03090118 CITY OF CUPIER'I'INO
BUILDING DIVISION PER? C01NTRAO-To it,INmRM N
BUILDING ADDRESS: SECURITY yROOFING AIR SYSTE ,RMITNo03090118
OWNERSNAME: 677 KINGS ROW PERMIT ISSUE DATE
CASA 00
E (408) 971-1777 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: n1JILDIN0 PERMIT INFO
BLDG ELF.Cf PLUMB MECH
0 0 0 0
+oo LICENSED CONTRACa'O,nom.mend, ICON
E u p 1 nereny arum that 1 am Iirensca rnepr pmviamna nil chapter v mnmmeapmg lob Description
;'aa win,snptinn nNN)h,rnmiaion3erthe nrsiners atm rremssa,na code,and my fiepnse is . .
ay
mmu rerpe dna Boren. +�� So 1oS°
ua s e up.n REROOF
n eI' -3T- - -cnmmc or ,
,Mn Dale
ARCHITECTS DECLARAT� p
f V 1 understand my plans ns shall M used as public rcmrJs r'h�J J f 2004
m Licensed P..mineral
a OWNER-BUILDER DECLARATION . .
1 herchy Mfirm'M1at 1 an,ccmnpt form the Crntraarrs Liters.Law for hire ,-
_p o (allowing reason.(Section 7031.5.Business and PrefIvAllas Code:Any ehy nil county t,
<m which requites a permit til construct,alter,improve,ecmelich,or repair any in uaure `- .�
�a> Pdonn its derarte.aLco requires the applicant for.such Permian file a signed statement
38
nEo that be is licensed pmaram to We mr.isirnsor the Cemreaors License Law(Chalue,9 Sq. Ft. Floor Area Valuation
2H (commencing with Section I0(10)nl'E;vision Sof Nc nuslncssvnd Pmrussi,ms Cadc)nr
$ mal he is emry therefrom dad the hams fill the alleged eramption.Anil inlatimi nil 32652008 . 00
Section 70311.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
nnl more Nan fisc hundred dollars(I
❑1,as owner of the property,or my employees with wages is their sole compensation,
will Jo the work,and the structure is not intended or offered person(See7w,nosiness J Ub —
and Professions Code:The Contrvaer's License Law docs nm apply to an owner or g��ttlr�d IOSPCCIIGDS
property who bunn,ds or improves thereoand who encs such work himself or through his 307 — INSUTAT"6y
own m dicyces,provided that such i mprovements are not intended or offered for side.If. 601 - ROOF TEAR OFF
however,the building lir int pavement is sold within one year of completion,the owner
builder will have the burden or proving that he did not build lir improve for propose or 602 - ROOF PLYWOOD NAIL
dale')' 603 - ROOF BATTENS
❑ Las owner of the properly,am exclusively contracting with licensed ennhdim's i-
mnseua does art p,l,belk4,naa, I andPmfcsaiens Cnar:)The 0ontraetr'. Li- 604 — ROOF IN—PROGRESS
rems.who reforms,Law atoms notch plr m an owner of ractorhr who nudes or ant to the Contra.dna
wMnseLw. for such projects with aenmm<ter(s)licensed pursuant the Commeror's
License Law.
❑ I am exempt under Sea ,11&P C for this..,in
Color Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
nand will maintain a Certificate of Conant to self-insure for Worker'sCempen-
os provided for by Section 3]W of the labor come.for the performance of the
work for which this permits unmet.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Code,for the performance of the work for which this pennil is)naiad.
My Worker's Cemmmsrom lasumnce carrier and Policy roamer at. 1'r/
Croner:__ KL IFi.�,�M�Policy No,: L5 )/'0y
CERTIFICATE OF EXCIAMON FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need am forma le¢J nine permit is torero hundred dollars(3IM)
in,Icxs.)
I county that In his performance of the work for which this permit is issued.1 shall not
employ any persor,in any morns,sn as to become sfored m the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,altar making Ord,Cant licam of F.acmptice,you ebnuld
become suhjcct to We Worker's Compensation provisions of the Labor Code,you must
0 forthwith comply with such provisions or this permit.shall he deemed revoked,
Z N CONSTRUCTION LENDING AGENCY
I barely affirm mal Were is a mnsweden lending agency rm the perrourancr or
1a ds work to,,which this parmh is issued(Sec.397,Civ.C.)
YQ Condo's Name
Z) z LenJcr's Address
0 1 ceuify that 1 have read this application and sate that the above Information is
1. P correct.1 agree to comply with all city and county ordinances and state laws relining to
U building construction,and hereby authorim minesorativei oldies city to enter upon the
shove-mcmidg a property for inspection purposes.
L CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
h in
equnce of ts,the coarsing expenses thismit. may inany way attruc against said City
J z APPLICANT
nap NDE granting STAN ollhiND WILL
Issued by: Date
'—' APPWCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATION
`f -01 Re-roofs
Signature odApplicantlContractor Dam
HAZARDOUS MATERIALS DISCLOSURE URE Type of Roof
Will Ceapplicanter future)pal Co e.Chapter
a 9.1 p,handle M1 Health
anmaterial
as defined io the Cnpertinn Municipal Cole Chapter 9.12,and tbp IleahM1 and Safely
Code,scedon 25532(an
X.0Y. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant lir future building occupant use pgrippr m or devices which If a roof is installed without first obtaining an inspection,I agree to remove
tacameas air mibrommnn as refined by'be Bay Area Air Qnalby Management all new materials for inspection.
elect,
❑Yes
Ihave mad the bvra,uo,,.m5505l2553ircmenlsunder 4.1,,Chapter 6.95 of We bidding
riakrmlhffi Safetyhe-r emontu sit x5yren,px5534,Iundrodyathsin,prorme
duce nm currently M1vvc a tenant,mait Is my rosponsl Mlily In nndfy hire r uncy. l rf Nc
rcyuircmcnm wny.mydt lip metpt;nr til ssranepnra cenireatepra pryy` AJ Signature of Applicant Date
owner eraw,rr�pa agent ❑p,e All roof coverings to be Class "B" or better
O
CITE' OF CUPERTINO
9 Di'm I2EROOF
• CUPERTINO PERMIT APPLICATION FORINT
APN# —3 .'2 _, 0 0 9 Date:
Cf`-/(o- 03
Building Address: /b r3 25� M
17
Owner's Name: Phone#:
CAS .Df 4a20 110A &o 5—
Contractor: Phone#: License#:
SouFl-;-r aF SS' s 97/ - /7-4 5020 ?D
Contact: Phone #: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
/" Built-Up RoofBuilt-Up roof
13Asphalt Shingles ❑ Asphalt Shingles
❑ Wood 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 Description: (�
� 4/k f0,)j'fW/
Residential ❑ Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with P113ping-Dept. if
there are any re tctions:
Co P 'ec C32-7 Type of Consl� Occupancy ou
Qty. if
A li Fee ID Fee Description Fee Group
BPERMFEE Bid Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING