03090116 CITY OF CUPERTINO �<
BUILDING DIVISION PERM* .
CONTRACTOR INFORMAWN.,
BUILDING ADDRESS: SECURITY ROOFING AIR SYSTE g'"ITND03090116
x-15—.nrtAnvATR # I
aER'S NAME: 677 KINGS ROW PERMIT Issue once
CARA OR AN7A 140A
NO.
PHONE: (408) 971-1777 SANITARY CONI ROIL NO.
ARCFIITEC'VENGINHER: BUILDING PERMIT INFO
BLDG ELECT PLUM❑ MECII
CJ O O O
]oa LICENSIiDCONTRACTOR'SDECLARATION b�I] nObDespription
LVF 1 hereby from but I am licensed under provisions of Chapter 9(commencing (,,4 `
eau with Se time 71X )hfDivision] fOe 'nets and Pmfessinnv Cole,and my license is
:may
or hill" y it effect �� j'O Lo TO REROOF
:�= Liecre.Rn e3 Lie.. MAY 1 ?
,' m Dale r ZOO.
cor
A 1117LCLARATION 4
4 a< �emlanA my plans shall he used as public recnNs /1 p
CQ Licensed Professors] Lj3U#&DO,'l'1` 0
OWNER-BUILDER DECLARATION O❑V
I herchy affirm that l am exempt frons the Commemr's License Law her the
M O following recoon.(Section 7031.5,Business and Professions Code:Any city or county
which requires a pennon,to comarun,alter,improve,demolish,or open,any.arunum
_2so Prior.its isenance.also requirestM1e applicant for such perm,to lilc asignedmatemem
< OuQu,is licensed purstantto We provisions of the Contractor.License Law(Chapter 9 Sq. Ft. Floor Area Valuation
21m (commencing with Section 700(buf Dividon 3of Wo❑usiness unit Pusfcoirms Coda)or
lost he is eacmpt loematm and the basis far he alleged counfoinn.Any vielmim,of 32652001 . 00
ane
Scene.7031.5 by any apphcam far apc.I,lflbjcmsme...hear,to a civil penally of APN Number Oecu T
not more than fisc handled dollars(S500).
P Y YPC
G•I,as owner of the property,or my employ ser With Wages aL their stile Compensation,
will do the walk,and the museum,is net intended or offered for salc(Sec.7044,Bust nese Required Inspections
and Professions Code:The Contractor's License Law does net apply m WCCDS an owner of q p
property Who builds or improves Wercon,and who docs such work himself or through his 307 — INSULATION
own employees,provided Wat..ch lmprovemems are am intended or offered(a,sale.If. 601 — ROOF TEAR OFF
however,We building or improvement is sold within one year of completion,We ownef-
huimor will have the burden of proving Wal he did not half Ill or improve for purpose of 602 - ROOF PLYWOOD NAIL
sale., 603 - ROOF BATTENS
❑ 1,as tweet of the(Srisal,am.
Business nexclusively conlranmg with:)cTheedomminu is to
Construct doesnnotaSec.town. ner(ifroprtywhiousdsoriTheo.stheeon,a 604 — ROOF IN—PROGRESS
cense Law etc f not apply to an nth a of properly who builds or improve.e Contras and
whp LOnlmek(llr such ptojECl[W ilh a Contractor(a)IICEnsEd pul.[Ilenl m IM1C CtnlraLlof 6
dwillonre Law
exempt under Sec. ,B&P C for(his mason
Dare
WORKERS COMPENSATION DECLARATION
I hereby off kinder penalty of pejury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insum for Wurker'sCumpcn-
work
work f a or which pmvttlthis
for by ScNan 37W of tM1e I�bnr Code,for the pertnrmance of the
for permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as acquired by Section
37DI1 of the Labor Code,for We performance of the work for which this permit is issued.
My Worker's Cnm,ylnsulinn Insymncc caeicr, and Policy nu Icrore:
Cartier: S''r'" t—N N� polity No.: �361
CERTIFICATE OF EXBMIbMN FROM WORKERS'
COMPENSATION INSURANCE
(This section need not d:completed note permit is for one hundred dollars(5100)
kir Icss.)
1 certify Our in the per❑emanc,of the work for which this permit is issued.I shall nut
employ any Drusen in any manners.u In,hecume subject m Rhe Winums'Cura,menlice
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.at making this Certificate of Exemption,you should
become subject to the Worker's Compc"sazfan provisions of the Labor Code,you mum
D O fotlbwdh comply with such provisions or this permit shall he deemed revoker.
CONSTRUCTION LENDING AGENCY
I thereby affirm that Were is a construction Imading agency Int the pcormormnc,of
Y. > Its work for which this perm,is issued(Sec.30'77,Civ,C.)
ALender's Name
z Lender's Address
p I crucify(hat I have read this application and true that the above information is
y F correct.1 agree to comply with all city and county ordinances and stave laws relating to
�U building conswclice,and botchy authorise representatives oflhis city to enter upon the
C above-mentioned property for inspection purposes.
y (We)agree to save,indemnify and keep harmless the City of Cupenine against
;j(q liabilities,judgments,costs and expenses which may many way accrue against said City
,Z in conwuchre of granting of Was permit.
I"^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGNS
Re-roofs
Signature of Applfeant/Conarsener Dale
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will We applicam m future building oweapant sI..or handle luamduus material
Ford by the CupeNnn Municipal Code,Chapter 9.12,and the Ilcalth and Safety
Section 25532(a)7
C]Y,s All roofs shall be inspected prior to any roofing material being installed.
❑Ye �u
Will the applicant of/future building becepaet use equipment or device.which If a roof is installed without first obtaining an inspection,I agree to remove
rums or,oulness air containment.as defined by the Bay Area Air Quality Management all new materials for inspection.
District? )
0Y. s.Q N,,
I have mad the hers dour mmerials requirements under Chapter 6.95 of the Cabfur
Ola licadh&SdeiyCodc,Socd.ns25505,25533and23534,Iunderswnd Outfit.building
taws not conemly have a tens".Nat it is my responsibility In unity the occupant of We
egmmmen`. napsnm m l�.ueneruoface 'III WtfoeToy v gnatureofApplicant ' Date
o ver o,mohm(i,ed agmn A� , All roof coverings to be Class "B" or better
0 0
CITE' OF CUPERTINO
..'' REROOF v
CUPERTINO PERMIT APPLICATION FORM
APN# OL/ ® I Date:
Building Address: //b"3
Owner's Name: Phone#s
C14S/4 D f 44)-2-0 Aotq Fo
Contractor: Phone #: License#: i
S�NuX;T aF S .s�S 97 7i ��� � S020Sv
Contact: Phone#: Cupertino Business License#:
SC617'?-1 —t
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 Mfg.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 Planni g-Dept. if
there are an rest ' ions: lJ /
Cost of t:, / Type of Construe o Occupancy gr p:
Qty. f
A tc 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
•