06070038 CITY OF CUPERTINOx <.a» '*-
6UILDING DIVISION PERMIT CONTRACTOWINFORMATION ;
BUILDING ADDRESS: EXECUTIVE ROOFING PERMIT N006070038
1117 STEEPLECHASE LA
OWNER'S NAME: PERMIT ISSUE DATE
JENSON & JOANNE JENG 313 INGRAM CT. 07/10/2006
NE: SANITARY NO. CONTROL NO.
(408) 458-6044
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+Gp LICENSED CONTRACTOR'S DECLARATION Job DescriptionwC 1 hemby alarm don 1 sm licensed under Provisions of Chapter 9(ewnmcneing
ZIW veil Section 70M)of Division Sof lbe Business and Professions Code,and my license is
imfull(omeand� S�QN( REMOVE (2) 3 TAP 20 .YEAR COMP. INSTALL ELK 40 Y
)4E Clean Mass ` Lic.g
enc Dam a'!-ro.oy F Con unuan 1 .D t:929 a, COMP. CLASS A
0� ARCHITECTS DECLARATION
9EXECUTIVE ROOFING RENEWED BL 7/10/06
f W U 1 understand my plans CHu IT E used public mewls
uh
a
eLicensed Professional
g OWNER-BUILDER DECLARATION
1 botchy al Nat I am ecmpt form the Canuacon's License Law far Ile
,� f
p 0 following mason.(Section 703 1.5,Business and Professions Calc:Any city or county
5 m which requims a Permit to conawcL alar,improve,demolish,or¢pair any mmum,
prior to its issuarcc.Aw requires the applicant for such permit in file a signed suamcnt
that he is licensed pursuant to the provisions of NC Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
e�C (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or $5060
y $ that H u eumpt Therefrom and the buss for the alleged rsempuon My violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars(35M).
01,mownerofthepmpwy,wmycmplaycuwi0wageu Neowlcco Nmdw.
winds the work and the saaclurc is not Intended in offered forsaa(Sec.]Odd,Business Required Inspections
and Professfou h Cade:TContractor's License Law does Intl apply m an owner of q P
property who builds in improvelsemon,and who doessnehworkhimself or through his
own ernployces,Provided Nalsuch improvements ase not intended or offered fissure.B.
however,the building or improvement is sold within one year of completion,die owner-
builder will have the bards.of proving Nat h did wt Wild or improve for purPme of
sal
0 1,
c a owner of the property,.Business euWsi elyand!co ilessi ng with;)Theed ounhcon's . U
caullLa Ne es mOL (Sec.in in rmoofroW Profusion Cade:)Tiro Conuunon.Lid qpJ
Genu law does r such ply m an with
a of porPeny who sex pursuant
Improves;thereon,and. {.)
who contacts for such porjects with a contractor(a)licensed puuuam w Nc CanvacmrS ��s$
Lkaa"Law.
01oroexemptunder Sec .B&PCfor Illsmown U( /9
Owner Daa ?0p6
WORKER'S COMPENSATION DECLARATION (((ygggJJJIII U
1 Hreby alarm under penalty of perjury one of the fallowing declarations: Di
/B
I Hve and will maintain s Cenifsau of Co..,w self-invert for Wwkces Compact. /l Jt`.} �y
suion,a provided for by Section 37M of Oen Labor Cade,for the Performance of Ibe (J/J�[Llt{"�f g
work for which Iia permit is issued.
0 1 hove and will maintain Wor s Compewtion Insurance,as required by Section
37M of Nc Mbar Codc,for Ice performance of Ne wank for which thus permit is issued.
My Worker's Compeuadon Insurance carrier and Policy number art:
Carder. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
This sectim recd vel h completed lith pons it is fm.ne humdredd.Rau($IO])
or Icss.)
1 certify Not in to performance of use work for which this permit u issued,l dull nut
employ any Perwniqay ma40er w u ha become mbjat m th Workus'Comperssxdon
Laws of Caliromtu.Qate /-10-og
Appliant Ilk,
NRCE TO APPLICANT.If.after making this Ccnifium of Exemption,you shauW
become subject ca the Wohcr'C Compensation provisions of Ne Labor Code.you mtw
.J z fonbwith comply with such provisions w this permit shall Is,deemed revoked.
? "" CONSTRUCTION LENDING AGENCY
ce IhOr whichtmlatdtercisoed(See m.30 len ding ageney fm @e pdunnanceof
W E dm woh fur which dtu permit ts issued(Sec.]09T,Civ.G)
GQ Undies Name
7 z Lenders Address
U O 1 comfy that I hale read this application and sum that the chum information is
U. P contact.l agree to comply with all dry and county ordinances and sum laws relating to
redO U building conswaion,antl M1ereby auNorim rapresenatims of Nis city menmr upon the /�� �,�\a�/�t�(/��//
ahovs-mcmidgmenta,property
ost favi epauon which
/"_v Wx/
(We)agree m ave,indemnify and keep hasmleas Ice City of Cupertino against
o-Fi N liahilidu.judgmonss.cosss and expenses which may in any way accmc agaitm said City
U z in eoeagw ec of the granting of Tis permit.
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR G LATIONS.
7'lo-oV Re-roofs
Sig m fApPliaw/Canuacwr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will that applicant or future Wilding occupanemrc or handle hauNau material
as defined by No Cupamno Municipal Codc.Chapter 9.12.and the,Health and Safety
Coda,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ye Na
If a roof is installed without first obtaining an inspection,I
Will the applicant or future building occupant use cquipmenl of devices which g agree to remove P
emit hazardous air conmminana dormer!by the Bay Arca Air Quality Management all new materials for inspection.
Disuicl7
O Yes Nu
I havemad Nehuard maarial3mgtlimmmmundcrC pmr6.95ofN Califw
ni.Herl&59,yCade,Say.m M5.25533and255M.1undcrssaM Nmiflc building
date rant c rmndy sate a mnanl Nat it as my mspaaihility to notify the occup rn of the
re uiromc uwhiahmuathmelpdormimum cfa Cervrwama(Occupanay. Signature of Applicant Date
a Qte All roof coverings to be Class "B"or better
O r amh.mcd agent Dam' g
CITY OF CUPERTINO
lam 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: B1k: . Lot :
APN . . . . . . . . : 35931047 . 00
DATE ISSUED. . . . . . . : 07/10/2006
RECEIPT # . . . . . . . . . : 35163
REFERENCE ID # . . . : 06070038
SITE ADDRESS . . . . . : 1117 STEEPLECHASE LA
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JENSON & JOANNE JENG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : EXECUTIVE ROOFING
CONTRACTOR . . . . . . . : DAVID BERKE LIC # 26871
COMPANY . . . . . . . . . . : EXECUTIVE ROOFING
ADDRESS . . . . . . . . . . : 313 INGRAM CT.
CITY/STATE/ZIP . . . : SAN JOSE, CA 95139
TELEPHONE . . . . . . . . : (408) 458-6044
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ----- -------- ---------- ----------- ------- - - - ---------- - - --------
BPERMFEE VALUATION 6, 000 . 00 126 . 36 0 . 00 126 . 36 0 . 00
BSEISMICRE VALUATION 6, 000 . 00 0 . 60 0 . 00 0 . 60 0 . 00
BUSLIC FLAT RATE 1 . 00 105 . 00 0 . 00 105 . 00 0 . 00
---------- ---------- --- - - ----- ----------
TOTAL PERMIT 231 . 96 0 . 00 231 . 96 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
------------ ----- ------------ ------------------
CHECK 231 . 96 1029
TOTAL RECEIPT 231 . 96
•
Wn Community Development
Ft 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
4JUPEkTINO
Building De artment
JOB ADDRESS: ������ �� (04—z
' � �_ PERMIT #
� �� �EL��C1Pt'ac% l.�C^�C-
OWNER'S NAME: jttx6r j I R/WAjL, -1 PHONE #
GENERAL CONTRACTOR DMta FAX #
I am not using any subcontractors: fU
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
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
7/f�•D�
Owner/Contractor Signature Date
Sit)
CITY OF CUPERTINO x4077 C38
REROOF
• CUPEkTINO PERMIT APPLICATION FORM
APN# 3;5q-31- 0+700 Date: 07 /o' 0
Building Address: STEE�IE 0k3t- � E
Owner's Name: Phone#:
.'fE,vSoN � Jo�nwE �N.b yor. 59sz9io
Contractor: ,ic 4FA- License#:
Contact: _)t N� &RXE Q_ XE Cupertino Business License #:Z� /
I
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
iil Asphalt Shingles A Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings Z ❑ Provide I.C.B.O.Report#
74 To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
• Job Description:
AAo✓c 3-rAB Zb yl Grv, . /1vS;rrc1,- cz,- yo yz (',4,p
Residential P Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are any restrictions: U
Cost of Project: So 4 o Type of Construction: /57- Occupancy group:
Qty. if
Applicable Fee ID Fee Description Fee Grow
BPERMFEE Bldg Permit Fees BUILDING
BENERGY EneEgy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
•