06050077 CITY OF CUPERTINO �g' ,
BUIL G DIVISION PERMIT t Nikkew R N "O, 'IATIf1 1
BUILDING ADDRESS: AL SEASONS ROOFING SERVI EEsn,"10.06050077
21979 OAKDELL PL
OWNER'S NAME: PERMIT ISSUE DATE
ROBERTSON ARTHUR D AND ANNE L1720 SMITH AVE 05/09/2006
SANITARY NO. CONTROL NO.
(408) 971-4455
ARCHrrECT/ GINEER: BUIWINO PERMITINFO
BLDG ELECT PLUMB MECH
0 . C= I=
i00 LICENSED CONTRACTOR'S DECLARATION lob Description
1 hereby affirm Nat 1 am Ikeved under provisions of Chaper 9(mmmcncing p
N Section RHKB a'DiNdon 3 of me Business and Professions Code,and my Ikeme is
a� ioall(aroeapDroREMOVE 1 LAYER SHAKE ROOF, INSTALL 36 SQUARES 7
Damn `° co»over OSB & INSTALL 50 YEAR COMP ROOF WEIGHT 3 . 6
s ARCHf1ELTSDEC RA IOt u JC,-"
I I understand my plans shall he used As public records
y
e G Licensed Professional
s OWNER exempt fi DECLARATION
1 berth,AIRnn on I am exempt from Ne Cunbacto o :Any c law for the
".0 following maw n. Parma i RD L3,Buu after,
land P,c.demolish.
Calc:Any mity or county
$�a which rtquiroa a permit re canvruc6 alma,hnpmste mmrmit i or repair any swnum
-z S^
prior bits issuance,also rtquima prft ows ns Or the Commer'3 Bkada=Jsaemmt
PP G Nat heislicensedpumuantbNeryovislomofNeConlracmrSUar,ml�w(LTapmr9 Sq.Ft.FtoorArea Valuat
(commendngwith Sadon7000)a(Division3of Ne Buunmss Pmfmiom Codo)o
a — mu he a exempt therefrom and the basis for the alkged esampdon.My vkhtian of ♦q�naw.�r/�,.rffl�yM� ERV /�
Session 7031.5 by any applicant for a permit subjects me applicant m a civil penalty of 3 L O 3 7 U U Y T 0 0 (/S\ Oy Type .
,rot a m than Rw hundred"Are DIM !'�+5
D1,uowerof Iliopmperry,mmyemployeewuhwagsutimkmkcmnpe Um.
will do the we&and the me=is rot banded or oRned for Ime(Sec.7044,Bviws Required Inspections
era Pmfavlma Code:The Conitanah Lia,sse Law dm rot apply b an osrm e of q p
e;� �a�"� �"°�� ' �� ;�Itow �' ded ; eMeOut nen �emn 1N 14 1006
however,the building or improwmam to mid wiWnarc year of mropleuan,Ne"Mr-
builder will Mw the burden of proving Nan he did rot build or impose for puryom of r[]{ �'ppf
❑1,as owner of Nsvi
e property,am exclusively contracting m licensed mnsacmn a
eovwathe es ML (Sec.7044,wner of and Pro wadov Code:)The Covheacon. fid
cave Law dao mos apply m he owner of property who builds or improve Nems^,and,
whoaa
c (orash projetyrenla
siaeactartgvm de
Ikeed purwame Contactors '
Licensermi Law.
❑Ion exemPs under See .Bd:PC fm Nia maven
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby•font under penury of perjury one of tiro fallowing declarations,
I be.and will maintain a Cenifiate of Covent to self-Wort far workers Campem
satire^,As provided far by Sermon 37W of de labor code.fa We perfamomem of the
wart for which this permit is luued.
❑1 have and will maintain Wolters Compensation In.Wrana,as required by Sam=
37W (me labor Case.for me pefirmaneeofme,weak for which Nu permit is Issued '
My Workers ComPausam frhtma,ne��^m MO Pole,num m M:
Carrier. �'r��'n �v 11Q Pdiry No.: 5rcIS
CERTIFICATE OF EXEMPTION FRO WORKERS
COMPENSA71ON INSURANCE
rrhlammm need rot be completed if me permit is two=hundood dollars(SIM)
or leu.)
1 anify Net in the performance of the were per which this permit is bound.I mail not
employ any penin in my man=r an as to become subject to the Worker'Compmssadan
Laws of Caliamia.Data
Applicant
NOTICE TO APPLICANT:IL no,making Na Cerdncaa of Exemption,you should
become object in the Workers Compensation provisions of the labor Cade you mss
.J z faMwim comply with such pm isiov or Na permit shall be domed revoked.
Z'r~�., CONSTRUCTION LENDING AGENCY
[.r 1herebyalfrn then Nem la a construction lending agency for dm performance of
cC> the work for which this permit is Issued(Sen.HNT,Civ.C.)
S Lenders we
]z lenders Address
til I oNfy that 1 have mW We AppliWion wm sum Nu the•bow infmmaliun B
Ds F corsom I agree to comply with all city and county on inmees and sate laws relating to
pU building construction,and hereby authorize mpm=nutisra of this city in enter upon me
W ahow-mentioned property for impaction pugmses
(We)agree to saw.indemnify and keeprm
halm the City of Cope
nina gai=t
IA Habilides.jueSmemameu and expenses which may ban,MYAterse agaimemid City
U Z LICANT UNDERSTANDS Aacence of the grunting of ND s permit.
APPLND WILL COMPLY WITH ALL NON-POINT Issued by: Date S: �L
SO R REGUL.gTONS.
Re-roofs
Signammaf Applia^VConummr Doc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII No applicant car forum Wilding aavpanlport ahandk hawtlov malarial
as relined by Um Cupertino Municipal Code,Chapter 9.12,and tiro Health and SafetyCam,section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya Ova
Will the applicant or future building ecmpam use equipment m device which If a roof is installed without first obtaining an inspection,I agree to remove
emir haxardnv air momenimna as defined by the Bay Area Air costly Management all new materials for inspection.
Dissict7 �/
❑Ya dlNu
Ihave mail the nvarddou,rn edals requirements underChapmr6.95 ofthe Califor•
tis HcalNh Safety Cod,Scedam 35515,25533and 25534.1 unmusand mulf tiro building
does WE currently haw•tenant met It 4 my responsibility b Audi,it.occupant of the
mqul mentawhich muss berm: car=aft Ccmncam of occupancy. Signature of Applicant Date
owner armmarired. em ,e All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
WUPEf�TINO
Building Department
JOB ADDRESS: Qkoye aS01y PERM�Qsd o 7�
OWNER'S NAME:A PHONE # Itog aO(o—a
GENERAL CONTRACTOR: FAX # _ 41-1
I am not using any subcontractor,.. how
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
2 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32639004 . 00
DATE ISSUED. . . . . . . : 05/09/2006
RECEIPT # . . . . . . . . . : 34320
REFERENCE ID # . . . : 06050077
SITE ADDRESS . . . . . : 21979 OAKDELL PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ROBERTSON ARTHUR D AND ANNE L
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : ALL SEASONS ROOFING
CONTRACTOR . . . . . . . : GORSHTEIN, VLADISLAV LIC # 21035
COMPANY . . . . . . . . . . : ALL SEASONS ROOFING SERVICES
ADDRESS . . . . . . . . . . : 1720 SMITH AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 971-4455
4tEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- --- ------- ---------- ---------- ----------
BPERMFEE VALUATION 4 , 000 . 00 104 . 76 0 . 00 104 . 76 0 . 00
BSEISMICRE VALUATION 3 , 600 . 00 0 . 50 0 . 00 0 . 50 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 105 . 26 0 . 00 105 . 26 0 . 00
•
CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# S2-L-Q , 3q — Date:
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Building Address:
oZ 0�1 O. a�
Owner's Name: Phone#:
( ,-kO�6
Contractor: License#:
A\\ S S DI-�k
Contact: Phone#:
C� sL-lofs ,�li k—Lg1SS
Applicant/Contractor: Fax#:
Building Permit Info:
Bldg f-e,( pcfc- Elect Plumb Mech
Job Descript'o, n: Je, \ \��
Residential: ommercial: CA ck,SS
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Goo
Type of Construction: Occupancy Group:
rec
Qty. if
A licable Fee ID Fee Description Fee Group
"BPERMFEE Bldg Permit Fees BUILIDNG
BENERGY Energy BUILIDNG
BSEISMICRE Seismic Fee Res BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
•