04080242 (2) CITY OF CUPERTINO
BUILDING DIVISION PERIVIIT C0NTRACTOR`�INFORMATI®N
BUILDING ADDRESS: OLD COUNTRY ROOFING PERMITNO04 O 8 O242
10371 CHERRYTREE LN
OWNER'S NAME: PERMIT WOE DATE
STEVE SCHECK 125-B GROBRIC CT Q8127/2004
ONE: SANITARY NO. CONTROL NO.
(707) 864-5557
ARCHIECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOp LICENSED CONTRACTOR'S DECLARATION I� tl /� ��®
U C I hereby affirm Nal 1 am licensed under provisions of Clmpwr 9(commencing lob Descript VS�A,I9CIe//r%\\\O
U with Section]WU)of Division 3 of NC Basins and Prufcssiun,Code.and my liecrvc is
'r N in mufntuinalaffec _ >3 t REROOF W/ COMP .
jy�z Liccnu�lass +4 Q CoLie*thran., rd,.P (�..k�
OCT /Q �/5 4
�� ARCHITECTS DECLARATION V LOO1
m< I understand my Plans shall M1c tied u puM1lic records
JyU
O L'ucnttd Pmfcssionel IJ t(�p ®ss
Oat I am exempt
from
DECLARATION O U L'If� 'lul'� �j�
g<I 1 hereby.(firm that 11. exempt from the Conuenao e:License Law for the u\UVI
po following reason.(Saito Rnstr Business and Pwfcssmm Code:Any city or county
1= which rtquircs a permit na ennawel.alter.improve,demolish,or span any structure,
,fZy pnarto ittia5Wncc,al5ortquonathca,plicam orsneh'iffillofilUaignedsuiliment
< lhnheislittnsed pursutuntorec pmvi9omofthe Conwcwri Ucenec Uw(Chapwr9 Sq.Ft.Floor Area Valuation
spm (commendngwithS lion]BD13)of Div ion3o(the Businessand ProfessionsCMe)or
y
that he u exempt therefrom and the breis for be alleged exemption.Any violation of
Section 7031.3 by my,applicant for a permit subjects the applicant to a civil penalty ofGane_r 0 Occupancy Type
not marc man fin hundred dollers($500). P Y YP
❑I.an owner of the property,or my employam with wages for their sole compensation,
will do ree work and the awaum Is not intended or offered for strict(Sec.7W,Business
and Pmfes lam Cattle:The Conuacwra Lt.=Law does not apply in,a owner of Required Inspections
property who Wi Ids or improves diction.an d who does such work himself or through his
own employees,provided that such improvements are not intended or offered rmsoc.IL
however,i e building or improvement is sold within ane year of completion.One owner,
builder,will have me burden of proving that he did not build or improve for purpose of
saleL
❑1,as owner of the propert,,am exclusively contracting with licensed contra bona to
construct tic project(Sec.7014.Business and Protectionist Cade:)The Conuacum s Li
nae Law does not apply in an owner or property,who builds or improves themon,and
who contnets for such projects wit a concractor(s)licensed pursuant o the Contractor's
License law.
01.exem7pty—der�Sec. B&P�Cy far this ruson
Owner ` '7 Date
WORKER'S COMPENSATION DECLARATION
m
1 hereby affirunder penally of perjury one of the fallowing de Uirstiom:
I have and will maintain a Certificate of Consent w selbinsurt for Worker's Compere
action,as provided for by Section 3]00 of the Labor Performance,for the Performenof the
work for which this Permit is issued.
0 I have and will maintain Worker's Compensation Insurance,as required by Section
3]W of the Labor Code,for the performance of die work for which this permit is issued.
My Wm k�cte,Compe�ns!atio�n 1��sun��n--c carr
ier and Polity number are:
CartAier: ikokl3.aan+t!/sv.Tf�policy No:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
COris section need not he completed little fcrunit is forone hundred dollars(SIM)
ver Rs.)
1 certify Nat in the performance of the work for which this permit is issued.I shall not
employ any person in any mannerso m in become subject o the Workers'Compensation
Laws of California.Dam
App]31
NOTICE TO APPLICANT:If.Offer making this Car ificam of Exemption,you should
become subject to the Worker's Compensation provisions of Ne Labor Code.you must
0 O forthwith comply with such provisions or this permit shall the deemed revoked.
z CONSTRUCTION LENDING AGENCY
[�. I hereby oRrm that there is a em¢wnion lending agency torte Performance of
tY
be work fur which this permit is issued(Sec.3097.Civ.C.)
D7 Q lender's
6. lender's Adtlm..
L) I certify that I hen read this application and sum thin die above ws on refiling is
0 U torten.1 agrte w comply wire all city and county hrdinanccs and cute laws refining e
0 U lihowngconsoed propond hcrtbYaureome«osis. tins of his city mcnmr upon the
04 ahavc(We) cd pmpcny for inspection purposes.
No
(We)agreewsaw.indemnify and keep hay is any
Uw City or ligiumno against
UZ inconser,om menhe graving eapomeswhich may in,nywaysecret aganslsaitl City
U z meonseANT NDER TAN of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat
SOUR
CER U(ATIONS.
Re-roofs
Sig--nmurc of ApplicandCmnracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of furore building acuPa^t sem or handle hasel material
u de1ncd by the
Cupenine Municipal Code.Cbapmr 9A2,and the Health and Safety '
oda.Scednn 15532(7)? T�,y�� All roofs shall be inspected prior to any roofing material being installed.
Cl Yes T
Will mea applicant or future building Occupant use a If a roof is installed without first obtaining an inspection,I agree to remove
nn s p a Air a vet devices which g
emit ha>aAnus air contaminants m defined by the Bay Arca Air Quality Managcmcnt all new materials for inspection.
Disvia?
❑Ycs 9�No
IhavcmaddiehaMousmawrialsmquimmanmunWrChapwr6.95ofrec Caliror-
niaMwlth&SmctyCode,Sccdan155o5.25533ud25M.lun&rw ifdw building t!—Z'� ..Uf—(
Joes not cunendy hart a mnanl,Nat it u my mspomihility w nodfy the axupant of the li�l o
recut rtmcntsw ch abc met p�rior)w issuance of a Ccrdf¢ate of Oc(c�upancy. SI ure Of pplicant Date
owner or aumanvad ascot Date All roof coverings to be Clas ,B"or better
CITY OF CUPERTI`O
REROOF D � C)E2
CUPEkTINO PERMIT APPLICATION FORM
�P` z 3 (g 3 3 C) v�3 Date:
O. cer's Name: Phone #:
c{✓ c- SG IG_cIL I & 6-,o 9y ob
Con,.-actor: Phone #:
O U A)i tL,4 �04DM 4/G � License
Czq C
�-b'a `r3oo
Con tct: J/ Phone -: 4/ p FR Cupertino Business License #:
L cSs /\csTCil l✓i�l �' a, g-30 a O < � e/
Type of Roof Covering:
Existing: Proposed: f
i 7 Built-Up Roof Z3 Built-Up roof
7 :\sphalt Shins!es X Asphalt Shingles
Wood Shakes ❑ Wood Shakes
7 Wood Shin_Ies :1 Woo Shinsles
7 Other (Spe-Ir. ) ❑ Other(Specify)
Nurnber of existing coverings 7 Pro%ide I.C.B.O. Report #
7 To be Rerioeed O Provide %Ifsr. Installation Specs.
Fla%e Read. Understand and Will Compl% With Cupertino's Tear Off Policy
Mb Description: Csxisi iti'u
NS.r osis 310 r�f�- Y D
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning D, ept. if
thereare any restrictions: L1 j
Cost Project,. Type of Const ction: ancy group:
`J Oo cs o F 3
A l'cab e Fee ID Fee Descri tion Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
/ BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDL IG
BPLANCHK Plan Check Fee BUILDING
BUSLIC j Business License 13ULLDL-NG
� I
66
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