030901214
I
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CITY OF CUPERTINO
' BUILDING DIVISION Iti
.,CONTRACTOR INFORM ON 2.
BUILDING ADDRESS:
SECURITY ROOFING AIR SYSTE`"T"fb3090121
OWNER'S NAME:
CASA DE ANIZA T-TnA
677 KINGS ROW
PERMIT ISSUEDATE
09116/9,003
ONE..
(408)971-1777
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
lob DDSCTIpt1o0
1 hereby affirm that 1 am under provisions ors (n (commencing
IR.Ilt Code
With Section ]olNq of Divixion3of NC Rosiness antl Pmfcasinns Cole, and myliccnse is
'
Liccnlseclusnd cffec . 13 U. 0 01- r'
-
REROOF ��Rqtappp I1g'
Dale ContrnctOr�
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■ `YPa�®�
ARC TE- DECLARATION
Iundc .d my plans ¢hal Mus.J as public records
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AUG 2of7T
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Licensed Professional -
OWNER BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p�qa�
following reason. (Section 7131.5, Business and Professions Code: Any city Or .Only
RYVItlN
BUILDING
which requires a permit to construct, alter, improve, demolish, or mpair any slruclum
,
prior to its issuance. also recruits the applicant for such Permit to Cite a signed statement
that he is licensed pursuant in the pmvisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division 3 of the Bm[ness and Professions Code) or
that he is exempt Nome.. and the basis for the alleged exemption. Any vinlauon of
32652040.00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
- - -'
APN Number
Occu ane T, e_.
not more than five hundred dollars ($500).
P yTYP ----
❑ I, as owner of the ampcny, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered forsal.(S.C. 7044. Business—
and Professions Code: The Continuities License Law does not apply to an owner of
gg Inspections
property who builds or improves theredoe
on, and who s such work himself or through his
3 0 7 - INSULATngd
own employees, provided that such improvements arc not intended or offered for sale. If,
601 -ROOF TEAR OFF
however, the building or improvement is sold within one year of completion, the owner
bull,., will have doe burden of proving that he did nut Wild or improve for purpose of
602 -.. ROOF PLYWOOD NAIL
sale I
603 - ROOF BATTENS
❑ I, az owner of Ne property, exclusively contracting with licensed cenactors le
[]1.'
, Business The C.ntrazted, Li-
come
ProfessionsCoda:)or
o
604 — ROOF IN -PROGRESS
nae Law done an Owner of i impro
La doesnetapply and
apply m an owner.( progeny who
Com.n,
who raw, for such projects with occe.retort(s)IicenseJ pursuanuo Ne Conuactoh
r such sed pursuant the
_
License Law.
❑lam exempt antler Sec. ,B&PC for this reason
'
Owner Dam
WORKER'S COMPENSATION DECLARATION
Ihcreby affirm under penalty of perjury one of the following declarations:
-
�IhaveandwillmaintainaCeniO.teof Consent to set Narrate for Workers Compen-
,user, as provided for by Section 3780 of the labor Code. for the performance of the
.. -
workforwhichthispermitisissued.
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❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 or he tabor Code, for Ne performance.( the woec for which his permit is issued.
My Worker',alio Imo/ice carrier and Policy number am:
CartsC ier: � r LAD PC l icy No.: "L�j3 97 J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This motion need not he completed if the Mrmil is fm.nc hundred dollars (iIIXD
less.)
1 comfy Run. in the performance of the work for which (his permit is issued, 1 shall not
employ any person in any mannerso as to become Subject o the Workers' Compematlon
Laws of California. Dat.
Applicant
NOTICE TO APPLICANT: If, after making this Ccnlfmne of Exemption, you should
become subject to the Worker's Compensnion provisions of the Labor Code, you must
fonhwith comply with such provisions or this permit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a convection lending agency lot he perfurmance of
Ne work for which this permit is issued (Sec. 3097, Civ. C.)
Lendces Name
Lender's Address
1 Cureify that 1 have read this application and stoic that the shout information is
Correct. I agree to comply with all city and county ordinances and state laws relating to
building convection, and hemby authorize representatives of this City to enter upon the
a owe-mmtll.ned property for Inspection purposes.
(We) agree to save, iademni fy and keep harmless the City.( Cupertino against
liabilities, judgments, casts and expcnsca which may in any way accrue againsl.,aid City
in consequo.. of the granting of [his Permit.
APPLICANT UNDER NDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULAT '1 �.
lr
cib'
Re -roofs
Type of Roof
Signature of ApplicaAnod Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building stem or handle
az defined by the Cupeninn Municipal Code. Chapter 9.12. and the Health antl Safety
e. Chaps Health and
Code, Section 25532(a)?
❑Y., P1u
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 future building on upam use equipment or devices which
it hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
is.ict?
Ihave met thodc, addotis Sector25505,2553ls 3r.memsunderdermadthatorthe Califon
ria Health &Safcyy Code, Sectors25505,255333and25534.1 undcrsnuN
Jots Or ng
not currently haw a .marl, that it is my responsibility to nnlil'y IW occupant of the
caccupnt
mqulmm.ts which must xm to issuane. or a Certificateor Occupancy
Signature of Applicant Date
A
All roof coverings to be Class "B" or better
Owner oranthorkzedagent I — Dat'
0
CIN OF
CUPEkTINO
• 4>
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
a3 7 V2
APN # , �� ` 5- q,
— (D 1 v
Date: p 3
Building Address:
'
Owner's Name:
CD£AaZA �UR
C/4v
Phone #-pp/ v
Con tr ctor:
SicN I-,? a s 3� s
Phone #:
. 1 ' I - / 77 L
License #: i
-0,2_051D
Contact:
SSVI1\,Ll-1,
Phone #:
Cupertino Business License #:
BUILDING
7 TI -la-•i
Business License
BUILDING
Type of Roof Covering:
Existing:
Proposed:
Built -Up Roof
Built -Up roof
❑ Asphalt 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: 2
Residential ❑ Commercial ❑
Fire Zone: Yes ❑ No ❑
Confirmed with Planni if
there are an restric ' ns:
Cost of Proj t: Type of do Occupancy grou .
Aii,
Anntcable 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
6-1
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