05050068 (2) CITY OF CUP ERTINO *' *� -X�
BUILDING DIVISION PERMIT CONTRAC�"TOR INI+ORMATION`,
BUILDING ADDRESS: CURT FLETSCHER ROOFING INC PERMIT N 05050068
110242 CQTP3� PIT
OWNER'S NAME: PERMIT ISSUE DATE
VTPnTNTTZI TERRY
JNE: SANITARY �ftOL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
CJ t� Q
uo0 LICENSED CONTRACTOR'S DECLARATION
r� G w I thereby affirm mai I am Rarsed under pervasion Of Cooper 9(commencing Job Description
U
with Section 7").f Division Sof me Busin. it ProfessiauC dc, my license is (Y
L full fnttt And nfRc yA L
a s _/LL/wkTY
�qi ueen:e clays� Lk.n REROOF W/ASPHALT SHINGLES
Da¢ • ARCHITECTS DECD ATIO
aL 1 undersand mY plans still be mud u ED
public rtor
>a
;oG LicensedPmfessional 2005
a OWNER-BUILDER DECLARATION S
s 0 I hereby affirm i m 1 am exempt from the Contractor's License Law for the - FW`Ip`9llpp
uOO following oresA (Seddon]1131.5,Business andve.dermas Cad,:An,city saaunty
m a which myuis u a permit re construe,alley,improve.demolish,nr mash try stmcmm
Zy thatbeor its issuance.purserequires the inion of for such the Contratoi'torile a icens, ned aw(Chtemem a Lwow
< NathciactuSWithSection7 7")
sn of
eBmcess nicenslaw(C Code)
Sq. Ft. Floor Area
,Fn (Corthat he h;exemithherefrom and the
Dosis n3 the
alleged
exemptiand on.Any
Cale)of
y Natio u 31.5 b therefrom and me aper it me alleged emicant t.Any violation of
Amin.]OJLSby any imntfor apertnit subjects Nc applicant acivil penalty of 3.A,nwi,.N....,6eCOO Occupancy Type
Am mart than five hundred dollars(SSW). Ytl C`J CYtl`Y
❑Lpeowncr .to propony,wmycmploytta ed orNwage,uteirrole compensation,,Bussss
will pr fe work.and the structure oCont is not s Liana,Law
dosed not a(Sec.R1an, wner of
and property
who
builds or
Thc msdozom r Licence Law dam not apply if an owner of Required Inspections
propertywhobuildsorimprovesthereon,and who goessuchwwk himselfi through his
Own employcuipmvidedOn,rsuch improid witarenet can of
forsele.If.
howewq the building or improvement is sold a within one Weld of mmplNoq the poseOwner-
builder will have the burden of proving Nu he did not Guild or improve for purpose of
role.).
❑I,as owner of the property,em exclusively contracting wit licensed conuactoa to
construct the project(Sec.7014,Business and Professions Code:)M Commodes Li-
cense Law docs not apply in an owner of property,who builds or improve,teseon.and.
who contras for such pmjeeu with a eontracmr(s)licemod pursuant in the Contractors
License Law.
❑1 am exempt under Sec. .B h P C for Nis mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby alarm under penalty of perjury ow of the following declarations: ,
1 have and will maintain a CerdOmm of Consent to self-insum for Worker'sCompcn-
xmian,m provided for by Section 37W of the labor Cock,for the performance of the
work for which this permit is issued.
have and will maintain Workcrs Compensation Insurance,u mquimd by Section
37W of the labor Code.for be far ormancc of On work for which tis p.it is issued.
M Workers sada rand Polio nu//qp/t�Mrat//tyyam�
Came, 5 rope mgsumnm trier
/IN,rCdL—
CERTIFICAii11TEE�E OOsF FXEMPfION FROM WORKERS'
COMPENSATION INSURANCE
midis section need not he eomplemd if the permit is fw one hundred collars(SIM)
or loss.)
1 certify tat in the performance of the work for which this permit is issued,1 shall not
employ any person in any mannerm as an become subject to the Workers'Compcuadon
Laws of California.Dace
Applicant
NOTICE TO APPLICANT:If,sties making mi.Comfiest.of Exemption,you should
become subject to to Worker's Compcnsntion provisions of the Labor Co 1c,you mus
.JZ forthwith comply with men provisions or Nis po,.it shall In deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm Nal there is a construction lending agency for the performance of
the work for which tis permit is issued(Sec.3W7.Civ.C.)
W Lender's Name
fY
Z Lender's Address
U
U O 1 certify than 1 have mad this Application aM sus Nat the above iws b ion r
W U co�ct.1 qac to comply with all city And county oNimnccs and sus laws r Upon
e
O U above-mentioned pro and herfor by ism cOan purposes.rscscnutiscs of this city mcnar upon Nc
W ahavc(We) ro to sawerty for emnify ankeepl
O. (We)apse to save,indemnify and keep harmless the City of
ruCupertino against
rn in
fhegrassing expenses;which may in any way accrue agaimt aid City
U in consequence of the gaming of this permit.
APPLIC 11ryjy�000UUUQQQQppIIIIDER NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: ago Date
SOU RCGO
`S Data 6� Re-roofs
Signature HDataAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or ftnure Wilding occupant uom or handle huueous material
as defined by the Cupertino Municipal Code.Chapter 9.13.and the Bonds and Safety
Code.Section 35533(x)? All roofs shall be inspected prior to any roofing material being installed.
IdoesC Ycs
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harardnus air contaminants in defined by the Bay Arta Air Quality Management - all new materials for inspection.
,
trin]
❑ve
IhowmadmebaaallousmamrialsmquimmcnsunderChapad men
ofthe cWilling
HcalNdr Safny Code,ScNou]SN)5.355J3 and 35534.1 undcnane Nail the Wilding
rams currently new a An Na it r my maprouln ity m amity the cxcupam of tic
uimm/�rm`tp°°rmismAneenneerdrataorampmcy. Signatur ofApplic nt Date
owner tersamoriaca.g� oat, All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRES PERMIT #_
3 C�� o s-ooG�
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: S'/ZY1J
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
1p Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
SCCd! CITY OF CUPERTINO
REROOFUfToS lsS ��
bF
CUPEIITINO PERMIT APPLICATION FORM
APN # Date:
Building 3 y s3 �J
AV
Owner's Name: Phone#:
t (to r-dLS3 --5-r�?—
Co ractt n� s Phone#: License #:
Contact: Phone#: Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles - n Asphalt Shingles
mood 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: $--
b Descriptioni t1,'
rla 5bAAe5--i r I Cxs 36 6 Fd�- 06 Yh
Residential -g Commercial ❑
Fire Zone: Yes ❑ No 'fig Confirmed with Planning Dept. if
there are any restrictions:
ost of Project: Type of Construction: Occupancy group:
Qty. if
Applicable 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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