Comill
Solon as provided for by Section 3700 of the labor Code,for Ne performance of the
work which this Permit is issued.
1 have and will maintain Workers Compensation Iwrmce,u required by Section
3700 of the labor Codc,for the Performance mf the work for which this permit is issued.
My Workers m nation Insurance carrier and Policy num am: _
Carrier. / � s' �" '�1` Policy N.,21�u G-1e1L�5
CERTIFlCATE OF MON FROM WORKERS'
COMPENSATION INSURANCE
Tois section need not W completed if the permit is Rome hundred dollars($10(1)
mr less.)
I certify Nat in the performance of the work for which his Permit is issued,)shall not
employ any person in my manner sit as in kcome subject to the Workers Compensation .
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Comficam of Exemption,you should
kcome subject to the Worker's Compensation provisions of Ne Labor Code,you must
.J O roMwill comply with such provisions or Nis permit shall W deemed revoked.
Z71 CONSTRUCTION LENDING AGENCY
Tru I hereby affirm that there is a construction lending agency for the Performance of
CL dm work for which this permit is issued(Sec.3097.Civ.C.)
GQ Undoes Namc
7 Z Lender.Add.
U Q 1 certify that I have read this application and sum that the above information is
Is, P cormcL 1 arra,to comply with all city and county ordinances and sum laws relating in
0U Wilding construction.and hereby authone,representatives of this city to enter upon the
ill above-mentioned property for inspection purposes.
(We).,me to save,indemnify and keep harmless he City of Cepenino against
Fr card liabilities,judgments.costs and expenses which may in any way ampoc against said City
U in consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATI
y� Gf— Re-roofs
S4��
rgnewre of Applic HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will the applicant or future building becupamstore or handle hazardous material
CudeRZ,1 by do,Cupno Municipal Code.Charter 9.12,and ftHcaldt and Safety
e.Setionzss3z(a)?erti
❑Y No All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hattr4ous air contaminants as dcfncd by Ne Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ON.
I have mw Ne bvardms mamrialsrequiremcnts under ChaPmrb.YS of the Califor- //��
niaHcolth&Safety Ca ,Sccumu25505.25533andn534.1undmrs thmiftk Wilding
does not currently hove a mnam,that it is my respmnsibilty m nouty the mecupmt of the
require c yqr wisumeemfaceniramarOcapaney. - Signature of Applicant Date
a! 4l$ d
Owner or amhorizcd agent Dam All roof coverings to be Class"B" or better
F Community Development
10300 Torre Avenue
%' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPER,TINO
Building Department
JOB ADDRESS: PERMIT 3�� o n (�
4I— too 6 t
�. awD 'L�
OWNER'S NAME: PHONE #6yu- Zo- y 3 6
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors
ignature Date
Please check applicable subcontractors and complete the following information:
66 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 'r Vii-.,
Septic Tank .
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
I2E12OOF (�S� il OT
CUPEkTINO PERMIT APPLICATION FORM
APN # / Date:
Building Address:
1v3r,_«^ (_jc�
Owner's Name: Phone#:
J'i l'F V" 1 aro ^ &rv-S'2o- 103-6S_
Contracto Phone#: License#:
�Sa-)TGT
Contact: Phone#: Cupertino Business License#:
moots 26S C27 V
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles I'll, Asphalt Shingles
Zr--Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Nu ber 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:
Qe-wow.- `0,. e.nsl�la . 5�....�... - 5,..,�_� v
Residential,-fn- Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of project: T e of Construction: Occupancy group:
' -6,t vo Qt
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