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05120138CITY OF CUPERTINO ¢i4�='' T©FAuaTI(N +a, BUILDING DIVISION PERMIT .»w,LZO M- BUILDING ADDRESS: PERMIT NOO 5120138 NAME: PERMIT PERMISSUE DATE 1 22 2005 NE: SANITARY NO. CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO ' BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION lob Description 1 krcby ifflm Net 1 an licensed under provisions of 9 (mmmense MN Section 701(1 .fLkvidan 3 ofoe BuzreuaM Profesdons Code. and my license is Code. is in full from andh�y 4-5V 2 Z/L 7</ REMOVE EXISTING CONCRETE TILE ROOFING. FURNISH Lianm ane Lic, a Dam Contractor INSTALL ONE LAYER OF 1/2" 5 -PLY COX PLYWOOD OVE ARC"ITEudusphlcrecrdlunderstood my plans halbese.o EXISTING SHEATHING AND CERTAINTEED TL PREMIUM Licensed Professional OW NER-BUILDER DECLARATION 1 hereby aRrm Nn 1 am exempt from the Conuactoes License Law for the fallowing mason. (Saban 703 1.5. Business and pretences Code: Any city or county which requires a Permit to mnsuacL when barrow. demulrh. or repair any structure prior m its esusec. also requires the applicant far such permit to,01e a signed saemem owned he is owed pursues, m Use pmvismnsof the Comracmrt License Law (Chase, 9 Sq. Ft. Floor Area Valuation (commencing with Salon 7x00) of Division 3 close Suntanned Professions Code) or $18242 2 that he is exempt therefrom and de basis for use alleged exemption. My violadm of Section 7031.5 by any applicant for a permit aub),me No applicant as a cavo penalty of APN Number Occupancy Type P y YP oat more Nan five hundred dollars (SSW). ❑ I, as owner of the property, or my employeex with wages u their mle compensation, will do the work and the structure is not intended or offend for sale (Sec. 7044, Business Required In and Can; Law does not apply lf an owner or Committees Licasecud ns mranpr who his property who ertywyees. dsorimpmvasthemamandwhatlmaamhwmk hi seelforthrougharnedfors own is own employees, pmWdrri Nar semenu art n ed moaefed for ask t- vem est isyear o want - builder, the building or improvement an year of mpro a far dust a diin builder wiB kw the lactim of pmNng Wt k did est build or Improve Ire purpose of purpose �® [:) 1. as owner of the am exclusively contracting with Hoven contractors to FE'® Property, conswct due ec pmject (S. 7W4, Business and Professions Cade:) 77e Contractofs U. �n'yyp case Law does not apply mtsowner of DroDan}who builds osantow manand, whonua wcocufor such projects with torW aeontraclicensed pursuant mlk CoConsaeroh Lkenu Law. ❑lorancen underSm. ,BkPC(ar Nla semen Owner Data WORKER'S COMPENSATION DECLIRATION\vJ� 1 kreby &Dian under penalty of perjury one of the following dalathons: 1 haw and will mdnuin a CenlOeamafConum m ac16;nsure for Woduas Comfort. noon. u provided fm by Section 3700 of de Labor Code. for the performance of the wed for which this Permit is bound. ❑ 1 ban and will maintain Wmkefs Compensation Insurance, as required by Section 3700 of the labor Code, for tion performance of the wort for which this permit is issued. My Wadee ramenuon toren artier cud Policy number ate: Confer. V T : e- PaOry No.: A'/3 76 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE , (This section wed not be completed if the parol is for we hundred dollar (SI W) or toss.) I cenify Not in the performance of the work for which this permit is issued, I hall but employ any person in any number an as w become subject to de Workers'Compensatim Laws of Califomia. Dae Applicant NOTICE TO APPLICANT: If. after making this Cenifiate of Exemption, you should become subjat he Ne Woftes Compensation provisions of the Labor Code, you mus forthwith comply with each provisions at this pard, hall w named raveled. CONSTRUCTION LENDING AGENCY I hereby aRim that Nmrc ban commas on lading agency for once Performance of oto wud for which this Permit Is Issued (Sec. 3007. Civ. C.) Lender'. Nam. ' lender's Address 1 cenify shat 1 have and this application and sum out, the show Information is mnmL I atrce to comply with all city and county on in mires and sue laws tehting to building construction, and hemby authorise mprewassans of this city to enter upon Ito above-mendoned Property for inspection purposes (We) erg. to tow. iMemnify, and kap haemess the City of Cupertino against Ilabilitiu.jungmeuu. emu and expenses which may In any way a. again, said City in contegueme of the granting of this pmmic APPLICANT UNDERSTANDS AND WILLnMPLY WITH ALL NON -POINT Issued by: Date SOTE It e -roofs Type of Roof L Signamrc of ApplicnUConuumr 1 Data HAZARDOUS MATERIALS DISCLOSURE Will Ne applicant or forum building occupant store or handle locations material as deRwd by thc Cupertino Municipal Code. Chapter 9.12. and the Hcahh and Safety de, Seeder, 25532(07 ❑ Ya o All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or factum bottom& occupant use equipment m devices which It havardnm air cmuminanu u defused by Ne Bay Ma Air Quhty Mnagcmem all new materials for inspection. rinl �/ ❑Yes DIN. Idas I haver mad the huadommaeriabmqulrcmenr under Chapmrd.95 of the Celifor. Health k SafetyCode, Suctions 25305.25533 and 25534.1 undereatd thuift a building oat currently hew a mom, the, I,it my responsibility to notify the occupant or the uirements which mut k met prior to issuance of a Comrade or occupancy.. Signature of Applicant Date All roof coverings to be Class "B" or better Owner orauthorimdagent Dam 0 MV t St, CITY OF CUPERTINO REROOF CUPERTINO PERMIT APPLICATION FORM APN # Sao- 1A - oo R,1 BldgPermit Fees Date: is - -Z a -os Building Address: � BUILDING BSEISMICRE Owner's Name: ?A BUILDING Phone #: 90/ I /t BUILDING -a29 - g2 lo Contractor: BUILDING License #: Business License BUILDING Contact: � /�� `C1.vD �IEfJor¢.ti) Cupertino Business License #: Type of Roof Covering: Existing: Proposed: ❑ Built -Up Roof ❑ Built -Up roof ❑ Asphalt Shingles lK Asphalt Shingles ❑ Wood Shakes ❑ Wood Shakes Cl Wood Shingles t Other (Specify) i E,* ri f t ❑ Wood Shingles ❑ Other (Specify) Number of existing coverings �_ ❑ Provide I.C.B.O. Report # )1(� To be Removed ❑ Provide Mfgr. Installation Specs. I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: spar/ ►�vc Job Description: Ra*mvE Exms� q tovcaFre-t;le`i FVek;;5f, A j2> gy )/Ate I <ZDX Pl u7oct-( ovim_ C-kl.S74 AC -A -)•4;!J /t••e +n..>fer� rt AmFmi�n0 Residential F-1Commercial Fire Zone: Yes E] No E] Confirmed with Planning Dep;,4f there are anrestrictions: C� Cost of Project: Type of Construction: Occupancy group - c 1 18.241.50 Cblr,rrrQac;aZ -4np J�J Qty. if Applicable Fee ID Fee Description Fee Group I BPERMFEE BldgPermit Fees BUILDING BENERGY Ener BUILDING BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILDING BPLANCHK Plan Check Fee BUILDING I BUSLIC Business License BUILDING