05050111 CITY OF CUPERTINOm;ts .at'cc 'r
BUILDING DIVISION PERMIT . CONTRA.CTURINFORMATI01` '
BUILDING ADDRESS: JOHN HENRY ROOFING PERMIT No 05050111
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY ST CONTROL NO.
ARCHITEC MNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� O
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
r� 1 hereby arrant Net 1 un licensed under phaviscats of Chapter 9(commencing
wish
Sudan]gMl)of Divislon3ofto Butlrru uM Profesduu Code,and mylicenae is ��� p ��®
^� in full fora anile ret O/ABY
z'�z panne cl_ �K r rREROOF W/SHINGLE
A HTIECI'S DECI.A 10 ,
I understand my plans shall M wed as public records '-C �� 2005
5� Licensed Pmfeui...I
g OWNER-BUILDER DECLARATION
8<I I h (SuNm u
. re I em empl(rum Ute Contractors License Law for the
mason.
po following recon.(Sadun 7031.5.Business and Rvfratiou Cade:AnYeilY or county
$Pi which requires a Permit to construct after.haprow,demolish,or repair any eweore
FZjr" prior te its issuance.abu requires dw applicant for such Permit In file a signed statement
q{Fp< thuhculicensedpurauanitoNcprovisionsoftheContrumrsLiccnse6w(Chapter9 Sq.Ft. Floor Area Valuation
63a (Commencing with Sectran7M)of Division 3 of the Business and Pnefessiona Code)or
that he is exempt du refrom and the huh for dee alleged cumpdon.Any violent on of
Section 7031.5 by any applicant for a permit subjects that applicant In a civil penalty of 3 2V4tX3*rI0 O Occupancy Type
nut more Nan five hundred dollen($5001,
0I,uownwofdRpmpmy.omywployeuwWwagsuNehwka pewdon,
will da NC work,and Nestruch R is rat Mended of offered farea a(Sac.71),M.BaAM3a
and Pmfeaelaw Cade:Toe Contractors License law den Out apply in an owner of - Required Inspections
prope ny who builds or improv thereon,and who does mw h work himself or Nrouih his
own employees.provided that such improvements are notimended proffered formic.If.
however.the building or improvement is mid within oro Jest orcompletion.the awwr-
builder will have me burden of proving that M did not Wild or improve for purpose of
.101.
❑1,u owde r of the property am eaciufively contracting with licensed rontrwtors in
consumer the project(Sec.7044.Business and Profcedona Code:)The Contractees U
cesee Lew does not apply ad an owner of property who Wilds ar improv memos.and
who commas for such prejecta wide a eommuctor(s)Hormaud pur exam to 104 Contractee,
Lkewt Law.
❑1 am exempt under sec. .B k P C for this n mon a
Owner Dam
WORKER'S COMPENSATION DECLARATION
I WRby affirm under penally of perjury one of me following doelm0ona:
am and will as
a Certificate of Consent to self-iuum for WortresCompcn-
Ilon.as pmvidcd for by Sudan 3700 of the labor Code,for the performance of the
work for which this permit Is Wood.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of Ne Labor Code,for the performance of the work for which this Permit is Issued.
My Workee,C Pen LIMIT senna ea rend Paltry numbersm:
Gnier. Policy No.:
CE ATE OF EK P ION FROM 0 S'
COMPENSATION INSURANCE
musscNm need notocompleted if the permit is farm hundred dallan(SIdR
less.)
1 Certify that in me Performance of the.,it for which this permit u issued.I shall oat
employ any Person in any manner an u N become subject to the Workers Compermad on
Laws of Celifamie.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Eacmpkon,you should
become subject in the Workn',Compensation provisiona of the Labor Cade,you must
.J O fordlwidi Comply with such in vhinu or this permit shall W dared revoked
._
'Z 51CONSTRUCTION LENDING AGENCY
(•" Ihereby affirm that there 1,a comnation lending agency far the Performance of
ai the work for which this permit Is issued(Sec.3097.Civ,C.)
u7 Q Lender's Name
z Leader's Address
U0 1 anify this I have rod We application and mm,that tM move Information h
LL4 r' comm I agree m comply with all city and county ordinances and sum kora misting M
C) building mnawetion.and Mreby aummins mpmmumativ o(this city to enter upon Ne
W .hove-menkonrG property for inspection purposes.
(We)agree Io save,indemnify and keep harmless the City of Cupertino against
N Ibbilides,judgments,cats and expenses which may In sty way wane against mid City
U 7 In consequence of thegaming of deis purnit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCERECUL N5,
Re-roofs
Si are ofApvl an Mus, w am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof .
Will ds,applicant or lot=Wilding occupantswm astraddle huardaus motorial
as de0ned by the Cupenlno Municipal Code,Chapter 9.17,and the Health and Safety
nue,sedan z5533(.)]
oYn a?fe All roofs shall be inspected prior to any roofing material being installed.
Will dte applicant or future Wilding occupant use equipment or devices,which If a roof is installed without first obtaining an inspection,I agree to remove
It havardnw air umand mis u deRwd by Ne Bay Area Air Quality Management all new materials for inspection.
iskin7 J
Q Yes Ono
Ihaw&Salcmad thehuardouam 25505,25533 and
55 underderPkrd.95ofdec Califon f ^��
nimFkalth&Safety he ba7awdmw 25505,35533 and nts un l rChapi rtNm Ulhc Wilding
does not comply haw a tenant,lad It is my responsibility to nodly th occupant of the
mquimmens whic tau Wmaidd,rtu ipu car toifm.tear Oeeaumy. naturedApplicant Date
nn ar,worFra .gem pte, All roof coverings to be Class "B"or better
J
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
� OCIF Fax(408)777-3333
UPEI�TINO
Building ID partment
JOB ADDRESS: PERMIT#
OWNER'S N PHONE #
GENERAL CONTRACTOR: FAX#
I am not using any subcontractor • �5-
Signature Date
Please check applicable su cont ctors 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 I
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# Date: ,2
Build Address:
Owner's arae: Phone#:
-
Cc tr ctor: Phone #: License#:
;?e) 5///4Z
Co tact: / hone#: Cupertino Business License#:
-eldcY p
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles 'yt'' Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood ShinglesC1Wood Shingles
Z 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 Deschpt on:
' -
esidential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Construc 'on: Occupancy group:
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