03090123 - CITV.OF CU�VERTINO �'• =
suaolNcorvlsloN PERMI* CONTR?iCTbRINkORMA
BUILDING ADDRESS: SECURITY ROOFING AIR SYSTE RMITNO03090123
OWNER'S NAME: 677 KINGS ROW PERMIT ISSUE DATE
2003
HONE: (408) 971-1777 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BGS ELDER PLUOMB MEOCH
i8z LICENSED CONTRACTOR'S DECLARATION � C 4
fP I home,affirm that l am licensed under provisions or Cham e,9(mmmencing I Ypp�A J b Description
.zu5' with Section 700s))of Division 3 of the Business and Professions Code.and my license is tl
'q? in full force and effect.
License claaa_ '3� Lia.a_ .0_ S� REROOF PUG 004 .
t- Date Ceramicist' f�^3
RCHITECCS DECLARATION
E w U 1 understand my plana shall he used as public records
save Licensed Professional BUILDING '
M3 OWNER-BUILDER DECLARATION
<P 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
O D following reason.(Section 71101.5.Business and Professions Code:Any city or county
m e! which requires a permit to construct,alter,improve,demolish,or repairanystructure 86492
_zin Prior b,issu
issuance,also requires the applicant for such Permit a flc a signed statement
p5< that he is licensed pursuant to provisions of the Commuter's License Law(Chapter 9 Sq.Ft, Floor Area Valuation
yl-� (commencing with Section 70M)of Division 3 M the B mi ness and Profcssinns Code)or
$ that he is e¢mps therefrom and the basis for the alleged exemption.Any violation of 32652066 . 00
Seca.,ion epush,r y hny undred icanars($5 Permit subjccu the applicant a civil penalty of - APN Number OCCU anC C.-
not more Nan five hundred dollars a Per. '' "- --' -- -- p y"ITyp -
❑1,as owner of the property,or my employees with wages ss Ihch sole Compensation,
will do the work,and the structure is notinrended or offered for sale(Sec.7W,Business _ — ����
said Professions Code:The ConuLicense Law LiceLaw does not apply a as owner or AggTY�qFd Inspections
prop
er who builds or improves thereon.and who does such work himself or through his 3 07 - INSUL
own employees,provided that such improvements sre 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,
builder will have the burden of proving that he did not build or improve fur purpose of 6 02 - ROOF PLYWOOD NAIL
Rale.). 603 - ROOF BATTENS
1,as owner of Project
property,,Business exclusively Prfessi ns with licensed tuna tes'a to
cense La nhesjot aSec.o anwneoandrty who builds
Code:)Thevesthemr's Li 604 — ROOF IN-PROGRESS -
cense Law dws not apply to an owner of property wbe builds or improve Colton,and
when contracts for such projects with a comrecmr(s)licensed pursuant a the Contractors
License Lew.
❑ I am exempt under Sec. ,B&P C for this reason ,
Owner Date
WORKER'S COMPENSATIONDECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Cenifeae of Consent a sdGinsure for Worker'sCompen-
mian.Rs provided for by Section 37M of the Labor Code,for the performance or the
work for which this Permit is issued. ,
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Comnperoadioo In;Z;,,carricf and Policy numM^ra .
Cartier: S'l sa Y M✓re Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE _
(Thissoction need not M completed iflive Permit is for one hundred dollars(SIM)
air lcssJ
1 comfy that in the Fortiori of the work for which this permit is issued.I shall nut
employ any Person in any manner so as to become subject to lM Workers'Cnmiame ation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject la the Worker's Compensation previsions of the Labor Code,you must
Oforthwith comply with such provisions or this Permit shall be deemed rtvoked.
ti tiCONSTRUCTION LENDING AGENCY
I hereby affirm Nat there is a Conswction lending agency or the Performance of
x > the work for which this permit is issued(Sec.3097,Civ,C.)
A Lender's Name
Z Leder's nAddress
J Q I certify shat 1 have read this application and vatic that the above information is
,r building 1 agree to comply with all city and county oN;oared and staff laws relating e V
�O building-ncalmood ogand hereby amhop representatives a(this city to corer upon the
LU Reale-mc judgments,
udg tl property for inspection
es purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Real ra'q
in
equnce or the cuss and a(this csmit. may in any way acted against said City
J 7 A APPLICANT
of UNDERSTANDS
Df this permit.
APPLICANT UNDERSTAND�S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of Applicam/Contracl pate Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant sere or handle ovardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Yes
ww thd anplidant nr'r emubauthng ocdapmm asd ego;pmdm ar ddmas whmh 1 If a roof is installed without first obtaining an inspection,I agree to remove
4 havardnus air con.2nanu as defined by the Bay Arca Air Quality Management all new materials for inspection.
triCl?
❑Vis [4o
EvocrI have mail the hmardnus materials requirements under Chapter 6.95 ofthe Cahker Healthffi SafelyCode,Sections 25505.25533 and 25534.1 understood that ifthe buildings not currently have a term,that it is my responsibility to nnul'y y}nAe meupamoftheuiremcnw which mush menp' r elssuance arm cenificae otcupandySignature Of Applicant Date
oriul oraedagCTI Date IAll roof coverings to be Class "B" or better
0
CITY OF CUPERTINO 030 o Z
REROOF
• OF
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: Phone M.
C� Df q�zr; y>A (JOS 9/
Contra tor: Phone#: License#: i-b ZO �jC7
A x,77
Ph
Contact
one#: Cupertino Business License#:
:SSS • ,A-,/lLy1 7--I -l-�-.? ?-
Type of Roof Covering:
Existing: Proposed:
X 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:
Residential ❑ Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with P _pt. if
there are an strictions �pLJ
C st of o' C9' > Type of Cons Occupan gro
'f
ab Fee lD Fee Descri tion Fee Group
BPERMFEE 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
01 1
2,3r 66
OFFICE OF COUNTY ASSTSSOR '" SANTA C L A RA COUNTY , CALIFORNIA
AVENUE- - - - � e_ooK PAGE r
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NOTES : MAP SHOWS FIRST FLOOR ONLY - -
1GpSp J 6 DENOTES GARAGE LIVING AREA
L DENOTES MAIN LIVING AREA
F o_ 53 A �i S DENOTES INTERIOR STAIRWAY AREA
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- COMPILED IM 6010FORMA MCE Y ITN EEC.327
OF TME REVENUE ANO TAXATION CODE
- - EFFECTIVE DATE MARC" 1,1975
DWIGHT L. MATH IESEN-ASSESSOR
BUING UNIT O.I7 PARCEL
NOO f f I C E O F t COUNTY., ASSESSOR "' S A N T A 'C L A R A COUNTY , C iA L I FORN IA
2 2 O. M4�� - •I r * /'to b0 MgRY 8 0 0-f( PAG E
4 4 Q' y AV 1>y CD PIL IR . RYANLEWrFR}{�L,; 32E
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14 14 G DENOTES GARAGE LIVING AREA •as- -++ r e s
15 t L DENOTES MAIN LIVING AREA. - •4 s bgi, k - !
I 15 S DENOTES INTERIOR STAIRWAY AREA •ay 44 7 .7 -
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CASA DE ANZNPPROVED -C�
I�
condominiums IN ACCORDANCEY�ITHTHECti4
n y S r ntiT CODES AND ORDINANCES
CUPERTl%o
cel! ►ertino calif.
SIGNEU ecifications
Cat of pans and sP rt is
This ab at all times and
De
kept on fire )' I�
silver real estate a
any changes or;
lawful tc mak eidlis5rc aU011 r 1111 w
cu �ertino, calif. wlthsut w ,trrr..P
4 on same C G}'!:oiy Cupertino. al Q ', f1
noe as-rvao the buIr
ilding, laaand s0cificaUorrs I_ �T� fr p*} 6'� J >. JIt I C
The s
pin tbas P erm, r to.be ar. l# W I- 1 , iAlll� ; i nil
NDrbe held toR��t r l lbfitlill!II BARRANCA C I
a pro 1 otl't epi -- -
65
f 3TC 3 InLun .. lit
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any ° IIS
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CtFFIC
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PL-- l 5 3' v 2, _ SE Gt�V IA' I C
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F
'I �AIW
In
f
lo�i5 �00r9 MARY SIREETI
1 ' a
n;
ACIFIC
JTATEs
MANAGEMENT COMPANY.
2510 Stevens Creek Boulevard
San Jose,CA 95128
Fax:(408)885-9125
(409)R95-9160
September 15,2603
City of Cupertino
Re: Casa de Anza Homeowners Associs tion
Roof Work
Dear Sirs,
This letter serves as confirmation th it the Casa de Anza Board of Directors has awarded
Security Roofing Sarvicos the contract to pe d'o>m the roof work.
Please let us know if you have any c.uestious or treed additional information:
•
Sincerely.
Pacific States Management
S l a c: Coffee
s�ov -- --- ----- -- � Fes. - - -
SEP 1 g 2003
By;
Z0'LZ0 B9tld 1W9W S31ViS DIdIDVd GZT698880P VT:9t 800Z/BT/60
�j
CASA, DE ANZA
condoininfuins
L!L-r
M ,xy STX
cuperfillo Calif.
Vill
LU
Aver real estate
cupe r t ino, Calif.
409 255-1910
T71 I-
LdIt BARRANCA C Ul
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X� Ell
SEGOVIA, ICI
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