00040147 . CITY OF CUPERTINO. PRINTING.
BUILDING DIVISION CONTRACTOR INFORMATION:
PERMIT Dob D
BUILDING ADDRESS: `C
1 i Lsa SANITARYNO. APPLICATION SUBM TTALDATE
OWNER'S E:/• jj'eA
(,i( A '/� '5
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�J(./ "'S kf� NIC CONTROLk i1
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RCHITECT/ENGINEER, BULDINOTERNETINFO
C�
Z y Z LICENSED CONTRACTOR'S DECLARATION
1 hereby.Rion Nat I am licensed uvder provicionr of Che ter 9 comment'
o z- p ( ng Job Description
F'm(=s�i wiNSation7")ofDivision3ofNe BusiMSSa RfMioni Cada MylianWis
o ' to Liani for.nd ellen, et.Aad Lic.« � 5fo 890 raft e_o e'�'• Qf N A`1'� . f'0 0•�`a
3,y Date Connector ..
$v�O ee • ARCHITECTS DECLARATION -
F yyyQ N J i understand mY Plans shall be used u Public rccada - � I ," ,
i q e LiceneW Pro(esalonel ,_
u�3
OWN'
R-BUILDER DECT.ARAHON
L b< - I hereby affirm Net I am"Cmpr from the Camractors License Law fm the '
I O following ream,iSeclum 7031.5,Business send Pm@Nom Code:Any city a co mr,
�m which requims a Permit in cunswct.Am,improve.demolish,or repair any mecnlm S Ft. Floor Area T�) 0
prim to its ismawe,also requims theapphck.I f...Ch permduo fileasigrcd statement , q' I J.al tlQn O
Not he is licensed pursuant to the provisions of the Conn'ector's Lienee Law(Chapter 9 ID G1/
of
( hele cing with Section ) armvi ptonat Code)
)aWt attempt lampoon sndNe basic Business mption.Any violation - APN NLIMber ccupancy Type '
Sweden 7031.5 by any applicant fa a permit subjects the applicant N e civil penalty of
^;f. Nan five hundred dollars(5500).
�I,ter owner of Nepropeny.mrmyempinyee:with w.gean Neir.mle wompemuion. _Required Inspections
will do the work,and memucrure is am intended or offered far.ale(Set.7W,Bu ns.
and Professions Cada:The Connumr's Liana law dm nm apply(a an owns of
Pmprty who builds or improves Merton,and who does such work himself or through Cs r
his own employees,provided that such impmvemanu are nor intended or offered fa %Oa
ame.If.howevci,the building or improvements is sold within one yearmfcormpietian,the _T�W O t r\SPe`"�{yV)
owouoboikkr will have the harden of proving that he did oat build or improve for Pur-
. pose,of sale.). ,
D 1,u owns of Ne propeny,am exclusively cono-acdni with licenced conuanots N
construct Ne project(Sec.7044,Business and Professions Cade)The Contmerors Li-
cense Law does two apply e ts owner or pectens who licensed
or ed tavm Norton.and .P j
License tact , such projeeta weal econvacmr(s)iicansed punuannor Ne Conbumrs
License Law. d. �/
01.1qunder . ,B&PC or/thts V
Game ."w, CA A!L1 Dane �q4 - Q
WORKER'S COMPENSATIO ECIARATION
I Creby a firm under penalty of perjury Can,of drt following deeluatiom: -
I have and will..Wa s Ceoifica,of Consent m self-imam for Worker.ComPen- �
tion,as provided fm by Section 37M of Ne Labor Cade,for the pemomanoe of the
Lor fa which Nis permitis issued
have and will maintain Worker's Compensation Insurance,as required by Section -
3700oft�he(L Cbqoms Code fur th�eerperformameofthe weak far
ryrywbhhhi�ich thus permit is issued.My Whose „
Camey: ys" aQr PaleyNloyW[,.t� wes7(tg. (P
CERTIFlCVCOMPE1NSAATTIION INSATE OF EXEMPTIONURRANCEMOM ORKERS `+
(Tho seniors need nm bw comPled fN fano Osforonehundmd dollars(3100) V ���///
or l<u) - -
IceoifyNatintheperformance of the amill,for which this permit ie issued,I shall mss. f'1 (77"not employ arty person in any Inman 1 0 4fcnrge subjen ro Ne Workers'Compen-
ration Law, idRomi.DataDs7 Y O a 11 ,
Applicant C Li
NOTICE TO PLICANT:If,after making this CtrWsta of E.mijimn,you should
becomes m the Workers Compensation provisions of Ne Labor Code,you must sr4 1'��, D
forthwith comply with such provision.or this permit shell W rand revoked. •+
z CONSTRUCTION LENDING AGENCY � l
I hereby alum that them is acons,uedon lending agency forthe performance of -
Z .~ dw work for which this fermis is issuW(See.M)7'Cie Q
�.a
'lenders Name
('(I ' Landers Address' - - '•
-E I certify,Nat I have read Nis application and state Nm the above information is
comet.l am a to comply with all city end county eminences and ems laws rtlaring to �,
-U O buildingcmnawcGon,and hereby moths se Mprcacnwivn of Nis city to enter upon the
.WvC-mCnri.d WmpCny far inme,dim,myr ace.
W Ew (We)agree in wave,indemnity and keep harmless Ne City of Cupertino against
C.) liabilities,judgments,case and espouses which may in any way accrue against said City
�w in consequence of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT _
V z SO CEREGUTATIONS.
c1w� 4.a`/de
Si
g t licamuConmene Dam
r HAZARDOUS MATERIALS DISCLOSURE
Will Ne aPplicanmrfuwrc building rocupem store or handle haaardamarmodal Re'roofs
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Seu mit 25532p.)y �_ ! Type of Roof
Cl Yen 19C. _
Will the applicant or futureding acupam use eqrca uipmem or devices which All roofs shall be inspected prior to any roofing material being
mi
et bmrdous afrommsminanta asdefinedby Ne Bay AAU Quality Management installed.-If a roof is mstalled without first obtamirig an inspection
", VN. gnature
ree.to remove all new materials for inspection: Applicant
E-]Yea
I have read Use hemrdouemutenalarryuiremenu under Clapper 6.95 of dm Cmi- erstands and will comply with all non point source regulations:
fomu Health R Safety Cade,Sections 25505,25533 and 25.514.1 understand Out if Oa - ►ws
!wilding does nee currently have a tenant,Net it is my respauuibility m notify d¢occupant '�a •k�a
of -remen=sw ' mot be ru��-n p�66rio"""r b```issuerce ofeC�^iflcm<a�Occu ncy.. sa
M3 a 4%T of Applicant Date
Ow rarauNenedagent Data '•
• ' . - All roof coverings to be Class`B•'or better
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
® BUILDING PERMIT INVOICE OPERATOR: kanenb
Sec: Twp: Rng: Sub: Elk: Lot:35606019.00
INVOICE DATE...... : 04/24/2000
REFERENCE ID # ...: 00040147
SITE ADDRESS .....: 11107 LINDA VISTA DR
SUBDIVISION .... ...
CITY .............: CUPERTINO
IMPACT AREA ...... .
OWNER . ........... : SELDEN
ADDRESS .......... :
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-4753
CONTRACTOR .......: MORAZAN, MARVIN LIC # 14493
COMPANY ..........: MORAZAN ROOFING
ADDRESS ..........: 740 SHAWNEE LN
CITY/STATE/ZIP ... : SAN JOSE, CA 95123
TELEPHONE ........ : (408)224-5785
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -___-------
BPERMFEE P 177.00 0.00 177.00
BSEISMICRE P 1.20 0.00 1.20
BUSLIC P 90.00 0.00 90.00
--------- ------------ -----------
268.20 0.00 268.20 ,
VID DESCRIPTION ___= VOICE ID DESCRIPTION
.. ...........e........... I ..s........................
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
II ACORD ��'. , i 11"' ,t ,. $i9 ��/'�I'�i��li(I III` �I�IV�r a\� `I.��I I �x i. i 7 DATE(MM/DD )
PRODUCER r`, ' t-I va' ,m m 'a. ' i
12/31/1999
Serial# . .. x' ..
MICHAEL J. PETKUS INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
6963 DOUGLAS BLVD.SUITE 131 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
�NITE BAY, CA 95746 COMPANIES AFFORDING COVERAGE
1-888.644-4600 FAX:916-652.2231 COMPANY
VILLANOVA INSURANCE COMPANY
A
INSURED COMPANY
MORAZAN ROOFING, INC. B
740 SHAWNEE LANE COMPANY
SAN JOSE, CA 95123 C
COMPANY
D
r�I 11
G
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED B Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION
LTR POLICY NUMBER DATE(MM/DDIYY) DATE(MM/DD/YY) LIMITS
GEN ERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGO $
CLAIMS MADE F7 OCCUR PERSONAL S ADV INJURY $
OWNER'S S CONTRACTORS PROT EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
MED EXP (Anyone person) $
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT $
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
NON-OWNEDAUTOS (Peri acoidenl)RV $
PROPERTY DAMAGE $
GARAGE LIABILITY
AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS L ABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WORKER'S COMPENSATION AND WC3-00748160
1/01/QQ 0
1/01/D1 X TORY LIMITS ER
A EMPLOYERS'LIABILITY EL EACH ACCIDENT $
THE PROPRIETORI INCL
PARTNERSIEUECUTIVE EL DISEASE-POLICY LIMIT
OFFICERSARE: EXCL EL DISEASE-EA EMPLOYEE $ 1.000000
OTHER
CONTRACTORS LICENSE NUMBER-#756850
ALL CALIFORNIA OPERATIONS
,.•'T. d' IY. '1'I„',. ,. �.i�' I. tit s N 7 ty, fit. A.' rnrfi,,3 :7i
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL EkdtXMM MAIL
3Q DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
EVIDENCE OF INSURANCE �xac�xar>w�cacawtsttacxawxx��xaLwxaccxx
® )OX*A A*Mxxn x)wxxowxowxnwcxtte x)oxxat-xxacetxxc K
.._:.,.,. ... .,e,.i$.e 3 E. t{h o-..;'` t .1(..,.r'It..{"Y.r t ,ff GI',illl i� ?, hf ..L n'�''�s�t fi ,. Q ¢���•"vti-llt.,