03100166 CITY or CUPEWf CONTRACTOR TNFORnVQN-
BUILDINGDIVISION DIVISION PERMIT �
BUILDING ADDRESS: ALL SEASONS ROOFING SERVIC Tg MIT NOO 3100166
11060 SANTA TERESA n?
OWNER'S NAME: 2640 PACER IN PERMIT ISSUE DATE
COLLINS DOUGLAS E AND GERAL NN 10/23/2003
` NE: 4089724455 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
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+Op LICENSED CONIRACTOR'SDECLARATION JobDescri I10n
h Semi
W 1 hereby efrom that 1 am licensed under provisions of Chapter 9(commencing
witn 7M))of Div is ion 3 f0 B cu end Pra(cuin ICode a rgcson'
1� mmumrc bermat / cnREROOF F' ALED
qLicenre C i Lic.N
-F O Dela O Coral r ei3T
fu y island my plmsshall usNARCHITE Das PuhlicrccmJ Z vn 5 JUN 0 7 2004
o G Licensed Profeuioul
3
OWNER-BUILDER DECLARATION BUILDING
i f I hereby affirm that I am exempt from the Contractors License Law Or the
a 0 following reason.(Section 7031.5,Business and Profession Code:Any city m county
3$2 which requires a Permit w construct.eller.improve,demnikah,or repair any stra=tumB 2 O O
a prior to its imuanec.also requires the applicant for such Permit to file a signed slnemcnt
ego (hal he is licensedpursuanlothe provisions ofthe Commeno'sLicense Law(Chapter 9 Sq.Ft. Floor Area Valuation
Z€ (commencing with Section 70)()of Division 3nthe Business and Professions Code)or 35617032 . 00
Z Nn he u exempt therefrom and the basis for the alleged emmption.Any violation of
7031.5 by any applicant for a permit cite applicant to a civil Penalty of APN Number Occu ane Type-
Section
Out more Nan five hundred Jollan($500). P Y
❑1,as owner of the pmpany,at my employees with wages as their mlc compensation,
will do she work,and the suuctum is not intended or offered for sale(Sec.7W,Basin.
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves Norco.,and who does mch work himself or through his
own employee,provided that such improvements art not intended or offered for sale.If.
however,Ne building or improvement is to within ora year of completion.Ne owner.
builder will hive the buNcn of proving that he did not build or improve for purpose of
sale.).
❑ 1,u comer of Ihe pmeany,am ucluively contracting with licensed contractors to
construct the project(Sec.7044,Business and Profusions Code:)The Contractors Li.
cense Law docs not apply to an owner or property who builds or improves thereon,and
who contracts for such projects with a contractmos)licensed pursuant to the Convector's
License Lew.
❑l am exempt under See. B k P C for this rtuon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following decimations:
I have and will monition a Cer ificem of Consent m selginsure for Worker's Camper
cation,u provided for by Section 1700 of the labor Code,far the performance of the ,
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,n requited by Section
3700 of ma
Ne labor Codc,for the performance or the work for which Niss
is pclmil is totted.
111 orker's Compensation Insurance carrier and Policy number art:
amscr: �.rTE ,4i g�3� PoS0
CERTIFICATEOFEKEMM FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Mcompleted if the Permit is for one hundmd dnllass($1016
Ica.)
1 cenify Nal in the per(nrmanea o(Ihc work for which this permit is issued.I shall out
employ any Person in any manners as In become subject to the Workers'Compensation
Laws of Cali pinions.Date
Applicant
NOTICE TO APPLICANT:If.after making this Ccnificam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
�z forthwith comply with such provisions or this Permit mall he deemed revoked.
Zy CONSTRUCTION LENDING AGENCY
1 herby affirm Nat there its construction lending agency for the Performance of
Lathe work for which this permit is issued(Sec.3097,Civ.C.)
LI Q Landers Name
5 z Lender's Address
Q 1 cenify Net 1 have mad this application and state that the above Information is
L mrrem.I&gree to comply with ell city and county ordinances and sine laws misting to
V
building construction.and hereby emhorim mpresenutim or this city to enter upon the
Uabovomemioned property far inspection purposes.
(We)agree to ave,Indcmni fy and keep harmless the City of Cupertino against
rA liabilitiu,judgmcats,ego,Umd esperucs which may in any way see=against mid City
I.
uristaf this permit
z APoL11 gceNT=UNDof ORSTAgo-AN�WILL COMPLY WITH AL NON INT Issued by: Date
Uft REC ON
43 D 3 Re-roofs
ii wrc of—A Pp b7c.972mractor Dale
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ur future building oesupml store or handle hatiruus materiel
Is defined by the Cupertino_Municipal Codc.Chapter 9.12,and the Health end Safety
ode,Sccuon 25532(x)7 t\ rt All roofs shall be inspected prior to an roofing material beim
❑r=a Na P P Y g g installed.
Will the kPPlicant or future building a¢apanl am equipment or devices wmm� If a roof is installed without first obtaining an inspection,I agree to remove
it haramnus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
,ariet?
❑Yes ❑ u
I have mad the munitions materials requirements under Chapter 6.95 of the Califor.
ma Health&Safety Code Smbm 25515.25533 and 25534.1 unwin=d tha if the huilding
dour rot currently has tenant.that u my rcaponsihiliry o nnury the oceuP t of the
re now ' st atpn wissuenceorICertificamof. pant Signature of Applicant Date
6 O All roof coverings to be Class "B" or better
net or authori a t Dee
CITY OF CUPERTINO o p l
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# 2f'- Date:
,/�( '� �' � 10/22/03
Building Address:
11060 Santa Teresa Drive
Owner's Name: Phone#:
Doug-, & Gerri .Collins 408-255-0998
Contractor: Phone#: License#:
All Seasons Roofing Service Inc. 408-971 -4455 759091 :
Contact: Phone#: 408-971 -4455 Cupertino Business License#:
Cecilia Carrasco 408-422-0781
1 2103r;
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles )( Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings / ❑ Provide I.C.B.O.Report#
A To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
Tear Off 1 laver of heavy
Residential 1 Commercial ❑
Fires Yes ❑ No Confirmed with Planni
there are anrestric ' ns:
Cost f Project: Type of Constructi Occupancy grou
$8. 200 Re-Roof
Qty. if.
Appilcab 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
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