08060106 7 7
CITY OF CUPERTINO > �at*�+,�r.�,gq ,+f.. t� �7W17- 1 ♦v '^'+-1,BUILDING DIVISION PERMIT ix�r�lliRAC'I'()RINFUS1VIr1TIONe�
BUIIDINGA DRESS: PERMITNO.
78 14C CLELLAN RD PRINCIPLE ROOFING & 08060106
OWNER'S NAME: PERMIT ISSUE DATE
V 7:VEK KOLLA 10160 STERN AVE 06/16/2008
NE: SANITARY NO. CONTROL NO.
(408) 898-7298
ARCHITECTIENGINEER: BUILI)ING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTORS DECLARATION Job Description
Ig� 1 bereby affirm that 1 iso li¢rvcd under provisions of Captor 9(mmmcminy P
with Section 70(10)of Division 3 of the Busireasaa,td Proresions Code,and my license is RE-RF RMV EXTNG WDSHK& INSTL OSBSHTHNG&
nZN in full forte and yecf _
5q_ evcclaaa ue.P 40CMPSHNGL
y,p Dato ARCHTIECI'S�E�CIAaAn CLS A 265Q
`Y 7W 1 mMuuand my plans shall be used as public recnNs
,yU
e G� Licsncd Professional
i5 OWNER-BUILDER DECLARATION
i f 1 W mhy afrrsu that 1 am exempt from the Conaactor's License law for fti.a O fallowing reason.(Section 7031.5,Business and Pmfcsaiuns Cods:Any city or only
$ which mquima•permit to construct.altos.improve,demolish.nr opal,any metum
Zy priorio its issuamc.also mcf.mas theapplicant fursuch permitue file a signed sulemcnt
s< Sq.Ft. Floor Area Valuation
that he is liecosed punuam to the provisional,of the Conmcmrs Uccom law(Chaptor9
yh (commencingwithSection70(0)of nsam
Division3oftheBusinsdProfusionsCade)m $8400
e 5$— that W u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type
W,more Wan five hundred dollen ISM 3 5 9 03 0 03 .'°�
0 1,u owner of the property,or my employees with wages a Weir suis compensation,
will the the weakand thiat octum Is not intended or offered foo sale(Sec.70-4,Busiws
and ProfetiON Code The Cm domme.LiPJLY Law it.nal apply in an ow0ce of Required Inspections
ourpropertywed Wihsuriroprovea Nunn,aM weddmssuN wmkhimrSlmduouN hu
however.the buiprovidedthatpmhimpmold wi amrm earndedmoBued(orale ,-
however.We building m improvement b sold within or you of hormontian,the owns-
builder velli have We burden of proving that W did w,build m improve for purpose of
OIC.).
0 1.as..of the property.am ntlmivcly conuscting with licensed mnuxtnn W
construct the pmjeu(Sec.70,14.Business and Professions Code:)Ta Contractor's Li-
mnos law does not apply man owner of property who builds or improv Norton,and
who contractor for such projects with a rnntractor(s)licensed pursuant in We Contractor's
License Law.
0 l am tempt under See ,B At P C 11"13 mason
Owner Date
WORKERS COMPENSATION DECLARATION
ON
amby affam under penaltY of Kd0 arc of the following decal om:
0 1 have and will for by
•Certificate of Consent W Crude.
tfor Workch ce of um
sedan,r provided for mi Saban 3700 of the V Wr Code.for the Performance of the
woh for which this permit ts iaued.
0 I have and will maintain Woraces Compensation Insurance,as me uiacd by Section
3700 of We Mbar Code.for the amforsuancc of the wort for which this permit is ismed. '
My Worker's o pensauoa Worur�ame nariv and Policy number are:
Policy No.:f Oe'<wlGfti-2lid.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
fflds section nerd not W completed if the permit is forme nonmed drat.(SIM)
or lass)
1 caadry,the,in We performance of the work for which*is permit is imued,l mall not _
employ anyperson in any summer an u co beeon a subject to the Workerf Compertsation
Laws of Califamie.Date
Applicant
NOTICE TO APPLICANT:11.after making this Certificate of Exemption.you Would
become subject W the Worker's Compemolion provisions of We Labor Code.you most
.,O foMwith comply with such provisions or this permit hall W doomed rooked.
z CONSTRUCTIONLENDINGAGENCY
1•y� 1hereby-frim Want then is a construction lending agency for the poduemance of
f1i We work for which this permit Is issued(Sec.3097,Ci,C.)
1 0 Indees Name
7 z LuMer's Address
J Q 1 comfy that 1 have mad this applleuion and mute this to above information is
Iy F comm.I egme to comply with JI city and county ordinances end same laws relating in 1
WWilding construction,aM hereby authorim reposenortives of this city to cover upon the
-IWVC-mentioned property for inspection purposes
�" fY
(Wo)agme to save,indemnify and keep harrelm the City of Cupertino against
N liabilities,judgments.costs and expenses which may in any way accrue against said City
Use inconsequence or the grand,of Wis permit. /
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S * Dale
SOUR EGUUTIONS.
�
Srgnum uof ApplicaD
rORe-roofs
HAZARDOUS
pato
HAZARDOUS MATERIA um'somIDSURE Type of Roof
Wits the applicant err fumes building aavpapt nom maedle Health
amotorial
m de.Sed io tie Cupertino Muhl Cadc.CMpver 9.I2.and We Healed-nd Safety
Code, CY.35332(a)? / All roofs shall be inspected prior to any roofing material being installed.
40 ❑Yes ONO
Will the, ream or future Wilding ams ant me equipment If a roof is installed without first obtainingan inspection,I agree to remove
pp g p q pmcnt or mvim Management
Pe
Dirt ho>ardnm car contsminanned by We Bay Area Air Quality Mamgcmrnt all new materials for inspection.
Districn P
❑Yes Nu
I bare mal the asardommamriab mquimmcros mulm Capter6.95ofthe Clilifer-
msHcalthhSafmy,Ccdc,SccWns 25505,25533 and25534.1 undesmand thuif Nc Wilding
dots not currently arc a term,that it is my responsibility W notify sive occupant of the
mriuitswhh WMLprior WimameofaCertirtoateofDceupmoy. Signature of Applicant Date
06/
Ownermamhonzed agent DamAll roof coverings to be Class'W'or better
'
CITY OF CUPERTINO
• 2 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35903003 . 00
DATE ISSUED. . . . . . . : 061/16/2008
RECEIPT # . . . . . . . . . : BS000005116.
REFERENCE ID # . . . : 08060106
SITE ADDRESS . . . . . : 7844 MC CLELLAN RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . .
OWNER . . . . . . . . . . . . .. VIVEK KOLLA
ADDRESS . . . . . . . . . . : 7844 MC CLELLAN RD
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4221
RECEIVED FROM . . . . : DERECK LOI
CONTRACTOR . . . . . . . : DERECK LOI LIC # 27564
COMPANY . . . . . . . . . . : PRINCIPLE ROOFING &
ADDRESS 10160 STERN AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . : (408) 898-7298
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
------ --------- -------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 8, 400 . 00 _ 0 . 90 0 . 00 0 . 90 0 . 00
1REROOFRES SQ FEET 26 . 00 338°. 00 0 . 00 338 . 00 0 . 00
----------- ---------- ---------- ----------
TOTAL PERMIT 338 . 90 0 . 00 338 . 90 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 677 . 70 MC
---------------
TOTAL RECEIPT 677 . 70
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
•
CITY OF CUPERTINO
REROOF
Y OF r
CUPEkTINO PERMIT APPLICATION
APN # ��� 3 6
Building Address: MG eLeLlo�
Owner's Name: Phone #:
✓iy�K ko�G4 � �'r�l6�i 2--
Contractor:
Contractor: by �u ¢ Phone #. tfoe y) ye7,y — , z2
Fax #:
Cupertino Business License #: Contractor License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ t-Up roof
❑ Asphalt Shingles e Asphalt Shingles
• d 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.
Job Description: ,,y� Gc,Yly-evlf ofg
4 26�
Residential Commercial
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the there are any restrictions: ❑
application or if applicable, include in plan
set & the sheet index.
Valuation:
$, 4ocz
• I Have Read, Understand and Will Comply with.Cupertino's Tear-Off Policy:
Signature
CITY OF CUPERTINO
REROOF
CITY OF
CUPERTINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1RER00FC0M Re-roof Commercial B 1COMMLROOF
IBSEISMICO Seismic Commercial B
Zd 1RER00FRES Re-roof Residential B 1SFDWLROOF
1BSEISMICRE Seismic Residential B
1RER00FMRES Re-roof Multi-Family B 1MFDWLROOF
1BSEISMICRE Seismic Residential B
1BUSLIC Business License B
•
• J
i Community Development Department
Building Division
City of Cupertino
• 10300 Torre Avenue
Telephone: (408)777-3228
Fax: (408) 777-3333
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance,you must agree to comply with 1997 UBC Standards
and manufacturers specifications on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City, the following steps are
required:
1) Pre-inspection and/or tear off approval.
2) h1-progress inspection approval.
3) Final inspection approval.
a) Spark arrester installation.
• 5. If plywood is installed, a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled
IMPORTANT:
1. Flat roofs must have a minimum of 1/4" per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: VJ VC/L_ ke—I"
Job Site Address: '7�'IY-
Roofing Company Name: �/I<t7y C
Applicant's Signature: — Date:_4*z j14
• Greg Casteel
Building Official
Revised 11/2/04
Green Building Plan Check
Index of Green Building Points/Categories
A. Category Example of an Index or Table of Green Plan Sheet or Page Points
Building Points Categories that must be
shown and referenced on the Project
Plans See below
4• e�
B. Site 9. Install H.E. Irrigation, (details/spec)' L-1 2 points
11. Permeable Paving, Nate L-1 2 points
C. Foundation 1. Use 15 % Flyash Concrete, (note) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) 5-2 2 points
6. B. OSB Sheathing, detail S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spec.) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec. A4 2 points
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11. A 2500 Gal. Tank, (Note/Spec L-1 10 points
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (Note/Spec.) A-3 1 point
3. Energy Star Refrigerator, (Note/Spec. A-3 1 Doint
P. Other 1. List Green Features on Plans A-1 1 point
EWE-IMMENW, TOTAL POINTS 40 points
P]
QUO
161008
•
Plan Review Process Work Book Page-12-Revised 3/25/08
Green Points Rating System for Remodeling Projects
• Due to the diversity of remodeling project types,assigning a"total points"value to a project to be considered environmentally friendly is
not feasible.However,25 measures have been highlighted to signify that every effort should be made to incorporate them into your
projects. These items have been chosen based upon their impact on the environment and the health of the home in coordination with
ease of implementation and relative low cost. These measures can be used as a starting point for'greening'your project.
A.Site
1.Recycle Job Site Construction&Demolition Waste
65°�-1 poink 75°h= 2 points;60%=4 points up to 4 Resource pts 0
2.Salvage Reusable Building Materials J 4 Resource pts y=yes 0
3.Remodel for Mixed Use,Adaptive Reuse,and
Historic Preservation 4 Resource pts y=yes 0
4,Protect Native Soil 2 Resource pts y=yes 0
5.Minimize Disruption of Existing Plants&Trees 1 Resource pt y=yes 0
6.Implement Construction Site Stormwater Practices 2 Resource pts y=yes 0
7.Protect Water Quality with Landscape Design _ 2 Resource pts y--yes 0
8.Design Resource-Efficient Landscapes and Gardens _ 4 Resource pts y=yes 0
9.Reuse Materials/Use Recycled Content Materials
for Landscape Areas 2 Resource pts Y=Yes 0
10.Install High-Efficiency Irrigation Systems 2 Resource pts y=yes 0
11.Provide for On-Site Water Catchment/Retention 2 Resource pts y=yes 1 0
B.Foundation
• 1.Incorporate Recycled Flyash in Concrete
25%Recycled Flyash=2 points;Add 1 point for every 10%
increase of flyash,up to 5 points up to 5 Resource pts 0
2.Use Recycled Content Aggregate 2 Resource pts y=yes 0
3.Insulate Foundation/Slab before backfill 3 Energy pts y=yesF--:: 0
1
C.Structural Frame 1 1
1.Substitute Solid Sawn Lumber with Engineered Lumber_� 3 Resource pts y=yes 0
2.Use FSC Certified Wood for framing
(For every 10%of FSC lumber used=2 points,up to 10) up to 10 Resource pts. 0
3.Use Wood I-Joists for Floors and Ceilings 2 Resource pts y=yes 0
4.Use Web Floor Trusses 2 Resource pts y=yes 0
5.Design Energy Heels on Trusses 6'or more 2 Energy pts Y--yes 0
6,Use Finger-Jointed Studs for Vertical Applications 2 Resource pts y=yes 0
7.Use Engineered Studs for Vertical Applications 2 Resource pts y--yes 0
B.Use Recycled Content Steel Studs for Interior Framing 2 Resource pts y=yes 0
9.Use Structural Insulated Panels(SIPs)
a.Floors 3 Energy pts y=yes 0
b.Wall 3 Energy pts y=yes 0
c.Roof 3 Energy pts y=yes 0
10.Apply Advanced Framing Techniques 4 Resource pts y=yes 0
11.Use Reclaimed Lumber for Non Structural Applications 3 Resource pts y=yes 0
IfUse0Sl3 __ —_
• a.Subfloors 1 Resource pt y=yes 0
b.Sheathing
1Resource pt y=yes p
1 1 1
INPUT Resources Ener_qy (ADIHealth
0. xterior Finis
1 Use Sustainable becking Materials •
a.Recycled content 3.Resource pts y=yes 0
b.FSC Certified Wood 3 Resource pts y--yes 0
2.Use Treated Wood That Does Not Contain Chromium/Arsenic 1 IAQ/Heafth of y--yes 0
3.Install House Wrap under Siding 1 IAQ/Health pt y=yes 0
4.Use Fiber-Cement Siding Materials 1 Resource pt y=yes 0
E.Plumbing
F1.Install Water Heater Jacket 1 Energy pt y=yes 0
2.Insulate Hot and Cold Water Pipes 2 Energy pts y--yes 0
3.Retrofit all Faucets and Showerheads with Flow Reducers
a.Faucets(1 point each,up to 2 points) Up to 2 Resource pts. 0
b.Showerheads(1 point each,up to 2 points) Up to 2 Resource pts. 0
4.Replace Toilest with Ultra-Low Flush Toilets
(1 point each,up to 3 points) _ I Up to 3 Resource pts. 0
5.Install Chlorine Filter on Showerhead 1 IAQ/Health pt y=yes 0
6.Convert Gas to Tankless Water Heater 4 Energy pts Y--yes 0
7.Install Water Filtration Units at Faucets
(2 points each,up to 4 points) Up to 4 IAQ/Health pts. 0
8.Install On-Demand Hot Water Circulation Pump 4 Resource pts y=yes 0
r.uecmcar -
I.Install Compact Fluorescent Light Bulbs(CFLs)
(6 bulbs=2 points,10 bulbs=3 points,12 bulbs=4 points) J, Up to 4 Energy pts. 0 •
2.Install IC-AT Recessed Fixtures with CFLs(1 point each,up to
5 points) Up to 5 Energy pts. 0
3.Install Lighting Controls(1 point per fixture,up to 4 points) Up to 4 Energy pts. 0
4.Install High Efficiency Ceiling Fans with CFLs
(1 point each,up to 4 points) Up to 4 Energy pts. 0
1 1 1
G.Appliances
(1.Install Energy Star Dishwasher i 1 Energy pt y=yes 0
2.Install Washing Machine with Water and Energy
Conservation Features 1 Energy pt y=yes 0
3.Install Energy Star Refrigerator 1 Energy pt y=yes 0
4.Install Built-In Recycling Center 3 Resource pts y=yes 0
1 1 I
H.Insulation
1.Upgrade Insulation to Exceed Title 24 Requirements
a.Walls 2 Energy pis y=yes 0
b.Ceilings 2 Energy pts y=yes 0
2,Install Floor Insulation over Crawl Space 4 Energy pts y=yes 0
(3.1 stall Recycled-Content,Fiberglass Insulation with
No Added Formaldehyde _ _ J 31AOlHealth pts y=yes 0
----
4.Usa Advanced Infiltration Reduction Practices 2 Energy pts y=yas o
5.Use Cellulose Insulation
a.Walls 4 Resource ptsy=yas 0 •
b.Ceilings 4 Resource pts y=yes 0
6.Alternative Insulation Products(Cotton,spray-foam)
a.Walls - 4 Resource pts y=yes 0
o.Cemngs 4 Resource pts y=yes 0
• Windows
• 1.Install Energy-Efficient Windows I
a.Double-Panedi 1 Energy pt y=yes 0
b.Low-Emissivity(Low-E) 2 Energy pts y--yes 0
c.Low.Conductivity Frames i 2 Energy pts y=yes 0
2.Install Low Heat Transmission Glazing 1 Energy pt y=yes D
1 1 t
J.Heating Ventilation and Air Conditioning
1.Use Dud Mastic on All Duct Joints 2 Energy pts y--yes 0
2.Install Ductwork within Conditioned Space 3 Energy pts y=yes 0
3.Vent Range Hood to the Outside 1 IAQ/HeaRh pt y=yes 0
4.Clean all Duds Before Occupancy 2 IAQ/Health pts y=yes 7 0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy pt y--yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
S.Install Sealed Combustion Units
a.Furnaces 3 IAO/Health pts y=yes 0
b.(Nater Heaters 3 IAQ/Health pts y=yes c
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEER/11 EER or higher AC with a TXV 3 Energy pts y=yes 0
_._. 11.Install AC with Non_HCFC Refrigerants 2 Resource pts y=yes D
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes 0
• 13.Retrofit Wood Burning Fireplaces
a.Install EPA certified wood stoveslmserts 1 IAD/Health pt y=yes 0
b. Install/Replace Dampers 1 Energy pt Y--yes0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15,Install High Efficiency Filter 41AQ/Health pts y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y--yesp
1 1 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts Y--yes p
2.Install Solar Water Heating System 10 Energy pts y=yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts y=yes 0
4,Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=18 points) Up to 18 Energy pts 0
6.SSefect Safe and Durable Roofing Materials _ y 1 Resource t
� --- -- P Y=Yes tttt
7.Install Radiant Barrier 3 Energy pts y=yes
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts y=yes 2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts y=yes 3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes
n oor Air Qua ity and Finishes
r.Use LowMo-VOC Paint r 1 IAQ/Health pts y=yes 0 •
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts pyes 0
L:use Low/No VOC'Adhesives _ ,-_ 31AQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 6lAQ/Health pts y--yes 0
6.Use Fxtedor Grade Plywood for Interior Uses 1 IAQ/Health pts y--yes D
7.Seal all Exposed Particleboard or MDF v 41AQ/Health pts yy as 0
6.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes D
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapidly Renawable Flooring Materials .� 4 Resource pis mes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes D
4.Install Natural Linoleum'in Place of Vinyl 5 IAQ/Health pis yges 0
S.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VDCs 4 Resource pts y=yes 0
Total Points AEEE1 1401 1301 57 .
Total Points Project Received: 0 .0 D
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•
r - Community Development
J 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
WUPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: l// l/G—C BGG A PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
411
r
Owner/Contractor Signature Date