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• BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
WELCH PAUL M AND JANE
PERMIT NO.06060083
21667 ROSAR
OWNER'S NAME:
PERMIT ISSUE DATE
WELCH PAUL M AND JANE
06
E:
SANITARY NO. CONTROL NO.
ARCHEECT[ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 herby affirm that 1 am licensed under provisions of Chapan 9 (commencing
P
with ScOkm 7") of Dividon 3 orate Business and Profcsskm Cods.and my license u
in full fora andeffea
TEAR OFF TILE AND REPLACE WITH ASPHALT SHINGLES
manse Class LIeN
ate
ARCHITECTS DECLARATION
KEEP EXISTI O LACE PAPER.
,rD E.FyI�
j�{
r
usedCona public
1 understand my plans shall M used u public recnrsts
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a {LIJtiG/\�J\
J V ` GG.. L Vh
JUL�Q� 1UU8
Licenced Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt room the Condmcter's License Law for the
following mason. (Scefion 1831.5. Business mood Professions Cade: My city or aunty
which requires a Permit W consorted alter, improve, demolish, m repair any anucmm
g
prior b its issuance. also M1Galrea the applicant for such permit to rile a signed aucarm,
F7 brr e Valuat b 0 0 0
Nat to u IicenceJ purswnt to the povisiov of the Contracar's license law (CTapdm 9
(commencing with Section 70Do)of Division Sof the B usinuu and Professions Cock) or
that he u eumpt therefrom and Ibu basis far Ne alleged exemption. Any violation of
/p�.ppjN�j gfN��7umber
Occupancy Type
P Y YP
Section 7031.5 by any applicant fa a Permit subjects dre applicant as a civil pointy of
not more than fiwe hundred dollars ISM
35619039.00
❑ I,uownp of ore poprny,mmy employees with wageas the'v sok campemvdon,
Required Inspections
will do the wart, and the structure k not intended or offered for sale (Sec. 7044, Busmass
add Professions Code: The Coruscar's License Law dors not apply W ,n owner of
�
property who builds car imposes thereon, and who does such wart himself or through his
awn employees, proWded laud such imp rmomenu are rmtimended muffucd for sale. IL
however. the building or improvement usold within ane yearof completion. the owner -
builder will bawe du heroes of proving that be, did rot hold., improve far pupeam of
. as owner of dee pmpeny, am exclusively contracting with licamed conummis to
connmct Ibe pmjea (See. 7044, Blaine ane Profnsimes Cade:) The ComracWls U.
cove Law dote not apply a an owner of property who builds or impm eet therman, and
who contracts for such projects wild a conuanteds) licensed pursuant a the Conuactarr
Lkence law.
❑1 funder Sec. . B h P C for this reason
� a
Ow Dade
WORKER'S COMPENSATION DECLARATION
1 by affirm under penalty of Perjury, ane of late following declamtiov:
1 W m and will mainuin a Cenifiau: ofConsem a self -arm fm WorteYa Compen.
sation, as pravide l for by Section 3700 of late labor Code. for late performance of Ise
work far which this Permit is issued.
Q 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the labor Code, for me performance of the work far which this permit u ismed.
My Worker's Compensation huurvae carrier and Policy number am:
Carrier: Policy No.:
_
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
.
(Thu suction seed not bu completed if roc Permit ls for are hundred doll= ($100)
or leu)
1 certify that in the performance of We work far which this permit u issued. I shall not
employ any person I,np an�y man rat alar e9ayyttre���� Worl Co don
Laws of Cal y C -J T
`fwais.Dad�
Applianl I U Y
NOTICE TO APPLICANT: If, after maki g this Cmdriate of Exemption, you should
become fubjen m the Workers Compensation Inonaloua of We Labor Code, you most
comply with such provisions or this permit shall he deemed remitted.
CONSTRUCTION LENDING AGENCY
1 heathy strip that there is a construction lending agm y for the perfarmana of
the wank for which this permit u issued (Sac. 3097, Civ, C.)
Lender's N.
Lender's Address
I certify that 1 have read this application and sate that the shows urmara doo u
coma I agree a comply with all city and county ordinances and see¢ laws relating to
building conswetion, and hereby audharim representative, of this city ld enter upon the
moroa-mcntioncit property Tar iaspeNenpurposes.
(We) agree to sale, indemnify and kap humless the City of Cupertino against
Iiabilitiv,judgments, eciusmd crepe.. which may in any wayaccrucagainst said Ciry
in consequeve of the granting of ldis it.
ANT UNDERSTANDS AN�l IL COMPLY WITH ALL NON -POINT
Issued by: Date
OUR REGULATI NS
Re -roofs
Type of Roof
l/
—
_nor
gnuu a Applmc HAZARDOUS MATERIALS DISCLOSURE Dare
dl the applicant or to. building aaeupant s me p handle haaaroov mamrial
u defied by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safety
Cade, Section 8533(.)?
❑Ye,
All roofs shall be inspected prior to any roofing material being installed.
Will theapplicant or future building occupant um equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove,
aak harardav air comamins' u define .by lax Bay Ams Air Quality Management
all new materials for inspection.
Dien"?
p Yv
I haws read the hvarldms materials mcquirtmenu underChaper &95.f lee Calif.,.
ria Health k SafctyCode, Sections 85115.25533 and 8534.1 undcnund that ifthc building
dues rat curcnd, hove s tenant Wm i m reapordibility b rwdfy the ampent of the
ire nu which most he Iprio oft Cutif sof
Signature of Applicant Date
All roof coverings to be Class "B" or better
antha scapho, Date 19
!m 1 of 1
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35619039.00
DATE ISSUED.......: 06/12/2006
RECEIPT #.........: 34792
REFERENCE ID # ...: 06060083
SITE ADDRESS .....: 21667 ROSARIO AV
SUBDIVISION .....
CITY CUPERTINO
IMPACT AREA ......
OWNER ............:
ADDRESS .....'.....:
CITY/STATE/ZIP ...
RECEIVED FROM ....
CONTRACTOR .......:
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP ...
TELEPHONE ........:
WELCH PAUL M AND JANE
JANE WELCH
LIC #.*OWNER*
WELCH PAUL M AND JANE
OPERATOR: amyw
COPY # : 2
*EE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
-------------------------------------------------------------------------
BPERMFEE VALUATION 5,000.00 115.56 0.00 115.56 0.00
BSEISMICRE VALUATION 5,000.00 0.50 0.00 0.50 0.00
TOTAL PERMIT : 116.06 0.00 116.06 0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT
0
AMOUNT NUMBER
------------ ------------------
116.06 120
116.06
OWNER -BUILDER VERIFICATION
1. (Check one) I or myimmediatefamily (paren , spouse r child) will perform
• A. V All the work authorized by this permit
B. _ A portion of the work
C. None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City, Phone # State License # Type of work to
vc - cmc �au:cu
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
• portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erformed
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner -Builder Informatioareverseside)
Property Owner's SignatureDate:
Job Address: J —ILQ v Permit # 6/n 664 (Y-3
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
0
CITY OF
CUPEkTINO
Dear Property Owner:
City of Cupertino Buildiing Department
10300 Torre Avenuo
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner -builder you are the responsible party of record
on such a permit Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself, you
may protect vourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you
should be aware of the following information for your benefit and protection
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is $200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer, you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding, federal social
security taxes, workers' compensation insurance, disability insurance costs, and unemployment compensatios
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law, contact the Internal Revenue
Service (and, if you wish, the U.S. Small Business Administration). For more specific information about your
obligations under state law, contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees, without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner -builder
building permit, erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
be obtained by contacting the Contractors' State License
Information about licensed contractors may
Board in your community or at 1020 N Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department,
City of Cupertino
Printed on Recycled Paper
C�
J
CITY OF
�UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building De artment
JOB ADDRESS: / 6 G -7 �� ��
PERMIT #
0 0604� 3
OWNER'S NAME:
Q
PHONE # 2710g-3
GENERAL CONTRACTOR: ner
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin information:
Owner/Contractor Signature
— / -2—O( o
Date
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
— / -2—O( o
Date
tuctu
•city OF
CUPEkTINO
•
J
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
APN# I9-- 0-89
Bldg Permit Fees
Date: �a7
BENERGY
Energy
BUILDING
Building Addre
Seismic Fee Res
ai
BSEISMICOM
Owner's Na
BUILDING
BPLANCHK
Phone #:
BUILDING
BUSLIC
Business License
L4 _ R1 PE -Ns
Contractor:
License #:
WY1
Conta
Cupertino Business License #:
Type of Roof Covering:
Existing:
Proposed:
O Built -Up Roof
❑ Built -Up roof
❑ Asphalt Shingles
�� Asphalt Shingles
❑ Wood Shakes
❑ Wood Shakes
❑ Wood Shingles n T
-SR::' Other (specify) l .e m Eno— I T
13 Wood Shingles
�P— ❑ Other (Specify)
Number of existing coverings I
❑ Provide I.C.B.O. Report #
To be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply
W'th Cu ertino's Tear Off Policy:
Job Description: T r OX -fi e_ g,2L G C.� W S n9 -es
Q
Residential Commercial ❑
Fire Zone: Yes ❑ No
Confirmed with Planning De t. if
there are any restrictions:
Cost of Project: _ Type
of Construction: Occupancy grow.
0
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