04060192 CITY OF COPERTINO �.Ip ,3. . ia � � �
BUILDING DIVISION PERMIT , , . h
BUILDING ADDRESS: PERMIT N004060192
PERMITLSSOEDATE
OWNER'S NAME:
NICK PERROTTO
NE: SANITARYNO. CONTROL NO
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
] 0 0 0 0
aIOC LICENSED CONTRACTOR'S DECLARATION Job Description ��
y�iF I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
n< w tion7")nf Division3oflhc Buai dPmfeuions Codc,ndmyliccnwis
<6666 in tormnndcf�9ct. (a — 3 REROOF
Lim 1.Glas 3 Lic.N ,1►�I 2004
qgo Date — —� CommEee66ter�L�����i CONTRACTOR: CUPERTINO ROOFING
E I understand my pins shall be used0asiOI dmemo BUILDING gg�91'���n,.G
3 w t; Licensed Proresaioml
3te5 OWNER-BUILDER DECLARATION
<� 1 hereby vflona'he'1 am exempt from the Cinumemrs License Law far the
i o O following remora.(Section 7031.5,Business and Professions Code:Any city or county .
v�9 which requires a permit to cnnawcL cher,improv:,demolish,ter mpoir any structure
prior to its issuance,also requires the applicant for such permit to file n signed imminent �}yp
FSC NethcislicenseJpunuanuothcpmvisionsofda.Contractor'sLicensefaw(Chapter9 Sq.Ft.Floor Area Valuatyv000
st that
I.licnsedSee'ion7000)of Division3of NCBusimsaand Pmfcealons Code)or
3 that he is exempt therefrom and The basis for the alleged exemption.Any viollation of
Section 7031.5 by any applicant for a permit aubjecer the Applicant o a Civil penalty of APN Number Occupancy Type
no'mom than five hundred dollars(SSW). 37525002 . 00
❑I,as ownerofthe pmpeny,ormychaploycas with wagessalheirwle Compensation,
will do thework.and theswcmre is mttntended or offered forsale(Sec.7044.Business Required Inspections
and Professions Cork:Tic Co asst or's Umme Law docs not apply to an owner of q p
property who bu ilds or improves dremon,end who dues such work himsel f or through his
awn employees,provided met such improvements are not intended oroRemd foraale.IL
however,the building or improvement is wld within one year of completion.the owner-
builder will have the burden of proving mal he did not Wild or Improve for purpose of
sale,).
❑1.as owner of the property,am esclusivcly contracting with licensed conrrectors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li.
cense taw does not apply to an owner of property who Wilda or Improves daemon.And.
who contracts for such pmjecu with a con'rscmr(s)licensed pursuant to the,Contracu's
License Law.
❑1 am exempt under Sec. .B R P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby aRimt under Nulty of perjury one of me following declarations:
1 have and will maintain a Cerufinte of Consent to self-inure for WorkersCompcm-
sation,as provided for by Section 3700 of the Tabor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as mquired by Section
3700 of the labor Code,for the performance of the work for which this permit is issued. '
My Workers Compensation FlC InsuranceCarrier and Policy number am::
CartF-+
Carrier: -�FC-C -d'EXn EMPOM WOw 1 RKERSK-ER4S
CERTITION FR '
COMPENSATION INSURANCE
(This section nccd notbecomplemd If IW Know,Is forum Wadmddnllars($1 00)
or less.)
1 certify that in the performance of the work for which dais permit is issued.I shell or
employ any pawn in any manner an As in become subject to'he Workers'Compensation
Laws of C.Iifo nia.Dau
Applicant
NOTICE TO APPLICANT:If.after making this CCNRCa a of Exemption,you should
become subject An the Workers Compensation previsions of the labor Code,you mon
O forthwith comply with such provisions or this Permit shall be deemed revoked.
„zy CONSTRUCTION LENDING AGENCY
4 1 hereby affirm that thea is a c naLreeion lending agency for the performncc of
ly' r7 me work for which this permit is issued(Sec.3097,Cl,C.)
{r•)Q Lender's Name
Z, Lender's Address
C)Q 1 certRy that 1 have read Nis application and sum that the above information is
{L F corecL 1 agree to comply with all city and county ordinances And nuts laws relating da
building construction,and hereby authmtlm representatives of this city la enter upon had
C)U U above-mentioned property for Inspection purposes.
(We)agree to save.indemnify and keep harmless the City of Cupertino against
tih Iiabilhos.judgments.costs and expenses which may in any way accrue against said City
U`L m mnec afthc gra mimgof'hiapermit.
AFPLIC UN RSTANDS D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURc�RE A N5. �/�
Re-roofs
Si A ican✓Cantmetor Data
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will'he applicant ur future building Occupant store or handle harmdous material
as defined by the Cupertino untempal Code.Chapter 9.12,and the Health and Safety
ct � 2(a) All roofs shall be inspected prior to any roofing material being installed.
❑Yea No
Will the applicant of future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.mil '.aNnus air c amu ss defined by dac Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yea a r�-/�
I have mad me havardoermacdalsrequimmenu under Chaplcr6.95 orthe Califon- I �_
Heal"Safety Code,Sections 25505,25533 nJ 25534.1 undermund matifmc Wilding /
J uncn0y haw a tenni thm it is my responsiM1ility m natil'y the occupant of me
requ rcmen most mel poor to issuance of a Ceoricate of Oceupney. Signature of Applicant Date
o rte r ulhorizcd ager Z p p All roof coverings to be Class "B"or better
CITY OF CUPERTINO 9
REROOF
• CUPERTINO PERMIT APPLICATION FORM
APN# 3,2 i-- 2,�_ 00 2 Date: C Z -
Building Address: g 5 9 S
L
Owner's Name: tv C ��ems- a Phone#: ' / / S_ �
Contractor: Phone#:License#: /
Cvl2e�� i � Z = h 913- � 12 -) �� S 'Y's �
Contact: Phone At: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ---21 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: �g 2 044 "0
h S
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrictio
Cost of Project: Type C nWCtio
Occupancy gro
UV Ccs
Qty/if
Apylip4ble 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