08070161 -
BUILDING DIVISION PERMIT C®NTR.aiGTQR INFORMATIOI�T .
BUILDING ADDRESS: PERMITNO.
101.55 WESTERN DR CASTILLO' S ROOFING 08070161
OWNER'S NAME: FERMrr ISSUE DATE
JOHNSON LEROY F AND MARGARET 1703 CATHAY DR 07/23/2008
NE:
(408) 251-3565 SANITARY NO. CONTROL NO.
ARCHUECf/FF3IGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
x 0 0 LICENSED CONT0.ACT00.'S DECLARATION O O O O
4 1 bumby affirm Nat L un 1kevd uudcr previsions of Chapter 9(mmmc ting Job Description
u
wimllfmce70llU)of0ividonloftheBusineuandPrefessiomCde.uWmylicermseu RE-RF T/0 WDSHKS INSNTL 7/16" OSB 30#LB FLT&LNDMK
<gi LicenlseoCl 'ndUfett 7 Llo.I '3� `� TL SHNGLS CLS A 25SQ
k, Dau Contractor
ARCHnEC o.DECLA N
44 1 understand my plans"I le used as public mccads
�W
go Licensed Pmfessiaal
5 OWNER-BUIIDER DECLARATION
ii I 1 hereby afrrm that I am exempt from the,Contractors License Law for me
coo following moon.(Sectian 7031.5,Business and Prefessions Code:My my or County
j$ff which".I.a permit to construct.alter.Improve,demulW,or repair any smctum
iy prior On its in....also requires me applicant for such Permit m file a signed summon,
that he is licensed purwanim the provisions of the Contractor's Licmue Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 ofine Business and Professions Cade)or $11000
S $ Net he ts exempt therefrom and the basis for the alleged gumption.My Anhuion of
Section 7031.5 by any appliant far a Permit subjects the applicant to a civil penalty of �p�p Number Occupancy ore roma man five hundred dollars(SM 3 5 9110,0 2 :V U' P .y T'Pe
I,u owner of the property,or my employees with wage a Neo selo compensation,
will da the work and the automation,is not Warned ar offered for sale(Sec.7044.Bosuns
and Prefealam code The Contractor,Ucemve Law does ant appy to an owns ar Required Inspections
Propaf y who builds asimproves tMsm^,and who docs such work himulf m tlwugh his
own employe,prenbd then such improvements an,not intended moRcred forale B.
however,the building Or improvement is sold within..yeu of rnmptetion.the ownes-
builder will have the burticn of proving that he did nm bmtiW a improve for purpose of
sale,).
❑1,u owner of the proton.em exclusively conaacting with licensed oonmeton no
cautruct the project(Sec.7014,Baine and Professions Cade:)The C000acwrs U.
cense Law thea not apply to an owner of property who Wilda or improves menton.and.
who contracts for such prejeaa with a conuacmr(s)licensed puwam m time Communes
License Law.
❑Iameumqundes Set ,Bh PCfmmismasm
Owns Date
WORKERS COMPENSATION DECLARATION
1 hereby animus under prnaby of perjury one of Ile following declvatimu:
I have and will msinuin a Cenjficau ofCoueenl m self-imam for Workers Campers-
sdhn,u provided for by Section 3700 of the labor Code,fee Ne Mcfarem.of the
wont for which this Permit is issued.
❑I have and will maintain Workers Compensation Insurance,as regvised by Section
3M.f de Vbv Code,fa the poRorron.arms,work fee which this Permit es issued
My Workers Com eaatiov hmsutaur.rycand Policy number amt: Q
carrier �v� Policy N,: 73 d '01)"?'f
CERTiFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fihla smiva used antbecomplemd if the permit u forme hundred dollars($IBM
or loss.)
1 certify,that in to performance of the wort fm which this permit is issued,I shall not
employ any person in any maamrm as to become wbject to the Workers'Compensation
Laws of California.Dau
Applicant
N0`nCE TO APPUCANT.Ir,after making this Certificate of Exemption,you should
become subject On me Wooers Compensation provisions of the Labar Cod,you mute
.,O foMwim comply with such pre,bdons m this permit shall be deemed revoked. -
z rjy CONSTRUCTIONLENDINGAGENCY
[—i 1 hereby aRm this them u•c
W (See.m lending agemuy for the performance W
Ci me work a which man Permit I.issuedd(See.J097,Civ.G)
Q Lenders Nurse
z
Lenders Add.
U Q I certify than 1 have mad W a application and sou mat mo above information 4
W E cosrmn.l agree to comply with all city and County ordinance and mm laws raking to
O building eomrection.and hereby sutharian mPmsenuties of this city It,enter upon the
aW.-mentioned property fm iapection parquet
Fr+4 (WO agree to are,indemnify and Imcp humleas the City of Cupenjnn against
finliabilities,judgments,cru and eapensu which may in any way amus,age.sum City
U Z in Coastal ace of the granting of this permil. --�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REG N5.
3 d� Re-roofs
u of AppliwnOConuecmr Dau
HAZARDOUS MAng..P5 DISCLOSURE Type of Roof
Allthet e applicant m forum building ar baps entre of handle hazardous material
u dennd by the Cupertino Municipal Code.Chapter 9.13,and the Healthand Saftty,
Code.securer 25532(.)±
0Y. ffwrAll roofs shall be inspected prior to any roofing material being installed.
sen time a Bean,ar fume buildingatom cat ase If a roof is installed without first obtainingan inspection,I agree to remove
PP W egvipmCot m delle Mich
uri'haurdna air coouum o nd by de Bay AAmAir Quality Management all new materials for inspection.
ctT
pees
I have mad me huardes smauriatsroquimmc us under Chapurii.95 of the Califor-
nuHcalmkSafetyCodc.Scotiam25 .25533ad25534.1undcrsund6uifmc building
due.not currently have a enant.Net I,u my responsibility m notify me mmput of me
requcro m met Pool Signature of Applicant Date
w a 7-M
All roof coverings to be Class'W'or better
O er m morvN agent Dau-
CITY OF CUPERTINO
• 2 ITEMS OF 2 PERMIT. RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35911002 . 00
DATE ISSUED. . . . . . . : 07/23/2008
RECEIPT # . . . . . . . . . : BS000005554
REFERENCE ID # . . . : 08070161
SITE ADDRESS . . . . . : 10155 WESTERN DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JOHNSON LEROY F AND MARGARET L
ADDRESS . . . . . . . . . . : 10155 WESTERN DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2940
RECEIVED FROM . . . . : CASTILLO' S ROOFING
CONTRACTOR . . . . . . . : JOSE CASTILLO LIC # 25850
COMPANY CASTILLO' S ROOFING
ADDRESS . . . . . . . . . . : 1703 CATHAY DR
CITY/STATE/ZIP . . SAN JOSE, CA 95122
TELEPHONE . . . . . . . . : (408) 251-3565
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- -- -- ---------- ----------
IBSEISMICR VALUATION 11, 000 . 00 1 .10 0 . 00 1 . 10 0 . 00
1REROOFRES SQ FEET 25 . 00 325 . 00 0 . 00 325 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 326 . 10 0 . 00 326 . 10 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- ------------- --------------------
CHECK 326 . 10 #15214
---------------
TOTAL RECEIPT 326 .10
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
•
CITY OF CUPERTINO
REROOF
• CUPERTINO PERMIT APPLICATION
APN # I , � Date:
Building Address:
bl SS In109krn -
Owner's Name: Phone
oh ngOn
Contractor: Phone #:
Fax #: e
Cupertino Business License #: Contractor License #:
'-I:5
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ B 'It-Up roof
❑ tjsphalt Shingles o-Asphalt Shingles
Wood Shakes ❑ Wood Shakes
41 ❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
N}ifiber of existing coverings ❑ Provide I.C.B.O. Report#
o To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: TeRp—d r- � W Shakesa-h � � �D"OS6
3�I �7_e jj c.ru{ LaYld►� a� -T L Sh n hes .
5
Residential E Commercial ❑
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation:
I Have Read Understand and Will Comply with Cupertmo's Tear-Off Policy:
Sign ture
Revised 6/16/08
CITY OF CUPERTINO
to REROOF
CUPEkTINO FEE SCHEDULE .
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1REROOFCOM Re-roof Commercial B 1COMMLROOF
1BSEISMICO Seismic Commercial B
1RER00FRES Re-roof Residential B ISFDWLROOF
2S
1BSEISMICRE Seismic Residential B
IREROOFMRES Re-roof Multi-Family B 1MFDWLROOF
1BSEISMICRE Seismic Residential B
1BUSLIC Business License B
Revised 6/16/08
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: , Ib � c5
Job Site Address: I O I�y,r 1 SqS�� l/V�Q �f�'r 1Z
Roofing Company Name: l TL L.r L d.S 12 O D �4
Applicant's S' Date: 108
• Greg Casteel
Building Official
Revised 11/2/04
Green Building Plan Check
Index of Green Building Points/Categories
A. Category 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
R' T.
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 point
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
Green Points Rating System for Remodeling Projects
Due to the 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.
A.Site INPUT ResDurces Energy IAD/Heafth
1.Recycle Job Site Construction&Demolition Waste
65%'=1 point;75%= 2 points;60%=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
6.Design Resource-Efficient Landscapes and Gardens 4 Resource pts y=yes
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=yes 0
1 1
B.Foundation I
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 I
C.Structural Frame
E.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 I-Joists 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 p
I12.Use OSB -— - ---- — ----- - - - - - -- -�
a.Subfloors t 1 Resource pt y=yes p
• b.Sheathing
_ 1 Resource pt y=yes p
i 1 1
INPUT Resources
Energy IAQ1Health
D. enor Finish
1.Use Sustainable Decking Materials
a.Recycled content 3.Resource pts y=yes 0
b.FSC Certified Wood 3 Resource pts y=yes 0
12.Use Treated Wood That Does Not Contain Chromium/Arsenic 1 IAQ/Health pt y=yes 0
13.Install House Wrap under Siding 1 IAQ/Health pt y=yes 0
14.Use Fiber-Cement Siding Materials --yes1 Resource pt y0
E.Plumbing
1.Install Water Heater Jacket - 1 Energy pt Y_-Yes 0
2.Insulate Hot and Cold Water Pipes — 2 Energy pts y=yes 0
3.Retrofit ell Faucets.and Showemeads 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. D
4.Replace Toilest with Ultra-Low Flush Toilets
(1 point each,up to 3 points) _ _ _ Up to 3 Resource pts. D
5.Install Chlorine Filter on Showerhead 1 IAQ/Health pt y--yes 0
6.Convert Gas to Tankiess Water Heater 4 Eneray 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
3,Install On-Demand Hot Water Circulation Pump 4 Resource pts y=yes 0
1 1 !
r-,tiecmcai
1.Instalf ompact Fluorescent Light Bulbs(CFLs) .
(6 bulbs=2 points,10 bulbs=3 points,12 bulbs=4 points) I 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. D
4.Install High Efficiency Ceiling Fans with CFLs
(1 point each,up to 4 points) Up to 4 Energy pts. 0
1 1 1
G.Appliances
1.Install Energy StarDishwashei - — l 1 Energy pt y=yes D
12.Install Washing Machine with Water and Energy
Conservation Features 1 Energy pt y=yes 0
3.Install Energy Star Refrige ator 1 Energy pt y=yes 0
4.Install Built-In Recycling Center 3 Resource pis y=yes 0
H.Insulation
1.Upgrade Insulation to Exceed Title 24 Requirements
a.Walls 2 Energy pts y--yes 0
to.Ceilings 2 Energy pts y=yes D
2.Install Floor Insulation over Crawl Space 4 Energy pts y=yes D
13.Install'Recy¢Ied-Oontent,Fiberglass Insulation with
INo Added Formaldehyde31AQ/Health pts y=yes 0
_
4.Use Advanced Infiltration Reduction Practices 2 Energy pts y--yes D
5.Use Cellulose Insulation
a.Walls 4 Resource pts y=yes 0
b.Ceilings 4 Resource pts y=yes C •
6.Alternative Insulation Products(Cotton,spray-foam)
a.Walls 4 Resource pts y=yes 0
o.ceaings 4 Resource pts y=yes 0
1 1 1
INPUT ReWurces Energy [AlIfflealth
ndows
11.Install Energy-Efficient Windows
• a.Double Paned 1 Energy pt y=yes D
b.Low-Emissivity(Low-E) 2 Energy pts y=yes 0
� C.Low.Conductivity Frames ___ _ _ 2 Energy pts y=yes D
2.Install Low Heat Transmission Glaiing 1 Energy pt y=yes D
1 1 1
J.Heating Ventilation and Air Conditioning -
Fl.Use Duct Mastic on All Dud 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 of y=yes 0
4.Clean ail Ducts Before Occupancy 2 IAO/Health pts y=--yes 0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
S.Install Attic Ventilation Systems 1 Eneroy pt y=yes p
7.Install Whole House Fan 4 Energy pts y=yes 0
B.Install Sealed Combustion Units -
a.Furnaces 3 IAO/Health pts y=yes 0
b.Water Heaters 3 IAQ/Health pts y--yes 0
9.Replace Wall-Mounted Electric and Gas Heater 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 stovesfinserts 1 IAQ/Health pt y=yes 0
b. install/Replace Dampers 1 Eneroy 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 4 IAQ/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 31AQ/Health pts y=yes p .
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-Vifire 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
.6.Selectt 8aie and Durable Roofing Mat ad-at _ 1 Resource pt y=yes p
7.Install Radiant Barrier 3 Energy pts y=yes p
L.Natural Heating and Cooling 1 1 1
1.Incorporate Passive Solar Heating 5 Energy pts y=yes p
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts ye
p
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes 0
• 1 i 1
INPUT Resoumes Energy IAO/Health
ndoor Air Quality and Fmrshes
A.Use LowAo-VOC Paint 1 IAO/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAO/Haaltlh pts y=yes 0 •
I&Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes D
4.Use Salvaged Mate ials for Interior Finishes 3 Resource pis y--yes D
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes D
6.Use Exterior Grade Plywood for Intedor Uses 1 IAQ/Health pts y=yes D
,7.Seal all Exposed Particleboard or MDF _ _ _ 4 IAQMealth pts y=yes D
S.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes D
9.Use Finger-Jointed or Recycled-Content Tdm 1 Resource pts y--yes D
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yas 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts Y=Yes0
L.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes D
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes D
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 Avai able: 1 1401 1301 57
Total Points Project Received:1 1 01 01 0 •
G:datalpmgsrgreenbuildnog-idelinesrremodeleygreenpointsfinal212.04prolecied.x!s
Community Development
4 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
qfUPERTINO
Building Department
JOB ADDRESS:I 0 15Srti PERMIT # p
-De-- UO 0'7 of
OWNER'S NAME: 0 h n s o " PHONE # 53- -19 3
GENERAL CONTRACTOR: CMZ' lu S Pxoftp� FAX # SSI-35Cas
I am not using any subcontr -71,-,-a 3 C)
Signature Date
Please check applicable subcontractors an 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& Lo
DDwner/ Signature Date