04060184 CITY OF CUPERTINO z%
BUILDING DIVISION PERMIT COIYTRAC'TORyINFURM&VON
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BUILDING ADDRESS: ROCKY LOWERLL PERMIT N004060184
10311 MANN DR
OWNER'S NAME: PERMITISSUE DATE
Alk ROCKY LOWERLL 2 04
ONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 I�
za0o LICENSED CONTRACTOR'S DECLARATION JbDescriP tion
z V 1 haffirm ereby airm No
al I am licensed under previsions of Chapter 9(commencing
a with Section 700E)of Divinon 7ofdm Business and Profession Coda.and my licensee
in fall tome and affect. REROO F
z License Claes 4e.M
Date Contractor
ARCHITECTS DECLARATION
I understand my plana shall he used of public meaNs
7yU
C Licensed Pndwianal
OWNER-BUILDER DECLARATION
0 I hereby mrso .mere o n I em exempt from to Cssime, o Licence City
o far to
E:00 fallowing recon.(Section IIDLS,Business and vis thoiun Cade:Any city car county
a�$ which magussu•permit m ennlNmL aluc improve,demolish.or repair any omctuha $2000
h,zya
prior to its issuance.Alan requires prevision of thusuch e Cosenomiuhrile aicense ned awoChument
that be encinwit Section
litho of Division offs nuaccarand erase L.w(C Code)
Sq.Ft. Floor Area Valuation
rc $
that
with Sccfore, 010)and
Division ofdeegedua pr Pmf Any
vi Chale)ur
Nat he b attempt terc(rom end to bole for du alleged cumptian,Any violation at
Section 7071.3 by any applicants for a permit subjects the applicant to a civil penalty of a Occupancy Type
not mom Nu Ove hundred dollars(00(y)
0 1.u owrcr of Me Property,or my cm,my= it wages u their sole mmpenutian,
willdoteworkandthesracnelsnhtimendedoraRemdfanale(Sec.7044,Bniuus \ -r
and Pmfessiun Code:The Controvert License Law does not apply to an owner of r---n ` Requaed Inspections
property who builds or improv thereon,and who door such work himself or trough his
own employ=,provided to such Improvements are mm intended or offered for s.Ie.If, f J ]_../
builder.the,Wildingtebrimpmwmmnla arhedidnaneWildofmprolehortohwner-
builder will have to burden of proving to he did not build or improve fm purpose of
sale.).
0 1,as owner of to property,am exclusively contracting with licensed rent acthss to
construct to project(Sec.7040,Bniow and Profusion Ccon:)The Chanteuses U.
cane low d=not apply to an owner of property who builds ar improve Mertre
on. d,
who contracts for such projects with aconmctor(s)licensed punmm in de Chnmcme,
I-Vense,Law.
x pt under e. ,B&PCrortisreeom Li I
Owns �ISIIII
Dau 1
WRATION
1 he by.ffrallowing declommon,
1 toward will reainuin aC.niMm of Consent toself-insam for WarkersCompen-
1031ODof
ion.a provided for by Section 37110 of IN,Isbor Code,for to performance of the
rk for which tis perm0 is ioued.
1 have and will main tai Workers Compensation Whounce,u requircd by Become
thelobo Code.for the pedormancc ofd=workfor which toFemi,is issued.
y Worker's Compensation Insraaunce rtier and Polity nmber arc:
rries Policy No.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This rosdon need not Ise completed if the perm,is for one hundreddollan(SIM)
or Iw.)
1 certify tet in t f on as o e wait for which tis fennit Is heated,I shall not
employ any pe ins tanner atm come subject to les arkcri Chmpensatian
Lava.(Cali
Applleant _(7
NOTICB TO P I NP.IL a feipg tit Certificate of Exemption,you should
becomes t ve he\ahem Cetp �aeon provisions of the Labor❑We you muss
.JO fortwitc mPlywit such prnvi'in.mirpeimiulmll he deemed hawked.
i7) CONSTRUCTION LENDING AGENCY
[ti I hemby affirm tat tete is a contraction lending agency for tiro performance of
C .�.r the work for which this permit is ismod(Sec.2i097.Civ.C.)
0 Leodces Name
n1. z Candela Addrce _—
(,)0 1 certify tat I have mad this application and shoo to to above information Is
Ur F certttl.l agree to comply with.11 city and coarmy orimmuc s and more law.relating to
O V building construction,and humby Buthorize representatives of Mi.city in cater open me
[n above-mentioned property for inspection purposes
Qr (We).gme to save.indemnify and keep harmless dm City of Cupertinoageina
In liabilities,judgments.costs and eapen=which may In any way accmc against said City
V^ AP nIjCADERM"OStAND WILL C MPLY WITH ALL NON-POINT Issued by: Da
Rno
`Z Z—0 Li Re-roofs
Sig tumof Appl' o tractor Dam
HAURDOUS MATERIALS DISCLOSURE Type of Roof
Will the cep karst or filum Wilding occuentstore or handle Innuendoes material
as defined by the Cupertino Municipal Code,Chapter 9.11,and to Health and Safety
'dowede.oYe,ssssz(a)7 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building receptor um equipment or dove=which If a roof is installed without first obtaining an inspection,I agree to remove
mit heurdous air conmminan s as defined by to Bay Am Air Quality Management w materials for inspection.
District?
O Yes H�
Ihave real tehverdnas T550alsrcqu and 255umdcrChapurdWe lite Wilding / ��
nie Hcal iks,hawm Ce de Scausaus50als reg7and15s under
Chapndtoifte Catlin-
=not curtc I haw a m..n Met it it my msponihiliry to notify tie aavpant of de
quircmcros chmuobe tpdormiuu.ncc of CcniOcam h(Occupwmy. Sig attire Of App net Date
Z !J
Ownrmr.uh. ; d net D.m All roof coverings to be Class "B"or better
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# ,?2— OI Dat
Building Addres$
0 311 l/►�c{h h
er's Name: Phone#:
C a IO :- Phone#: License #:
tact: Phone#: Ll oCupertino Business License#:
9 3 0 —�7
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
�l(Jpe''ksphalt Shingles .-.a—Asphalt Shingles
ood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ 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 Comply With Cu ertino's Tear Off Policy:
Job Des on:
OO�
Residenti Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning_De t. if
there are any restr' ons:
Cost of Project: Type of Cons c ' n: Occupancy gr
o
U
Qty.
A c le 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
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