05050066CITY OF CUPERTINO'''''
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INF R_ K?RON �;
BUILDING DIVISION PERMIT
P.RACT�ORA
BUILDING ADDRESS:
CLIFFORD W COUEY
PERMIT NO.
05050066
OWNER'S NAME:
PERMIT `L SUHDATS
NE:
SANITARY Q&tOL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG PLUM
O O
LICENSED CONTRACTOR'S DECLARATION
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Job Description
1 hemhy affirm that 1 am Iicanaed under provision of Chapter 9 (commencing
-
with Section 7M) of Division 3 of the Business and Profession Code, And my license Is
in full forte ad enea
Licenc Clue Lic.g
'
REROOF W/ ASPss T,E
ED
Debt.TSDECe
ARCHr1ECr5 DECLARATION
I undenunJ my plan shall he and u public ncnrN
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_ ZU05
Licensed Pnfnshmal
OWNER- frDECLARATION
(
exempt from Cite Donlon License taw for the
I hereby .(Sero than 1 Bengt
Co
71131.5. Buahmu and Code:Any City mcounty
followingmns a. 1.
ra W. or rtpalr any srucun
armitt Improve. demolish.
which lequires s e4 albs improve,
eemso h per
pastee,slcensed issuance. also the of for each permit Io0basigned statement
quires l
loons
Camecbr'end
Sq. Ft. Floor Valuat on
(het he is licensed pumrant 7000) oprovision D3be
Prof Code) sir
(commencing with Section 7 of Division 3 of 00e BusinessandCode) or
es. My
that he ts essmpl duo(rom and she basis for the alleged examples. My violWon of
aisre ad
�A,rd),7�s7,,,.,3,
3 gS9 Fit VtE;r0 0
Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant 70 a Civil penalty of
act mart Nan frw handled dollars (5500).
❑ L As owner of dm property, or my cnpiayc m with wage, As their sole Compensation,
Required Inspections
wilt do the work. sad W) swnure is nor branded or offend far ask (Sm. 7014. Butinu,
and Pnftselon Cela: The C enuecncs Ys Liam Law donot apply b an owner of
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property, who WiIdsor improves thereon. and who duessuch work himselfor through his
own employees, provided that such improvements art not Intended an offered for talk. IL
howewr, the building or Improvement Is sold within on year of completion. the owner -
Wilder will have the burden of proving Nat he did ant Wild or improve for purpoe, of
sale.).
0 h ea uwnr of the property, am "elusively connecting wish released Cannmbrs b
rontmm the project (Sec. 7014, B"ineu end Profession Cade:) The Connamoet LI-
amse Law docs out apply b an owner of progeny who builds or improves berpon, and
who contracts for such projects whina eomonor(O licensed pursuant b be Conbma es
License taw.
❑ lomnemptunder Sea ,B&Pcforthuree.
-
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Ne following declension:
I have nd will maintain a Confined.(C.M.t In self-WarmforWerYefaCompen-
Al on, M provided for by Section 3700 of the labor Code, for 00e performance of the
work for which bio permit b issued.
❑ 1 hew and will maintain Worken's Compensation Wallace, as acquired by Section
3700 of the Labor Code, for the performance or the work for which this permit is issued,
My Warker's Compensation Ivunnce )artier and Policy number are:
Center: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This==. mood mot becampleted If the permit r loran hundred author (SIM)
or M34)
I anfy dint in the performance of the work for which Its Permit Is issued, l shall not
employ any person in my manner caboroeAubjat 70 00) Wy+a Compelled."
Laws of California. Date - I r
Applicant 6 1 `,
NOTICE TO APPLICANT: If. after making this Cen w¢ of Esemp' you should
become subject in the Worker's Compensation provision of the lahnr , you am
'
forthwith comply with such provision w this permit Alton be 0amd rewkd. '
CONSTRUCTION LENDING AGENCY
1 hereby of h m that Wren W • atmnction IeMing agency far the perfoemnrte of
art .,it for which this permit A Issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Addw..
I cenify that I haw and this application and state that the slow information Is
CorrteL I ague 70 comply with all city and cowry ordinances and sub laws totaling 70
Wilding convection, and hereby authorise representatives ofthis city meaner upon No,
above-mensiond property for InpeWon purposes.
(We) agree to caw, indemnify and keep harmle m the City of Cupertino similar
liabilities,judgments. calm and erpenes which may in my my accru)against mid City
In consequence of the Looting of this permit.
APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON -POINT
SOURCEjaULXqONS.
Sk/ 6 JOr
Issued by: Date
Re -roofs
SignmuoofApplicanVConrmbra— e
HAZARDOUS RATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant Yom or handle hmrdau material
As deMcd by be Cupentan Muni ]pal Code. Chapter 9.12, and the Health and Sarcly
,
cede. Seale. 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Ym u
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
It hemmous.1,emu ninnu &flood by be Bay Ane Air Quality Management
all new materials for Inspection.
Istria?/y
❑Yes HNu
1 haw nod In, hmandomermurlalanquinmcnr under Chapmr Q95ofthe Caiifor.
nW Health& SafetyCode. SeeGola25505,25533 ad2553/.1 undenund thoif be building
does not Currently haw a mnam, that It W my rupamibility in notify the occupant of db
m ullemcals man be mea etumew.ofa Cerdficateof ran
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Signature of Applicant Date
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All roof coverings to be Class "B" or better
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ownm aranbarise�
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Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
1 ,
PERMIT #
a oo cc
OWNER'S NAME: C -I, G otxa
PHONE # qZ
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors:
Signature Date
Please check avvlicable subcontractors and complete the following information:
Owner Contrr Signature
Date
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 Contrr Signature
Date
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CUPEII;TINO
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
APN # � / � L� --o /
Bldg Permit Fees
Date: t Z, b S
Building Address:
Energy
l{
BSEISMICRE
d
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Owner' Nam :
(Cocke
Phone #:
406 Lj�Z Z�/Q
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Contractor:
Phone :
License #:
Contact*
4 L►b
Phone #:
-4-.2—
Cupertino Business License #:
4
20
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
❑ Asphalt Shingles
G✓ Wood Shakes
Asphalt Shingles
❑ Wood Shakes
Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
❑ Other (Specify)
Number of existing coverings —X—
❑ 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 Description:
Residential It Commercial ❑
Fire Zone: Yes ❑ No ❑
Confirmed with Planning Det. if
there are an restrictions: 15
Cost of Projec : T�! of Co struction: Occu cy gr p:
SSoO
Qty. if
Aonlicable
Fee TD
Fee Descrintinn
Fre C:rnnn
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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