03090125 CITY OF CUPERTINO
BUILDING DIVISION
PERM TQ
C�) CR�iC12 INT!) M N s
BUILDING ADDRESS: SECURITY ROOFING AIR SYSTE ERMIT"°03090125
OWNER'S NAME: 677 KINGS ROW PERMIT ISSUE DATE
"Er (408) 971-1777 SANITARY NO. CONTROL NO.
ARCHITECI'IENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
C7
]00 LICENSED CONTRACTORS DECLARATION Job Description
1 hereby affirm that I em ftf licensed under provrt Ins of Chapter 9(commencing rnmuh, p
izZ . f Sect ]d iof Drnaon3of NC Businew lid Pr fcssusm CoJc,end my bccnx is .%
lir. a d rrcc, �•ptipo REROOF /
adz License Class Lic Contractor �r.�
FW Derc• DELL
££� AR HITECTS DECLARATION
1C IundcratanJ my plana shall he used as public rceoNs /
eyU ,^
yo1 Licensed ProfessionalV�
S OWNER-BUILDER DECLARATION
C<0 1 hereby.(Sero that 1 am exempt from Nc Contractor's fit License c Law for the _
p o which
farina arch I 7131.5,Business and Professions demolish,oe:Any tiny lir county
which requires a permit re mresthe,alcee ire for su hPermttor repair any structure
priuZY thathe tsennance,alsunLiolhuhovtsiocarrtfeCDnmctoi's Blesc signed hapictnt
6230
ESo than me(commencing
wJ pursuant mmc pm visions of Nc Comraemr'snd Pruf Law lChaper9 Sq. Ft. Floor Area ValllatlOn
2. (ce,he I. xempth Section and of Diad.f3nfineegednaand Pro An, C 1.1)
� That he is exempt mert(rom and da bazi.far the alleged exemption.Any violenion a( 32652075 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of . ane ccu APN Number OType
not mom than me hundred dollars(SSW). - Occupancy
1,as owner of the property,or my employees with wages as Nei,sale mmpensatinm,
will do the work,and the swcwn:is not intended or offered for sale(Sec.7W,Business .3 b FRAME
f and de:Th
Professions Coe Contactor'.License Law does not apply to an owner of — Re uired Inspections
properly who builds orimproves gumen,and who does such work himselfor through his 307 INSULATION
own employees,provided that such improvements are not intended oroRered formic.If, 6O1 — ROOF TEAR OFF
however,Ne 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 for puryox of 602 - ROOF PLYWOOD NAIL
salt.).
01,as owner or the property,am exclusively contacting with licensed contractors to 603 - ROOF BATTENS _
construct the project(Sec.]Osa,Business and Pra(essions Code:)The Contractor's Li. 604 — ROOF IN-PROGRESS
tense law it..not apply to en owner of property who build.or ire pmvea Chemo t.and
who contacts for such projects with a contmcnor(s)licensed pursuant to the Contractors
L'¢enae Law.
❑ I am exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
Ibercbyaflmtun der penalty of perjury one ofthe following declarations: ... .. ._ _
have and will maintain a CertiOcace of Consent to self-insum for Worker'sCumpen-
union,as provided for by Section 3700 of the Labor Cade,for the performance of the
work for which this permit is issued. ,
❑1 have and will maintain Workers Compensation Insurance,m required by Section
3700 of me Labor Code,for the performance of fee work for which this permit is issued.
My WmkerE mpensa'on lry40mnttcarier and Policy num her am;
Cartier._ 1 I&� Policy No.: Xu
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE .
(TMs scmirm need Out he completed Bribe permit is formic hundred dollars(91(10)
or less.)
1 certify that in the performance of the work for which oris permit is World,1 shall not
employ any person in any manner so as In become subject o the Worsera'Compensation
Laws of California.Dane
Applicant -
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject 1.the Worker's Compensation pmvi.ions of the Labor Code,you must '
Oforthwith comply with such prnvismas or this perm it shall be deemed revoked.
ti CONSTRUCTION LENDING AGENCY
1 hereby olTtm that mere is R coestuninn lending agency for the performance of
Ya > the work for which this pernin is issued(Sec.3097,Civ.C.)
Q Lenders Name
z Lender's Address
J Q 1 certify mat I have read this application and sate that Be above information is
Hcorrect.1 agree to comply with all city and county ordinances and stare laws relating to
V building construction,and hereby authorise rcpresenadws of his tiny to enter upon the
G above-mentioned property for inspection purposes.
y (We)agree to save,indemnify and keep harmless the City of Cupertino against
W liabilities,judgments,costs and expenses which may in any way accrue against said Cityin
J^
APPLICANT UNDERSTANDSof the counting of tAND WILL COMPLY WITH ALL NON-POINT Issued by: Date /
SOURCE REGULATIOJ&S as
If�•Y�rL''s "'a Re-roofs
Signature of Applicant or Dace
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will meepCu"t-tur future buildingoccupantstore lir handle Health
sd Safety as defined by the Cupertino Municipal Codc.Chapter 9.12,and the HcaIN and Safety
Code,Section 25532(.)7
❑Yes --Qo All roofs shall be inspected prior to any roofing material being installed.
' ,.y
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hovardaus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
"Lon"
❑Yes ms 25
Ihave mad me haaa,dous materials requirements under Chapter 6.95 of the Califor,
ties nIffi ote&Safety Cade,Secant, 255(15.25533Mid
po25534.1 to
Netrup buorme t( l
Jots not currently have a tenant.Nm it is my rcsponsihility,m nntily the ceeupant of me
requirements which moru�:irriltpd.,I.Isar anre ora CcnlrcRre or Occupancy. Signature of Applicant - Date
Owner u...therircd ii
r ( Dated All roof coverings to be Class "B" or better
CITY OF CUPERTINO
e REROOFCITY OF
"3
• CUPERTINO PERMIT APPLICATION FORM
APN# /3 r L(o S-,-L .,v-�L-�, Date: ?-/(v 0 3
Building Address: /b . � Q7
A
Owner's Name: 1 Phone#:
CA.4 Df ga2n �/r�A B6CDS 9/ !ov
Cont r tor: Phone#: License#:
77 �/C7
Nti;T (lF S � s 77/ - i7; `� .S
Contact: Phone#: Cupertino Business License#:
SCd< �GF �ILy;
Type of Roof Covering:
Existing: Proposed:
X Built-Up Roof Built-Up roof
LI 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:
134/k /evJ•T»-ll � t�
Residential ❑ Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are anrct o s: LJ
Colf o ybject: Type Co struc 'o Occup up:
49 �j
t
Qty. i
ApplaFee 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