05050125 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORhINFORMATION
euiLDING ADDRESS: WAGNER ROOFING CONTRACTORS 'MENO05050125
OWNER'S NAME: PERMIT ISSUE DATE
GIRT_ RA JARAM 12249 qARATC)(-ASjZZjY1ZA1
ONE: SANITARY NO. CONTIgOL NO.
8 777-8331
ARCHITECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION JobDesc
UF I bemby affirm that 1 am licensed under provisions of Chapmr 9(commcming
zj r� with Swrion]0(11))uf DivisionJof the Business and Prpfcuians COdf.and myliccnu is ���®
^ yin anfoneandercmy._zo 672AL� REROOF W/COMP. SHINGLES
j q Z License Class `�-'—�Lic.
i gi Date Contractor Q
n r-� ARCHITECTS
of
I understand my plans"I he mud as public ucsrdsis V
{7 C
Licensed Prufcuional 2005
05 OWNER-exempt ROECLARATION t'..1 q ry
0 I hereby maxo •(firm that I L exempt Item iPr Contractors Code:A n c law for tM IL l�
i 0 0 following massa.(Section](131.3,Business and ve.demolish,
e ons h, Any city or county 16h1+Hyq
Z v` which requires•permit to construct,alter,improve,h per i h,or repair any structure
prior to its issuance,alio n in due du applicant for such permit m file soLm,(summcm
EZo that(commencing
pursuant )ofDiviomnrtheCommaorandPimicaw(Chapmr9 $q.Ft. Floor Area Va Da n
1! that ba is exempt
Section7")Use
Dindiion3 themeged sscas aider,Any vi Code)or
- that he u ea1.3 b Oxmfrom and the buts fm the alleged ezempdon Any it Penalty
of
Section 7031.5 by any applicant for•permit subjects the applicant to a civil penalty of 3 tlJ M 0 Occupancy
not more than five hundred dollars(5500). panC y Type
❑1,uownmoftheproprrt mmyemployeswithwagesuthcusolecompensation,
will do Our work,and theswaure IS notimended or oRemd Tonal.(Sec.7014,Business
and Frofasdom Cade:The Contractors Lime law does nataOdy b an.,of Required Inspections
propeny he builds orimproms thereon,and w1bodoessuchwork himself or Ouough his
own employees.provided that such improvements are not intended oroffered formic.IL
however,lie building or improvement is cold within one year of complcuon,the owner-
builder will have du burden of proving thn he did not build or improve for puryose of
sada).
❑1,as Owuer of the property,not exclusively contracting wim licensed cantnctom to
construct the project(Sec.70,ti,Business and Prefcssiom Code:)The Commutes Li-
cense law does not apply m an owner of property who builds or improves theman,and
who contracts for such projects with a conuactai licensed pursuant to the Contractor,
License law.
❑1 am exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ace of the following dxlamdorm
I have and will nom uin a Certiea¢afConsent toself-insumfor WorkersCamper-
Ic-
ion,m provided for by Section 3]00 of the Labor Code,for the performance of the
d for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,u required by Section
W of the labor Code,for are performance Of the work for which this permit is issued.
y Worker ad Imypn¢cattier vndPolicymnabcjatyc.. r/nier. C;; Policy NO.: 12 t!? 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not hccomplctc(if the permit is far one hundred dollars(SIM)
sr leu.)
1 wooly that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner m as to bcoame Subject o the Workeri Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation Provisions of arc Later Codc,you mum
.JO forthwith comply with such provisions or this permit shall he deemed ranked.
z to CONSTRUCTION LENDING AGENCY
F_ 1 many aRrm that mere is a construction lending agency for do perfurmanccor
0:> the work fur which this pctmil is issued(Sec.3097,Co.C.)
{a) Lender's Namc '
=z Lenders Address
V Q I certify that 1 have read Nis application and sato that the above information is
LL F' conecL I agree to comply with all city and county minnows and sack laws reladng to
O V building cmuwction,and hereby autboa a representatives of this city to enter upon the
shove-mentioned propertycosts
for exinaion which mParins.
F y (Wc)agree to saw,indemmry and keep h,rmleu the City of Cupenum agsinst
rg liabilities.judgments,coining eapenunamil. may in any way acaue vgainitsaid City
C..3z in conscqucncc of the gaming of this pcnnil.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULAT S.
Srjsur rc of AppbcaDate u Re-roofs
HAZARDOUS
S MATERIALS DISCLOSURE Type of Roof
Will the applicant Or forum building occupant rare or handle Health and
u defined by the Cupertino Municipal Code.Chapter 9.12.and the"calm and S,fny
Cak.Sccuon 33532(¢)?
❑Yea ep.a - All roofs shall be inspected prior to any roofing material being installed.
72F1- Will dm applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it Ireardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
:4!t
❑Yes Nu1 have mad the ho,anlnus marialsseyuirements underChap or 6.95 ofthe Califon l nolth&rent(yCodc,Sadao aid it i my r spo 25531.1 indcrsuM le occa c buofthe ��o ��
nos currently hate s W'INc mal la i my Iespof.ccau c poa,r ce O stry. of me /�/l/1uimmcntsw hmu - mnpri nuisa cc oraCcrtificamorOccvnancyy' SI tureofApplicant Da
aathorirsG.,car All roof coverin to be Class'T or better
a
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEt�TINO
Building De artment
JOB ADDRESS: PERMIT#
l G/G -5, t cD R b o
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR `{/' FAX #
I am not using any subcontractors: osoZf/d�
Signa a bate
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
Owner/Contractor Signature Date
r
CITY OF CUPERTINO _o l ZS'
Zuz REROOF � S
•CUPEkTINO PERMIT APPLICATION FORM
APN # 2 / 2 >�rolo Date: z G�
Building Address: ��,
i
Owner's Name: / o� �<94 clRM Phone #: 777—L8-
7_f53 3 d/�
Contractor: Phone#: 7 77_ S33 License#: 2 9 Z F/
Contact: a V I Phone #: Cupertino Business License#:
W 7.77 -633
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles 4--Xsphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Numbee f existing coverings ❑ Provide I.C.B.O.Report#
;/ be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:;,ROM S ` ,_ �-6 ctM
Residential P]/ Commercial ❑ d _
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
q
Qty. if
Applicable 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
7 St
70. s-6