05120023 CITY OF CUPERTINO n" "TZ �'�}��"sp'�j j� '7 '7,W fir
BUILDING DIVISION PERMIT �CU1ITRAG�TQR INFO^"'—ATIUN
BUILDING ADDRESS: DAN ELLIOTT' S ROOFING CO PERMTTNO.05120023
19367 GREENWOOD DR
OWNER'S NAME: PERMIT ISSUE DATE
AGENT MARY ® INVESTOR' S MGIIET2669 COIT DR 12/05/2005
HE; SANITARY NO. CONTROL NO.
(408) 559-7327
ARCHIIECrIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMBMECH
0 0 0
300 LICENSED CONTRACTOR'S DECLARATION Job De n
I hereby affirm that 1 am finned under provisions of Chapter 9(commencing
with Section 7000)of Division Sof de Business and Pmfassiau Code,and my license is
n
in full REROOF--T/O SHAKES, . IN T � ES
Llem2 Dam Clan Coon
��— Dam Gn DECLARATION ARCHITECTS DECLARATION
iundorsunJ my plans siWlMuseJU public mcortls 4/' .
] Vth
g l.u:cvcd Pmfessionat V
�^o OWNER-exempt RDECLARATION �7
9 0$ I onaso .nim that I am exempt Imre the Contractor's o License Law for the
$o following recon.(Section 703",Business and Profession Cole:Any oily or county
$ which requires issuance.permit to id.M 4 alar,impmw,do ermit t ear e a sir my atrvnum 8 6 0 4
prioraiu nsedpalta mquims Meapplicantfor ach peones m RleasLnedsumment
�< that heiswith
pursuant to Mus of Division
of the Comracmr4lJceno6w sCom)9 Sq.Ft. Floor Area Valuation
(hat he IS exempt Section TODD)of Divisionrothceged cesmdon.My violation
— Natio u 31.5 b therefrom and ate assns(t the cts Me esempdm.Any violatlnn of
Section 703 L5 by arty applicant for Permit objects Ne applicant to•civil penally of 3 -Occupancy Type
sent mese dun Rn buMred dNun(f3001.
❑1,Is owns of the property or my employaa with wages Is Man oto compermasion.
will do to work and Meswnum is notinterlded oronered four am(See.TOW.Business Required Inspections
and Professions Cade:The Conuacros's Llessam Law darn not apply m e ns an Owner of 9 P
property who builds or im proses demon,and who dao such work himself ser through his
awn employeu,praNded thataueh Improvements are notinunded ornRered for axle.If,
however,Ne building or impmvement is old within ane year of mmpledon,the owner.
builder will ban the amount of proving that he did net bulla or improv for purpose of
sale.).
❑I.as owner of the property am exclusively contracting with licensed contrassors to
construct the project(Sec.7014,Business and Professions Cade:)The Communes Li.
ave Law data not apply in in owner of property arm builds or improves demur,W.
who contracts for such projects aids s camracmr(q licensed pursuant to the Canonicals
License Law.
❑lam exempt under Sea .B&PCfx MIsmssoa
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of pujusy arc of the following declaration:
IZ37'1100
lura and will mainuin•Ceofscam of Consent m self-insum for Warer'sCompen-
ion,u provided for by Session 7700 of the labor Cade,fur the performance of deh far which this permit is issued.
_I dean and will maintain Worker's Compenudon Inorana,u required by Section
of the Labor Code,fn the performanu of the work fur which this permit u issuce.
WarkcrsCampnsssim l=am aoa and Policy number am:rrier.,4NI[�Lv`4., /-�rrwy Policy No.:
y7' �y/
Cd1 LATE OP E%EMPTION FROM WORKERS
COMPENSATION INSURANCE
(Tblamctim nttd net he completed Irt a permit Is foram hundred dollen($100)
unless.)
1 certify that in Ne performance of she woh for which this Permit is issued,l shall not
..play my parson to my manners,ate in became subject m Me Warkera'Comers nHdm
Laws of Califomu.Due
APPlwmL
NOTICE TO APPLICANT:If,arm,making this Cenificum of Exemption,you Jould
become subject to the Worker's Compensation previsions of the Labor Code,you most
�p forthwith comply with such Provisions or this permit Nail he damW ranked. '
,zt 55CONSTRUCTION LENDING AGENCY
[. I hereby arm Nat dem is a avtvssim landing agency for de perfo rmana of
Cli the work for which this permit is usued(Sec.3097,Civ.C.)
Q Undoes Name
7 z Lender',Addmas
U O 1 aNfy that I Nn mad this application W sum that the&bon Information Is
E correct.I agree to comply with all city and county ordination and sure laws mhting to
p rUbuilding contraction,and hereby authorlm represenutims of this city m cow upon Ne
W slave-mentioned property fm impecdm purpose&
fi
Me)agree In,save.indemnify W keep harmless the City of Cupeom against
y liabilities,judgments.costs and expenses which may in&ray way acera all said City _
fJ Z in consequence of the graming of this permit
APPLICANT UNDERSTANDS AND WILL PLY WITH ALL NON-POINT Issued by: Date ` J
0 Cfi REGULATIONS. _
Re-roofs
ign ure of ApplianVConuactor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII tae applicant or futum building=upmtatom arhandle hundms mawdal
u donned by the Cupeom Municipal Cade.Chapter 9.13.and de Health W Safety
Cole,Ighon 23573(e)7 1 All roofs shall be inspected prior to any roofing material being installed.
Will dsa appilcmt or future building builJing arupans use equipment or Jcvima which If a roof is installed without first obtaining an inspection,I agree to remove
It haraonu aircmuminanu u defined by the Bay Area Air Quality Management all new materials for inspection.
trimT
❑Yes �Nu ��///��//
Ihaw mW the husrdms metadahreyuiremcnu under Chapter A95 ofJte Glifor- G �'
nix Health&SafetyCode,Sections 23505.25533W 23534.l undenona that lfde building —�J'—
doas maIcurmmly hew a muni,th It u my mpouihiliiy m notify the=amt of the �L
I nuwhichmost f CertlfcateofOoapuey. Signature of Applicant Date
Owner onumono. a em Dam All roof coverings to be Class„B„or better
Community Development
910300 Tom Avenue
Cupertino CA 95014
CITY OF Telephone(408) 777-3228
9CUPEkTINO Fax(408)777-3333
Buildin ,De artment
JOB ADDRESS:
10L-1- 61 t Va PERMTT#
31o'1 �t tiee n�tso-P�Q �/2 .Z
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR %- S S CI--7 3Z
,o S FAV# og-Ssq=►3 67
I am not,using any subcontractors: 1
ture
Please check a Iicable subcontractors and complete the win 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 A
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Si ature Date
aL
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN#
Date: _
Building Address:
1 Z-S-o.y
Owner's Name: Phone #: �{O
Contractor: Phone#: License #:
`lo -S�c =t3Z'I io 133�b C-3�]
Contact: Phone#: Cupertino Business License#:
0.
Type of Roof Covering-
Existing: Proposed:
® Built-Up Roof m Built-Uproof --Ck6LSs At <44e }kvY\
❑ Asphalt Shingles ❑ Asphalt Shingles
® 11
Wood Shakes ® Wood Shakes --6kekss. 'A' sy,.L
El Wood Shingles 13 Wood Shingles YV�
❑ Other(Specify) ❑ Other(Specify)
Number existing coverings ❑ Provide I.C.B.O.Report#
B Tobea Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Com 1 With Cu ertino's TearOff Polic
Job Description: �rnu� � e x�S��nh lr1}u t spy -ad sive 3 mer c1Uss`A'
C �1a� Roo Sq } 0-V_X c1Ut;s \ 13 Sbw ce, o-e t x-72
Residential Uy Commercial ❑ �� 5
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are anrestrictions: LJ
Cost of Project: 0 y 117 Type of Construction: Occupancy group:
Qty. if
A licable Fee ID Fee Descrition
BPERMFEE Fee Group
Bld Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
2.2�