08040198 CITY OF CUPERTINO
BUILDING DIVISION PERNHT CUIVTRACTQR$INF,URNIATION
PERMIT NO.
BUInClI 9"TUSCANY PL WESTERN ROOFING SYSTEMS 08040198
OWNER'S NAME: MRMIT ISSUE DATE
CHANG CHIA-MING AND CHI-MAN C 1328 .WHITE OAKS RD 04/28/2008
WN E: - SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
RE-RF, 1/0 WDSHK FILLSHEANG BLDG ELECT PLUMB MECH
Sao LICENSEDCONTRACTDR'SDECLARATION O O 0
01
1xrebyarnon wtIam11anedunder Provisoesofcmpbr9(cwmmesins --- -- --------_._� .._ .. _ .,.Job-Description
on
wits Section 70M)of Dhirian 3.fft Businsstib PourcasioesCode,and my]I..is
in fullmRandert�"S9 ti7Z'f
i•. z Urns Claes Lk.
I-, D81G f,6�.-n r GWItrKb!
9 �"�T wRCHMM DEC .
1 undenund my plans shall W used d Pu Ile 2!
ksad Licensed Pvfeuimml
OWNER-BUILDER DECLARATION
I herM air..Net 1 am mempt from the Contractor's License law for the
A O following recon.(Section Rn I.S.Business and Podot om Code:Any city or county
9 which sequhm•penot to cornu n:4 attar.borrow.demolish.or repair any someone
�S^ pier b its issuance,also require,one applicant for such permit to file a signed smemen,
�< "Wislicensed Protocol tothe roviummofineConarecbr't License Law(Chapter 9 Sq.Ft. Floor Area Valuation
9 (commcrcing wits Smion T000)af Divuion3Orthe Buvn<saaM Pofeuiom Code)or
that he u asempt therefore,and Jct basis for tho alleged ttemptiom My violation of
Section 7031.5 by any applioant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
of mom than five hundred dollars(5500).
❑I,u owner of Ne ptoprny,m my employem with wage,u theoole ompemadon,
andPrthewoes andthe smuanmrturotksended Lawdure,sa apply to N,Budneu
and Aty.1so m cone:Th Conmdno's rad law am sat apply lf r oa'mr are Required Inspections
Poperywho b.promimporvea Ntt prove who dmauchwmk Mmselrer tlwugh Ms
however,
the Wiporvlw I Net such rat is improvements art net inteMN OroRerd fm sale.E.
however,that building m improvement is veld within one year of console fthe Owntt-
buildtt will low Ne dWo of provingving Nat he did eat build or improve for Puryose of
sale.).
❑1.u oweer of and popery.am reclusively consuming wits leveed commons to
omwct tie project(Sec.ION.Business am Professions Code)Th Coouacbr's U.
come law does not apply he an ewnm of property who builds or Improrn thercon,.4.
who controls for such projects with aeemacier(a)Ikensed panumt b the Contracto s
Lkeme law. '
❑I an exempt under See ,B l P C for this cation
owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby slam under penalty of perjury one of the following decldadons:
have and will maintain a CeWOotaof Consent ve self-insure for wortees Common.
Fmm.u provided for by Section 7'1!10 of Ne Labor Code.for Ne performance of the
for which this pmnft u ieued.
Nve tib will matntsin Workefs CampensWon Ice,u squired by Schon
of the Labor Code.for the performance ofthe work far which Nis Permit u luued.
WorkeYs Compewoo�nt1 Insurance oricr end Policy number ail:
Cartier: A Ar K Firnv.e IMww. PolicyNo.: �/Y 1T
CER'fl— wGTEOF�E MCNFROM WORKERS'
COMPENSATION INSURANCE
(lbusection nerd of M completed If ase permit Is froac hundred dollars(SIM)
or ams.)
1 oNfy Net in the perfmmano of the wort for which this perm],is coots,l"I not
employ any person in any manner an as to beome object to the Wortrrs'CompwWo
Laws of California.Dae
Appumnt
NOTICE TO APPLICANT:If,after making this Counmte of Exemption,you should
become subject to the Worker's Compensation provisions of the labor CMe,you must
rJ Z forthwith comply with such Provision or this permit shall be doomed reeked.
zCONSTRUCTION LENDING AGENCY
J-n I herebyaRrm that thew u acommuctinn kndingagmey,for the performarnc of
ai w�.l Ne most for which this Permit is useed(Sec.3097,Civ.C.)
W�Q Lenders Name ,
7 Z Lender's Add.
U0 I emtiry that I haw rets We application W suit that rho W.ufmmW un is '
^' omen.I agree to comply with ata city and county colorless and state laws relating to
Q SV' Wilding communion,uW hereby sumonse reprosenuowa of this city to enter upon the
GUabove-mentiry
oned property for Inspection puoeL
(We)agree to saw,indemnify and keep baemlms the City of Cupertino against
it y
liabilities,Judgments.costs and expenses;which may in any'w'ay accoe agaim,cid City '
(„)Z in consec se tce Of the totaling of this permit.
n--' APPLICANT UNDERSTANDS AND WI L COMPLY WITH ALL NON-POINT Issued by:3 Date ,Z
SOU CU O
RENS.
- 2 Re-roofs �--='
guru pploan onmCb Date
HAZARDO s TERI DISCLOSURE Type of Roof
WRIlheappl4.wntorfuterebw 'ng Paulsboro or handle loosens material
as doRned by Ne Cupertino Mu ids .Chapter 9.M and the HmIN and Safety
Code.Section M5I2(a)T All roofs shall be inspected prior to any roofing material being installed.
❑Ye, ler�e
will the applicant nr future dolling occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I locummus air contaminants u defined by Ne Bay Area Air Quality Management all new materials for inspection.
e7
❑Ye,
1 haw mad dee bantdom macruusetpriremanu under Clupteo 6.95 crime Califor. 4—
on
nu fkal"Sofeny COW,S"Go 5,25533aW2I534.Iunderrondthdifthe building L/
dm t curren0y how a tenon it u my respomihility b notify Jct accuput of the
mnentswto ' r ofaCmifcamofOccupamy. $1Ure App ' a Date
Ow nut Oenedagent Dam' All roof coverings to be Class'W'or better -
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35929041.00
DATE ISSUED. . . . . . . : 04/28/2008
RECEIPT #. . . . . . . . . : BS000004600
REFERENCE ID # . . . : 08040198
SITE ADDRESS . . . . . : 1036 TUSCANY PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . .. CHANG CHIA-MING AND CHI-MAN C
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4352
RECEIVED FROM . . . . : MICHAEL D LUNNEBORG
CONTRACTOR . . . . . . . : MICHAEL LUNNEBORG LIC # 25896
COMPANY . . . . . . . . . . : WESTERN ROOFING SYSTEMS
ADDRESS . . . . . . . . . . : 1328 WHITE OAKS RD
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (831) 278-1837
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 16, 500. 00 1 .70 0. 00 1 .70 0. 00
1REROOFRES SQ FEET 32 . 00 416 . 00 0. 00 416 . 00 0. 00
------=--- ---------- ---------- ----------
TOTAL PERMIT 417 .70 0. 00 417 .70 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- -------------
CREDIT CARD 417 .70 VISA
---------------
TOTAL RECEIPT 417 .70
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------- ---
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
Green Building Plan Check
Index of Green Building Points/Categories
A. Cate§ory Example of an Index or Table of Green Plan Sheet or Page Points
Building Points Categories that must be
shown and referenced on the Project
Plans See below
B. Site 9. Install H.E. Irrigation, (details/spec)' L-1 2 points
11. Permeable Paving, Note L-1 2 points
C. Foundation 1. Use 15 % Flyash Concrete, (note) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) S-2 2 points
6. B. OSB Sheathing, detail S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spec.) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec. A-4 2 points
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11. A 2500 Gal.Tank, (Note/Spec L-1 10 points
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (Note/Spec.) A-3 1 point
3. Energy Star Refrigerator, (Note/Spec. A-3 1 oint
P. Other 1. List Green Features on Plans A-1 1 point
TOTAL POINTS 40 points
•
Plan Review Process Work Book Page-12-Revised 3/25/08
1 �
Green Points Rating System for Remodeling Projects
Due tolhe diversity of remodeling project types,assigning a"total points'value to a project to be considered environmentally friendly is
• not feasible.However,25 measures have been highlighted to signify that every effort should be made to incorporate them into your
projects. These items have been chosen based upon their impact on the environment and the health of the home in coordination with
ease of implementation and relative low cost. These measures can be used as a starting point for"greening"your project.
. de
1.Recycle Job Site Const uction&Demolition Waste
65%=1 point;75%= 2 points;80%=4 points up to 4 Resource pts 0
2.Salvage Reusable Building Materials 4 Resource pts y=yes 0
3.Remodel for Mixed Use,Adaptive Reuse,and
Historic Preservation 4 Resource pts y=yes 0
4.Protect Native Soil 2 Resource pts y=yes 0
5.Minimize Disruption of Existing Plants&Trees 1 Resource pt y=yes 0
6.Implement Construction Site Stormwater Practices 2 Resource pts y=yes 0
7.Protect Water Quality with Landscape Design 2 Resource pts y=yes 0
8.Design Resource-Eff cient Landscapes and Gardens 4 Resource pts y=yes 0
9.Reuse Materials/Use Recycled Content Materials
for Landscape Areas 2 Resource pts y=yes 0
10.Install High-Efficiency Irrigation Systems 2 Resource pts y=yes 0
11.Provide for On-Site Water Catchment/Retention 2 Resource pts y=yesi 0
1 1 1
B.Foundation
1.Incorporate Recycled Flyash in Concrete
25%Recycled Flyash=2 points;Add 1 point for every 10%
increase of flyash,up to 5 points up to 5 Resource pts 0
2.Use Recycled Content Aggregate 2 Resource pts y=yes 0
3.Insulate Foundation/Slab before backfill 3 Energy pts y=yes 0
1 1 1
C.Structural Frame
1.Substitute Solid Sawn Lumber with Engineered Lumber 3 Resource pts y=yes 0
2.Use FSC Certified Wood for framing
(For every 10%of FSC lumber used=2 points,up to 10) up to 10 Resource pts. 0
3.Use Wood IJoists for Floors and Ceilings 2 Resource pts y=yes 0
4.Use Web Floor Trusses 2 Resource pts y=yes 0
5.Design Energy Heels on Trusses 6"or more 2 Energy pts y=yes 0
6.Use Finger-Jointed Studs for Vertical Applications 2 Resource pts y=yes 0
7.Use Engineered Studs for Vertical Applications 2 Resource pts y=yes 0
B.Use Recycled Content Steel Studs for Interior Framing 2 Resource pts y=yes 0
9.Use Structural Insulated Panels(SIPS)
a.Floors 3 Energy pts y=yes 0
b.Wall 3 Energy pts y=yes 0
c.Roof 3 Energy pts y=yes 0
10.Apply Advanced Framing Techniques 4 Resource pts y=yes 0
11.Use Reclaimed Lumber for Non Structural Applications- 3 Resource pts y=yes 0
12.Use OSB
a.Subfloors 1 Resource pt y=yes 0
• b.Sheathing 1 Resource pt y--yes 0
1 1 1
„ 1
INPUT Resources Energy
Ifienith
xtar or n a
1.Use Sustainable Decking Materials
a.Recycled content 3 Resource pts y=yes 0 O
b.FSC Certified Wood 3 Resource pts y=yes 0
2.Use Treated Wood That Does Not Contain Chromium/Arsenic 1 IAQ/Health pt y=yes 0
3.Install House Wrap under Siding 1 IAO/Health pt y=yes 0
4.Use Fiber-Cement Siding Materials 1 Resource pt y=yes 0
I 1 1
E.Plumbing
1.Install Water Heater Jacket 1 Energy of yryes 0
2.Insulate Hot and Cold Water Pipes 2 Energy pts Y--yes 0
3.Retrofit all Faucets and Showerheads with Flow Reducers
a.Faucets(1 point each,up to 2 points) Up to 2 Resource pts. 0
b.Showerheads(1 point each,up to 2 points) Up to 2 Resource pts. 0
4.Replace Toilest with Ultra-Low Flush Toilets
(1 point each,up to 3 points) Up to 3 Resource pts. 0
5.Install Chlorine Filter on Showerhead 1 IAO/Health pt y=yes 0
6.Convert Gas to Tankless Water Heater 4 Energy pts y=yes 0
7.Install Water Filtration Units at Faucets
(2 points each,up to 4 points) Up to 4 IAQ/Health pts. 0
8.Install On-Demand Hot Water Circulation Pump 4 Resource pts y--yes 0
r,erecrncar
1.Install Compact Fluorescent Light Bulbs(CFLs)
(8 bulbs=2 points,10 bulbs 4 points,12 bulbs=4 pointe) Up to 4 Energy pts. 0
2.Install IC-AT Recessed Fixtures with CFLs(1 point each,up to .
5 points) Up to 5 Energy pts. 0
3.Install Lighting Controls(1 point per fixture,up to 4 points) Up to 4 Energy pts. 0
4.Install High Efficiency Ceiling Fans with CFLs
(1 point each,up to 4 points) Up to 4 Energy pts. 0
I 1 1
G.Appliances
1.Install Energy Star Dishwasher 1 Energy pt y=yes 0
2.Install Washing Machine with Water and Energy
Conservation Features 1 Energy pt y=yes 0
3.Install Energy Star Refrigerator 1 Energy pt Y_—Yes 0
4.Install Built-In Recycling Center 3 Resource pts y=yes 0
H.Insulation
1.Upgrade Insulation to Exceed Title 24 Requirements
a.Walls 2 Energy pts y=yes 0
b.Ceilings 2 Energy pts Y--yes 0
2.Install Floor Insulation over Crawl Space 4 Energy pts y--yes 0
3.Install Recycled-Content,Fiberglass Insulation with
No Added Formaldehyde 3 IAQ/Health pts y=yes 0
4.Use Advanced Infiltration Reduction Practices 2 Energy pts yryes 0
5.Use Cellulose Insulation
a.Wells 4 Resource pts y--yes 0
b.Ceilings 4 Resource pts y--yes 0
6.Alternative Insulation Products(Cotton,spray-foam)
a.Walls 4 Resource pts y=yes 0
b.t;eilings 4 Resource pts y--yes 0
1 1 1
/
'17winclovirs INPUT Resources Energy MtHealth
1.InstaIPEn6rgy-Elficient Windows
• a.Double-Paned I 1 Energy pt y=yes 0
b.Low-Emissivity(Low-E) ( . 2 Energy pts Y--yes 0
c.Low.Conductivity Frames f 2 Energy pts y=yes 0
2.Install Low Heat Transmission Glazing 1 Energy of y=yes 0
1 1 1
J.Heating Ventilation and Air Conditioning
1.Use Duct Mastic on All Duct Joints 2 Energy pts y=yes 0
2.Install Ductwork within Conditioned Space 3 Energy pts y=yes 0
3.Vent Range Hood to the Outside 1 IAQ/Health pt y=yes 0
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy pt y=yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
8.Install Sealed Combustion Units
a.Furnaces 3 IAQ/Health pts y=yes 0
b.Water Heaters 3 IAQ/Health pts y=yes 0
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEER/11 EER or higher AC with a TXV 3 Energy pts y=yes 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts y=yes 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes 0
13.Retrofit Wood Burning Fireplaces
• a.Install EPA certified wood stoves4nserts 1 IAQ/Heallh pt y=yes 0
b. Install/Replace Dampers 1 Energy pt Y--yes 0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15.Install High Efficiency Filter 41AQ/Health pts y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes 0
1 1 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts Y--yes 0
2.Install Solar Water Heating System 10 Energy pts y=yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts y=yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=18 points) Up to 18 Energy pts 0
r6.Select Safe and Durable Roofing Materials -� 1 Resource pt y=yes 0
7.Install Radiant Barrier 3 Energy pts y=yes 0
1 1 1
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts Y_-Yes 0
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts y=yes 0
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes 0
1 1 1
0
INPUT Resouices Energy IAO/Ilealth
. n oor r ue ty en n s ea
1.Use Low/No-VOC Paint 1 IAO/Health pts y--yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAO/Health pts y=yes 0 A
3,Use Low/No VOC Adhesives 3 IAO/Hsalth pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61A0/Health pts y--yes; 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAO/Health pts y=yes 0
7.Seal all Exposed Particleboard or MDF 4 IAO/Health pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAO/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAO/Health pts y--yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y--yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y--yes. 0
1 1 1
Total Points Availableq 1 1401 130 57
Total Points Project Received:1 r 01 0 0 •
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o ( 99
CITY OF CUPERTINO
REROOF
•CUPERTINO PERMIT APPLICATION
APN # Date:
Building Address:
O 3lo Tc...s c a�• Q l ,
Owner's
Name: Phone #:
Wei i,., L•} P„� L(a? Zi R- -Ab(09
Contractor: Phone #: 10E,3`q q,-n
� (rJ Q--0jR")S 57 V�N Fax #: vkUv1;:13 3 .
Cupertino Business License #: Contractor License #:�
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) 'poc_ Other (Specify) k 1-e
Number of existing coverings ❑ Provide I.C.B.O. Report # Sj,-L(,p
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description:
T or wooA eMke � fill rdea�� At Need4.d, 40 Ns
,tiVV'% l� Mit +.lz pckr4�.-, syrUM
Residential Commercial
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the there are any restrictions: ❑
application or if applicable, include in plan
set & the sheet index.
Valuation:
I Have.Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Sig atur
CITY OF CUPERTINO
REROOF
•CUPEkTINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1RER00FC0M Re-roof Commercial B 1COMMLROOF .
IBSEISMICO Seismic Commercial B
52,
1 REROOFRES Re-roof Residential B ISFDWLROOF
( 1BSEISMICRE Seismic Residential B
1RER00FMRES Re-roof Multi-Family B 1MFDWLROOF
IBSEISMICRE Seismic Residential B
IBUSLIC Business License B
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
Fax: (408)777-3333
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance,you must agree to comply with 1997 UBC Standards
and manufacturers specifications on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City,the following steps are
required:
1) Pre-inspection and/or tear off approval.
2) In-progress inspection approval.
3) Final inspection approval.
a) Spark arrester installation.
5. If plywood is installed,a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
IMPORTANT:
1. Flat roofs must have a minimum of 1/4" per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the 'above stated policy on re-roofing.
Homeowner's Name: �e i C a r WAN 4
Job Site Address: — /()34,. TAI CA.
Roofing Company Name: Werer--%
Applicant's Signature Date:
• Greg Casteel
Building Official
Revised 11/2/04
Community Development
10300 Torre Avenue
pe
Crtino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
4§UPEI�TINO
Building De artment
JOB ADDRESS: �( PERMIT # U C R
(0 3(o c
OWNER'S NAME: Ove h
PA,, PHONE #
GENERAL CONTRACTO • Gr/eli FAX # 3ry X73
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
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ tractor Signature Date