03110097�jBu1LDINC DIVISION PERMIT
ARCHITECT/ENGINEER:
I hereby affirm That 1 am licensed under provisions
with Sentan 78TH)) of Division 3 of the Business-aProfess
in full License Cla ofgTf fcM q �(/�CI v
infall rcas/ - ' .-1 / Litt.
my plans shall IN used as public record+
Licensed Pmfcssinnel
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7f 131.5, Business and Professinns Code: Any city or county
which requires a permit to construct, altar, improve, dcmuleh, or repair any strucmm
prior in its issuance, atsu requires the applicant forsuch Permit o fie a signed sfatmar nl
that he is licensed pursuant In Re provisions of Ne Contractor's Licenac law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Cedcl or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7831.5 by any applicant for a permit subjects Ne applicant to a civil penalty of
not more Nan rive hundred dollars ($508). ' -
I,ssownerof the propcn, or my employees with wages as their sole marmadon,
will do the work, and the sweure Is nm intended of offered for sale (Sec. 7044, Business
and Professions Cure: The Contractors Liceva law docs not apply to an owner of
property who builds or Improves themon.and whodoeswch work himselfor through hu
Own employees, provided that such improvements are not intended oraRemad for are. IT.
however. Ne Wilding Or improvement is sold within ON year Of completion, Ne +writ:
builder will hare the burden of proving that he did not Wild or improve for pumo�gf
sale.). /
❑ 1, as owner of the property, am exclusively contracting
construct the project (Sec. 7044, Business and Pmfaaians
can= law does not apply to an owner of property who but
License Law.
❑ lamexemptunder See, ,B&PCfor0Hsmson
We,
Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations
0 I hew and will maintain a CeniOcam of Consent to self-tosure for Workers Compere
senors, u provided far by Salton 37M of dee IaWr Code, for the performance of the
work for which this Permit t+ issued.
❑ 1 Mw and will maintain worker's Compensation Insurance, as required by Section
37W of the labor Code, far the pe fmor.rem of the work for which this rennin is issued.
My Workcr�ampenutimllnsunnce 4mtcr and Policy numbgf
mOr section used not he completed if IN Permit is for one hundred dollars (SIM)
or Ices)
1 certify Nn in the pmro mance of the work for which this Permit is issued, )shall not
employ any Person in any manner so as to became subject In IN Workeri Compensation
Laws of California. Dale
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become object m the Workcri Compcmadon previsions of the Labor Code, you most
Oforthwith comply with such Provisions of this permit+hall W deemed revoked.
ti N CONSTRUCTION LENDING AGENCY
1 hereby affirm Nal there Is a construction lending agency Ire she performance of
x > the work fur which this permit is Issued (Sec. 3097, Civ. C.)
4 QLenders Name
a. %r Lenders Address
:) Q I cenify Nat 1 have read this application and Sulo that de above infmmatiun is
y F correct. I agree to comply with all city and county ordinances and state laws minting to
�rJ building construction, and hereby aohorim represenmihmS of this city to enter upon the
N WU above-mentioned property for inspection purpeaes.
(We-) agree to save. Indemnify and keep harmless the City Of Cupertino against
�VLI, liabilities.jjodgments, costs and a pensee which may to any way same against said City
in
of IN grami OR of
J ^ APPLICAbri'cUNDERSTANDS AND
Iirs rWILL COMPLY WITH ALL NET! -POINT
H ,RDOUS MATERIALS DISCLOSURE
Will Ne appli a orfmure Wilding Occupant store of handle harallous mistrial
ed by the Cu Inn Municipal Code. Chapter 9.12, and she Health and Safety
lection 25532(.)?
❑Ye-+ )(INu
Will the applicant or future building occupanl use equipment or devices which
4ardous air conlaminenu defined by the Bay Area Air Quality Management
?
n Yes Nu
Secuons U50S. 25533 and 25534,1 understand that if the Wilding
tenant. Not it is my resporeti hil ity an notify the weapon, of the
be me,poor to issuance of a Cerdficam of GGcuIumY —
TEO'S ROOFING
"t""' `03 110097
PERMIT ISSUE DATE
Job Description
REROOF
REPLACE SHAKE W/40YR ELK.
35919030.00
Required Inspections
i
Issued by:
Re -roofs
Type of Roof
Date ` �,
CONTROL NO.
100
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
all new materia for inspection.
Signature of Applicant ate
AI roof coverings to be Class "B" or better
C
0 CUPEkTINO
n
r
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
X3//097
APN #
b
Date:
Build'ngAddress:
Energy
7 __I L
/ BSEISMICRE
Owner'
BUILDING
# 7
Seismic Commercial
BUILDING
BPLANCHK
Contractor:
Phone #:
License #:
Business License
BUILDING
Contact:
�cc
Phone #:
Cupertino Business License #:
68.-gyg�ds��
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
❑ Asphalt Shingles�3'
Asphalt Shingles
qL Wood Shakes
_a Wood Shakes
❑ Wood Shingles
13 Other
❑ Wood Shingles /'// (i
` 0
(Specify) 13 Other (Specify)
Number of existing coverings ❑ Provide I.C.B.O. Report #
\To be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will_Co!!!AWith Cupertino's Tear Off Policy:
Job Descriptio
Twr es k C�_ ke
_
V S,t ( Y z k-4- 4 OYLAA I
Residential
Commercial ❑
EirEZone: Yes ❑ No ❑ Confirmed with Planning e
there are any restricti s:
Prcject:
M10,
T� of Cgnstnuctio� —� ccupancy gro16�0
���' �d
Qty. if
An�l'icable Frr m
FPP r1PCnT�n},nn
X
BPERMFEE
I 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