04060047 (3) CITY OF CUPERTINO
BUILDING DIVISION PERMITCmNTRACTOR INFOR�MAT—ION
BUILDING ADDRESS: APACHE ROOFING PERMIT NO 04060047
OWNER'S NAME: PERMIT ISSUEDATE
AOL YIN CHANG
NE:
SANITARY NO. CONTROL NO.
(408) 363-0205
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION
uF 1 Wuby affirm Net 1 am licensed undo visions of Chapter 9(commencing F I NAL EDeBGription
Zul wiNSeclion7 )of DivisionJof Ne Basi Profcssiom CMe.and my license is
�Z„ inraiunmelq cc VVV "�S'� REROOF
License Class Lk.s
ARCHITECTS DEC 1 1
Da Comrac NOVj I��g
In lutde—ndmypunsshallWuscdispub�lterecmi, V ( �- 2007
J�U
3O� Liccnmd Professional
3 O703L5.UILDER comesDECLARATION BUILDING
ray I herthy eRrtn that I am exempt from he Consonant's License Law far the
E p O fallowing sawn.(Section](131.3,euineu and improve.
derons Code:Any city m county
5_w which uyus u a permit m construct,slur.improve,demolish,ore a sig any a eros
_ prior to itsissuance.also uquiru tM applicant for weh pumil mfileasigned auumem
z< that Walicensed putsuanitodicProvisions ofthe ConmatersLoankc aw(Chapter 9 Sq.Ft. Floor Area Valua[Ion
YFC (commencing with Section 7")of Division 3 of NC Business and Profusions Coital or
y $ that be u exempt therefrom and ted bulk for the alleged exemption.Any violation of
Section 7031.5 by airy applicant for ap moist subjects the applicant to a civil penalty of 'ATNSl1➢fln'8er00 Occupancy Type
not mom law Bw hundred dollars($500).
❑I.uownaorthepmpmy.ormycmployaswithwaguulheirwlccompenutlon,
will On Nework.and she structure iiiaminundcd or offered forest.(See.7014,Box=,
and Probations Cade:The Contractor's Licence Law does at apply to a owner of Required Inspections
property who builds or i m proms hereon.and who does such work hi use If or though his
own employers,provided that Improvements sue notinunded oroReree for sell.IL
however.he building or improvement is sold within one year of completion,the owner.
Wilder will have the burden of proving that he did not build or impmw for purpose of
isle.).
❑1,as Owner of he prepeny,am exclusively contracting with licensed contractors to
construct he protea(Sec.7044.Business and confusions Code:)The Convector's Li.
can.Law docs not apply 1.an owner of progeny who builds or improves hereon,and.
who contracts for such purism with a contractors)liecued pis moat u IW Conlnmora
License Law.
O I am exempt under Sec. .B&P C far his moon
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby of rm under penalty of perjury am or the following emigrations:
1 bre and will maintain a Cerdbuu ofComem a self-iname for WarkersCompcn-
ution,u provided for by Station TIDO Of he Labor Code,for he performance of the
work for which his permit is issued.
�1 haw and will maintain Workers Compensation Insurance.u rtyuired by Section
3700 of she labor Cade,for the pormnammar he wart for which his permit is issued.
My Waroces Compensation lnsvrame camel and Polity number are
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTnrachouneedno Wmarripleted ifthe permilisfar on=WndmJdnllare(SIM)
or less.)
1.annoy hat in Nc performance of he work for which this Permit is Wand,l hall nut
employ any ploom in any mano=r so as he become subject to he Workers'ComPcwtim
Laws or California.Data
Applicant
NOTICE TO APPLICANT:If,after making Nis CeniOszu of Exemption,you should
become subject m he Workers Compensation provisions of IM Lahr Cade,You moa
.J O cm bwdh comply wish such provisions to his permit hal w amount mwked.
z CONSTRUCTION LENDING AGENCY
[ti l hemby solo hal hem iso mammalian lending agency Or he Nof.morou:c of
du work for which this permit lk issued(Sm.3097.Civ.C.)
[g3 Q Lender's Name
6r Lend.ri Add.
J Q 1 certify that 1 haw mad his application and sou ha h.above information is
u. F correct,T ague to comply with all city and county ordinances and suis laws relating m
O V building conswaion,sued hereby aohorim mpruenutiws of his city to enter upan he r
W show-(We)agd to save fm inspection Purposes. I
y es.ju agree to cave.indemnify esti keep ha in m the way scene,
n Cupertino agmina
UZ inconal,thince of mcmtsand ofpcnvamitcn may in anY'+'+Y accmc against said City
V z Aconsequence or the granting of his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CE RE CATIONS. ,
�OY Re-roofs
ig m ofAppJr'an onlrcmr/' au
HAZARDOUS+ ATERIAIS DISCLOSURE Type of Roof
Wit ft applicant or but uilding necupant store Or handle hacubous material
as defined by the Cupertino Munni Code.Chapter 9.12.and the Build,and Safety
Cadc,Section 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
0Ta eu
ivIf a roof is installed without first obtaining an inspection,I agree to remove
Will he applam or bums building arupam use cyuipmenl or devices which
..nl hanrdous air cconvinants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Donata7
❑Yes V
I ban mad the odauknons 2555.2553 immcnu under Chepurd.95ofhe Glding
nus no,cur Safely Calc,secteram,go,
2my.,3 and 75534.1undcrsundhaicap Wilding
Jaa not currently ham a umnt,Nat il'u my mspouihiliry 4 notil'Y the rceupant of We
imme a cbmuu W ntvriorto as M.of.Cenir g\�coapaxn, Signature of p icant Dale
verses sur ash gcJ spentDas All roof coverings to be Class"B" or better r
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37529017.00
DATE ISSUED. . . . . . . : 06/04/2004
RECEIPT ##. . . . . . . . . : 25763
REFERENCE ID # . . . : 04060047
SITE ADDRESS . . . . . : 10728 GASCOIGNE DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : YIN CHANG
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : M MEL ESCARCEGA
CONTRACTOR . . . . . . . : MEL ESCARCEGA LIC # 23025
COMPANY . . . . . . . . . . : APACHE ROOFING
ADDRESS . . . . . . . . . . : 5829 EL DORI DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95123
TELEPHONE . . . . . . . . : (408)363-0205
•E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 10,000.00 157.00 0.00 157.00 0.00
BSEISMICRE VALUATION 10, 000.00 1.00 0.00 1.00 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 158.00 0.00 158.00 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- __
CHECK 158.00 3058
TOTAL RECEIPT 158.00