03090119 (2) CITYIOP CUIFEWHNOe `
BUILDING DIVISION PERMI18 CONTRACTOR iNFORMAVWN::.
BUILDING ADDRESS: SECURITY ROOFING AIR SYSTE YMfr"903090119
10321 MARY AUR 4 2
OWNER'S NAME: 677 KINGS ROW PERMIT ISSUE DATE
140,"E' (408) 971-1777 SANITARY NO. CONTROL NO,
ARCIIITE-C`UENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECII
1K� G7 O O O
too LICENSED CONfRACIDR'S DECLARATION
Job Description
U U 1 hereby affirm that I am liecnwd under provisions of Chapter 9(mm cconang p
w with Sectio NXIB of Divi.' 3of Me Busines,and Professions Code,srd my damsels
Division
jqTd iafaufareenndefm.C3 "D v9'a REROOF .. .
Llccnsc Cl' a Courtrai_� ) t„� !, - t,
gyp Dam�_a�_Cnmacmr
t}` CFFii1TECTS DECLARATI r
K a I understand my plansshall M used ani records
All I I, 7000.
eaV
ay Licenwd Professional
Is as OWNER BUILDER DECLARATION
aS 1 hereby affirm that I am exempt from the Contractor's License Law lot the - SI I v
p o following mason.(Section 711315,Business and Profcsxinns Colo:Any coy nr county ( .. .'.�.�-.
<m which requires a penult la construct,altar,improve,dcmnliM,or repair any structure
230
ando In its itmance,than requires the applicant forsuch permit to lila a signed slatcnmat
5S&thatheiaueensedpursuamlameprovootmtsnrmeContractorsLicenseLiw(Chapter9 Sq.Ft. Floor Area Valuation
2'a (commencing with Soetion 7000)ol'Division 3 ofthe Business and Ptomsdans Cwle)or
i R$ that hecisempt therefrom and the basis for Me alleged exemption.Any violation of 32652009 . 00
Section 7031.5 by any apdoon,fnr a permit subJecu the applicant to a civil penally of APN Number Occupancy Type
not dt
store than five htmed dollars($500). P Y YP
❑ I,as owner of parr,party.or my employees with wages for their.sole compensation,
will do the work.and the structure is not intended ser offemd for Into(Sec.70M•1,Bmsiness
and Professions Code:The Contractor's License Law does am apply In an owner of Required Inspections
property who builds or improves Mereun,ind who does...b work himselfnrthrough his 307 — INSULATION
own empleyeas,provided that such improvemenu are not intended proffered for sale.If. 601 — ROOF TEAR OFF
however,the building or impravemna is sold within one year of completion,the owner-
but Mar will have the burden of proving that he did not build ry
or improve for puosc of 602 — ROOF PLYWOOD NAIL
sale')' 603 — ROOF BATTENS
❑ 1,as owner of Me property,am exclusively contacting with licensed emtracmrs to
renamed the project yaw.7044,11 striate;and Prntcssinns Code)lite Contractors Lt. 604 — ROOF IN—PROGRESS
we law does not appy to an owner of property who builds or an proves memos,and
who matmets for such projects with a conuacm,E)licensed pursuant to the Conoach is
Liecnse Law.
❑I am exempt under Sec. ,13&P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of tis following declarations:
have and will maintain a Certificate of Consent m sel Fissure for Worker's Compcm
workas provided for by Section 37M of the Tabor Code,fnr the pcdnrmancc of the
for which this perdu is issued.
❑1 have and will maintain Workers Compensation IaSuadox.as required by Sectio
37W of Mc Labor Code,for Bre verfmmanm of the work for which this permit is i,esued.
My Workcr'sC pensI lnsumncc c'"icrand Policy numbcrace
comm: ?l�J� F+� policy Na.: °./13o q
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nm be complered if the permit is forma hundred dollars($100)
Its”)
I ccnify that in the performance of the walk fnr which this permit is issued,1 shall not
employ any perm any mannerso u m become subjeCvo the Workers'Compenaalled
Laws of California!Dale
Applicant
NOTICE TO APPLICANT:If,after making this CcriEcmc of Estradion,you should
become a miccl la the Workcrf Compcatuden pmvisions of the labor Code,yen mast
� z forthwith Comply with such provisions or this Permit shall Five deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
1 herchy unfair Mat Mere is a counteraction lending agency for the performance of
Y. the work far which this permit is issued(See.3097.Civ.C.)
QLender's Name
3.
z Lender's Address
J p 1 ccnify Mal l have read this apPlicatinn and stem that the above information is
F-' cored.1 agree to comply with all city and county ordinances and state laws relating to
U building conswese
ction,and hereby authorise mprnms it city tivato enter upon the
U .hove-mentioned property for inspection pmpous.
(We)agree to save,indemnify and keep harmless the City of Cupc,line against
J~ fA liabilities,judgments,costs and expenses which may in any way accrue agmnsl said City '7
z in consequence of the gmming or this permit.
"-' APPLICANT UNDER TANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGUL N 34to_� a __$
"? —1 C -3 Re-roofs
Signature or AppliCATUMantracher Date
HAZARDOUS MATERIALS DISCLOSURE. Type of Roof
Will Mc applicant or future building actuator store or handle ha'zaNuus material
as dcGned by the Cupertino Municipal Coda.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? / All roofs shall be inspected prior to any roofing material being installed.
1 Yes 14
Will the applicant or future building occttpam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
40,hazardous air Canmminan6 as derned by the Bay Area Air Quality Mamagcmcil all new materials for inspection.
at?
0Ycs Nu
I have read Me hazardous masrials requirements under Chapter 695 ofthe Califon
.in Health an Safely Cale,Sections 25505,25533 and M534.Iunderstand Motiflhc building
does not curcnlly Item a t Ma it is my rcsPonsibiliry m nobly the txcupant of Mc
regm,emcnm wbiclaZ to lssu.acenr a Ccrtfiemo of ocmpretcy, Signature of Applicant Date
or -i f. I
Owner ar authorised ageat Data All roof coverings to be Class "B" or better
CITY OF CUPERTINO
aea REROOF
® CUPERTINO PERMIT APPLICATION FORM
APN # r3 a ' Date:
Building Address:) /o 33 I Pv\ ky�,
Owner's Name: /�vA Phone#: 9�
C/40 D£ AA2A
Contractor: Phone#: License #: i
SSUXj a SJ-Xrns � �/ ��� 3 50
Contact:
Contact: Phone #: Cupertino Business License#:
-Scoff �6F�n�t-�, � H �-� -t�•� 3-
Type of Roof Covering:
Existing: Proposed:
X
l"' Built-Up Roof Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
O Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report It
❑ To be Removed ❑ Provide Mfgr. installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
��Ma✓t f34,1 /�l•fh-// fj��.�
Residential ❑ Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with PlanningDe t. if
there are an res,jet,' tons:
Cost Pr ro : Type of Const OccupancyVeA
up(�
Qty. .
A 1'ca e Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
ENERGY Energy BUILDING
SEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
� Z316�
Z28. 7�
BUILDING UNIT PARCEL 0 F F I C E O F COUNTY ASSESSOR, S A N T q ,C L A R A C O U N T Y C,A L I FOR N I A
NO NO N I MgRY .:1
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- iWARY OFFICE- OF COUNTY ASS_rSSOR SANTA C L A RA COUNTY CALIFORNIA
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' 9
COM FI LED IN CONFONMANCE WITH SEC 327
OF THE REVENUE AND TAXATION COLE
EFFECTIVE DATE MARCH 1,1975
DWIGHT L. MATH IESEN-ASSESSOR
• • m
0
CASA DE ANZA a';,a;''fCO'.
Condoi ii1i"It1S_
f!lllArti[lo =c-l�l�. Ir: ACCORDANCE VATWITO
l� 9CUPERTfNO CODES AND'ORDS�. ,: II(III�'
Yp
r DATE
[h - l
silver real < ' z j IK
res{,te This set 0L-anti ' :pull:',:, atl,.
61 IIIIU
cupertinc� , kali(. ne.w ,�A:e`;''�a ZILI �Ls[n r ` °
40R ?55— -'
1070 _ '��(al'lfLS i0�-s"-�"en�.
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ozsame.rait u: �. Ltca perm# b�jc'�=�_p..� bgs lltllll4 '"S I,,,nit
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xe�ll�ll�i ,s�,anandssscatiorfl BARRANCA I Cl
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CASA DE ANZA
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condominiums
41
Calif.
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cuperlino, Calif, LU
Pt) o
silvelt re, estate
409 255-1910
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ACIFIC
NATES
MANAGEMENT COMPANY.
2510 Stevens Creek Boulevard
San Jose,CA95128
Fax: (408)885-9125 r
(408)RR5-9160
Selitetrtbe;115,20 03
City of Cupertino J�
Re: Casa de Anza Homeowners Assocls tion
Roof Work
Dear Sirs,
This letter saves as confirmation th it the Casa de Anza Board of Directors has awarded
Security Roofing Servicos the contract to perform the roofwork.
Please let us know if you have any c uestions or need additional information.
Sincerely,
Pacific States Management
8 c: Cotlee
sCst
BOD — -- --- — --
(C'p j'78
SEH 1 � ?003
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