05050059 CITY OF CUPERTINO TIP 7 h' •,•�;,"�"1 d;ga'x�d, --•.
BUILDING DIVISION PERNIIT CyO RACTQRANF0 ,\rIATTO
BuaDINC ADDRESS: LINDY ROOFING CO INC PERMIT NO
I
OWNER'S NAME: PERMITISSUEDATE
ONE: SAN TARY3:112 OL NO.
ARCHI7ECTIENGiNEER: BUILDING PERMIT INFO
BLDG
l� PLUMB MECH
IS
30o LICENSED CONTRACTOR'S DECLARATION
yd 1 hereby affirm Net 1 am licensed under previsions of Chapter 9(commencing Job Description
with
Section and calf Divisionc��vf WO Business Profession Code,and my is FIN ® LE®
g m0duenmanIf 3'1 216 i REROOF W/COMP. S d/rr`�
t i Diatense C Contgrecmr
ARCHIlEGTS DECLARA ON
I sande my pins atoll W stood as public rands
Licensed Professional 2005
OWNER-BUILDER DECLARATION
E 1 hereby effnm met I em exempt from the Conuamr'a License Law for the
cc O following moron.(Section 7031.5,Business and Profcsaions Code:Any city or county
j$E which nisi a Permit to construct.alur.impmte,demolish,or repair any mnoture
_xi poor in its issuance.also requires the applicant for such permit to file signed mumem
that he ulicensed pursuant m the provisions of Na Connector's uccnac Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Salioo70(10)of Division 3 of Um Businessand ProfedionsCede)or
'(t $
that be m exempt decefrom and the basis for lie allegW nemptim.My viNmlon of
Section 7031.5 by any appliant for a permit subjects the applicant he a civil penalty of 3%''Fol ro 0 Occupancy Type
not mom than five hundred dollars(5500).
0 I,an Owner of tine property,or my employees with"Saw their now compensation,
will do the work,and the suuctume is not intended oronered Income(See.70".Business Required Inspections
std Pmfessimu Code:The Commutes Llttme law does not apply m in owner of q P
prefatory who bui Ids or improves thereon.aad who does such wok himself or Nrouih his
own employees,provided that such Improvements rte noinunded moffemd total..if,
however.the building or improvement Is sold within one you of mmplauon,she Owner.
builder will have the burden of proving that he did not build or Improve for purpose of
um.).
0 1,as owner of tiro Property.am exclusively eomenctlng with licensed conmmod ro
construct we pmjen(Sec.7049,Business and Profaslons Code)The Conuacmis U.
cave law docs not apply to an owner of property who builds or improve themen,and,
who contracts for such projects with a conuacmr(a)licensed pursuant to the Contractor's
License Law.
O l am exempt under Sm. .B&P C for thin moon
Owner Dau
WORKER'S COMPENSATION DEC"RAT10N
1 hereby affum under penalty of perjury arc of the following dalan0mu:
1 have and will maintain a Certificate of Consent insel6inure for Worker's Compere
1037100
on,a provided for by Section 3700 of the labor Code,for the performance of we
rk for which this permit is Issued. t
1 have and will maintain Worked Compensation Insurance,u required by Schon
of Ne Labor Code,for the performance of the work(ver which this permit is issued.
y Worker's Compauation Insurance cannot and Policy number art:
rtier, OC4Af`*0-z^ Policy No.: (SS I O.D4rol O) I .
EMPr10N FROM WORKERS'
P SATION INSURANCE
rMis=tionncednothac pleudifthepmmitisforoahundo doHm(SIOOI
Orion"
1 c.Nfy mat I 9he performance of the work for which this permit Is issued,I Nell not
employ any pe Me in any manner an u u become subject to the Worked'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPUCANT*.If,after making this Cen riusu of Exemption.you should
became subject to the Worlhes Compensation provisions of the Loiter Code,you most
3.,Z forthwith comply with such provisions or this permit Nnd n
all be doemaked.
�zzo CONSTRUCTION LENDING AGENCY
S F+4 I hereby affirm that them is xWentrominn lending agency for she Performance of
F > we work for which this permit is Wuedi f5a.3097,Civ.C.)
f W A Lender's Name ll
((((Ov Leaders Adddu
''V Q 1 certify that I have tend this applumio ,std some this Ne above inlomation I.
PW conutt Iagree in comply with tll city and cuuniy QQNinances and sum[am reading i
lO building construction,and hereby authorine repnsanblives of Nu city to enter upon the .
tg7 aMvcmenuorcA property(or Inspection puryOus.
6. (We)agree m save,indcmnifY std keep humleti City of Cupertino aialrm
' y ilal litiu,judgmenu,eosu antlexpensu which mryin any w ecclose against said City
t)Z 1 fi of the treating of this permit
PLI UNDERSTANDS AND WILL COMPLY WITH ALL POINT Issued by: Dale
~ SO GULATIONS.
��—' S1( �) Re-roofs
Signmur pplican mdgwwr Dam
i HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant mom"handle harudou mammal
u ticMeO by the Cupertino Muni ipal Cade.Chapter 9.12,antl the HuIN and Safety
code.Section 2553x(.)7 � All roofs shall be inspected prior to any roofing material being installed.
[:3 Yes Nu
WIII the applicant r luwrc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it h cardous air com en inane an defined by the Bay Area Air Quality Management all new materials for inspection.
IauicR
n CYen �Nu I
I have ncsd the h�nd/mnsmamrlau requirements under CluPur6.95 of the Glitor.
nu HcslN&SefetYCode.Satiau25505,2SSJ]and255J4.1 undcnund thullde building
docs not curendy have a unanr.that it u my MPOMINhity m notify the aceupant Of the
requiremenu which mum W met pdormissuance refs Certificate of a r, Sign of Applicant Date
zc
O e - autharincd egcnl II Data All roof coverings to be Class++B++Or better
k
'r
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
oclo Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS:—7 QQ PERMIT #
O l ( ��' 1 � Ci 'J �� Q soon
OWNER'S NAME: BELFN 'Sv "—fJ PHONE #
GENERAL CONTRACTOR t N d 1 FAX #
I am not using any subcontractors:
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
iGlass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Omamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
ST, OS
Owner/C actor Signature Date
/0 300 7ZY3"e i9
O� -Tortee 2
r,✓ L, _
a" �fiCITY O PERTINO
REROOF
COPE TING _ERMIT APPLICATION FORM T)c
5- D D Date:
APN#
.7 `,r= ll-oS
Building Address: Ido C 70
J C�-n t G Blvd
Owner's Name: � s, � Phone
Contractor:
n/ . CoI License #:aIS el
Contact: W iW07'fCupertino Business License #:
3821
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles A(' Asphalt Shingles
,A' Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide 1.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: S V rti5
aL-
Residential Commercial n
Fire Zone: Yes ❑ No Confirmed with Planning Deft. if
there are any restrictions: LJ
Cost of Project: Type of Const ctiom Occupancy groyp
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
-�f? 7- -314-7-9 _ . ,