04090228 CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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1 BUILDING ADDRESS: CROSS & ASSOCIATES PERMIT"x04090228
190
OWNER'S NAME: PERMIT I SUE DATE
SIMON LEE
7ARCHITECTIENGINPER:
NE: SANITARY NO. CONTROL N0.
408 262-
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uLICENSED CONfR R'S DECLARATION O O
11(r tent'ARirm NAt 1 am lions- )der novivaa.of Chapter 9(...leg Job Description
SatiA),(Division 3 oftho Business sad Professions Code.and my litems,ie
11 few teff I REROOF W�jmc CI Lit.N ,LII — Coral /7 '�'��, fl
9 ARCHITECTS M use DEC TION v \ / / DU _
1 understand my Plem atoll M used is rtcnrN
c Licensed Pmf,ssisnal
OWNER-BUILDER DECLARATION
1 hereby Maso anbm o n 1 1. exempt from the Contractors
ssions o License Law for my
p O following massa Permian 7fo3 LS•Business and ere,dem li Code:Ani oily Of minty
$ which its requires a permit In airs the
aper,improv,demolish,a mpnr any aaamm
pd.mitsismaaarsu ntin to lMvisionof for such COmwmil m file ZLAW(ed swemem
FgFF< NnheincingwJpmmemmNcpmvisionao the of
ni nd ProelawlChcp)0, Sq.Ft. F1oorArea Valuation
6d0 that he 6ingwit mfm7 00)ofad
basis n3 of lbc gcd axe pion.Any
CMc)ar
$
that he ts acempt tierttrom and Ne bola for W alleged exemption.Any violation of '
Secdm 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 WN9e uhber0 0 Occupancy Type
apt mom thm Rw hundred dollars(5500).
wi 1.aaw o of tie pmputy,umYot s not inmadedwIN.urges r Neo mm7044.B sanim.
will sip Newark,And the he mm mint's LMnse LAW red
s.1 applyW an caner of Required Inspections
and property
ywhiol Cade:The Conuacmfa d who law don or apply lf r t.war of q P
propertyvrho s.pro iireprovesthemon,and whorimaeuh wit himselfed through his
ownemployee,pintari prow Improvements Intendedocpr lBon.17prale H.
howew,Ne building vetmpmwment is mid within au Mean or completion,the ose of
builder will have the burden of proving that M did rot build or Improve(u purpose of
aleJ.
❑I,as ov ar of We property an exclusively contracting with licensed smnhacl.n to
concoct the project(Sec.7040,Business and Profusions Code:)The Conlncto'a LI-
came law does not apply to An owner of property who builds or improves thenen.red.
who contracts for such projects with a conawwr(s)licensed pursuant to the Contractor.
Lice.law.
❑1 Am exempt under Sec. .B&P C for this..A
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby a17fimt under pandit'of perjury one of the following decimations:IMw and will msi...•Certi cam.(Comae,m self-insure for Workers Compere
cation,As provided for by Section 3700 of the labor Code,for We performance of the
wort for which this permit is intend.
❑I have ad will m tintsm Worker'Compensation Insurance,As required by Section
3700.17 We Lanor Coto,for Ne performma of the work fuwhich this permit is luued•
My WorkarqaC m Me Immpt cecamu and Polirynumbcxue:
ter.CJ (J Polity No.: t/
CE IFICATEO•EKEMPfIONRKERS' `
COMPENSATIONINS IRV I. i
ffhismNon nede nothecumplemd tried permit is forone hundreddsllen(5100)
or Ins.,)
I certify Net in the performance of the work for which this permit is issued.I shall not
employ any person in my mannerm u m become subject in tie Workers'Compenudon
Law'of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become subject to We Worker's Compensman provisions of the labor Code,you mum
3z forthwith comply with such provisions or this permit shall be deemed revoked.
„zt Q CONSTRUCDON LENDING AGENCY
F+ )hammy.Ment Nat them is a comuuctino lending agency for the performance of
!Y> the work for which this permit u issued(Sec.3097•Civ.C.)
a0 Lenders Nano
r7 z Lenders Addmv
U Q I certify Was 1 haw:mad this application and tum Wt the above information is
cone,L I Agra to comply with all city and cmmy ordinances and mese laws minting to
building comwetion•ad hereby mNorne representatives of this city to enter upon We
4 .leve-mentioneA property for inspection put)esea
(We)agree to ave,indemnify ad keep hanmless the City of Cuarts.mom,
F to IIabIIWnjudgments,cosumdexpemu which maylnmyWayacerue againsnaid City
(„)Z in consequence of We grmbng of this permit,
^� APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: /Date '��
SOURCE ULATIONS. qq
I ���
Signet pplmanaconammr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will 0m applicant or future building occupant stem u handle hvardons material
As defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
cote.Section 2ss72(an `/ All roofs shall be inspected prior to any roofing material being installed.
[3 Yes 7)�J]No
Will me applicant AT future building accupam um equipment or devises which If a roof is installed without first obtaining an inspection,I agree to remove
emit havardnm air contaminants As defined by the Bay Arca Air Quality Mmagcmem 11 new materials for inspeGllQn.
District? \/)
❑Yes Nu
I hew mal the harardnnsmawrialercquirements under Chaptcr695ofthc Caii or, (� ^�D �D
nu llealN&Safety Coto.Suti 5.23537 uW23336.1 mdcr.tsM Nail Ne buil ng _ f/
s'not cuantly haw a sena Not itis my rtspsmihulity m a6ry the oc upant of
Mull which muude tpnor ofa Ccni ofomm Of Applicant Date
eathairedagent Daam � All roof coverings to be Class'YStOr better
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# �Q Date: _ z m —O
Building Address:,
I g b 2 O Ul
d "- Uri
- Owner's Name: h� Phone #:
Contractor: �� l Phone#: License#:
CI �o za z�51q- �36���s
Contact: u Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
O Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles * Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ 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 D ription:
+ ew Icy sh fes++ I us�w it d 1H Sh l�
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: 44 Type of Const :ti Occupancy group:
Qt
A 1' a le 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
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