03090122 (2) CITY OF CUPLIYI'INO
BU LDING DIVISION PERm.10 CONTRACTOR,INFORMA 1Nk_.,.,
Bat LDING ADDRESS: SECURITY ROOFING AIR SYSTE CCR"ITN®3090122
0 W NER's NAME: .7PERMIT ISSUE DATE
677 KINGS ROW
rqA IIE ANTzA RnA 03
(408) 971-1777 SANITARY NO. CONTROL NO.
ARCI IITICTIENGINEER: RUILDI NG PER M IT INFO
BLDG ELECT PLUME MECH
fop LICIiNSED CONTRACTO0.'S DECLARATION C] O O O
�as 1 hereby affirm that I am liecnmd odder movi,inns of Chapter 9(eo nme.emg Job Description
zjot with Section 7fkMpof Divixi n3 urth,Businessan mfcaient Code,andmyliecnsci,
? N In full force and effect REROOF
e y z Llccnse Class C39 Lic.N
LAR�{IITf:CPnOP_tor N
C w a 1 understand my plans shall nc used as public records
r -1 L Il
.may Licensed Pndcssional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Cnntmoor'a License Law lot the
00 lidlowing risen.(Section 703L5.Business and Prof,..tor,Code:Any city or county V11'
<m which requires a permit to construct,alter,improve,demolish,or repair any strectum '
u on our toils witant'e.al6noncimea meapplinanlfor such parmilto file ruiliolmaterrom
a o mat he i,licensed puauatn In the provicomeofthe Contractor,Lie,n.:c Law Charter 9 Sq. Ft. Floor Area Valuation
CI—$ (commencing with Section 7100pof Division 3df the Business and Professions Code)or
i .. mat he is exempt therefrom and the basis for the alleged cacmption.Any violation of 32652056 . 00
Section 7031.5 by any applicant for a permil subjects,the applicant¢t a civil Penalty of APN mNumber Occupancy Type
not more an five hundred dollars(S50a).
I] I,as owner of the mbpbay,or my nnpinycca with wages as their into eempcnsitinn,
wi 11 do the work,and the structure is not intended or offered for sale(See.? W'Business 3 115 - FRAME
and Pmfcssienx Code:The Contactor',Doient,Law does nm apply man owner of Rec�wired Inspections
property who hui Ids or i mptnvesthereon,and who aces such work himsef or through his 307 - INSULATION
om
, pmo
y,,,pmvidetlthat,uch impmts
roveenare no,i mended ur offered I.,saln.If,
howevcq the building or impmvcmem is sola within one year of completion,the owncr-
601 - ROOF TEAR OFF
builder will have the bora,.of proving mal he did oral build or improve for panic.of 602 - ROOF PLYWOOD NAIL
:ala.). 603 - ROOF BATTENS
1, owner of the property,am exclusively contractingpecrwith licensed r contractors to
construe'Lathees hot apply
owner
andrty won builds
Code:)The ConOamor's Lj-and. 604 — ROOF IN-PROGRESS
whse Law doe,not apply m an own,(or property wce sed p or improves Commences,dna.
o contacts for such projects with a rnntranor(s)licensed pursuant m @e Conbacwrs
0 am Law
❑ .
laexempt Under Scc. ,B&PCfor this rcann
Own Date
WORKER'S COMPENSATION DECLARATION
1 hereby oflon under Penalty or perjury one of the following declarations:
1have provided
for
lnector,37W(ifthe Code,
fieferforma Compere
amino,as hick(hi for by Benson 3700 of me Libor Cnae,for We performance of the
ark for which this Permit is issued.
❑1 have and will mainmin Worker's Pandemonium Insurance,a required by Sermon
3700 of the Labor Code,for me performance of me work far which this p,mtit is issued.
My Workers Cempensmit Insu+ dyer and Policy nu b1�7
Cartier: Policy No.: 7
CERTIFICATE OF EXEM ETON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M:complce d iDre permit is fornuc hundred dollars(51(kl)
v less.)
1 certify Ihit in the pwforommee of the work for which this Pvmit is issued,I shall not
thorny any person in any manner sal as it,become suhject to the Workers'Compensation
Laws or California.Dam
NOTICE TO APPLICANT:If,alter making this Cerrifieale of Exemption,gnu should
became subject to the Worker's Compensation provisions of the Labor Can,you must
= 0 forthwith comply with such provisions or this Permit shall M deemed revoked,
CONSTRUCTION LENDING AGENCY
I hereby affirm that mere is a emrsbumion lending agency for the pc morn ante of
1' > the work far which this permit is issued(Sce,3097,Civ.C.)
Q Leidens Name
Z
Lender's Address
J Q 1 comfy mat I have read this application and sham that the above information is -
J. H correct.1 agree to comply with all city anti county ordinances and state laws rclming to
J V building constriction.and hereby authoriac representatives of this city to enter open the
a ebovcfe,judncd Property for iexpenses
ponies purposes.
r (We)agree to save,indemnify and keep harmless the City of Cupertino against
y in consequnce of thecoasand of
csmit. may in any way accmc against aid City
z A consequence UNDERSTANDS
of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIRe
OyFf�,
I/TN�FJ f(x—?
Signature ofAPPlicaHAZARDOUS MATERIALS DISCLOSURE �CfradmirDac Type of Roof
Will me applicant e,future building occupam share an handle havardous material
as derned by the Cuponino Municipal Cede,Chapter 9.12.and the Health and Safety
Code Senion 25532(.)? ,��1��
E3 yes `�'� All roofs shall be inspected prior to any roofing material being installed.
Will the a Tieant or future building toot! ant ove If a roof is installed without first obtainingan inspection, I agree to remove
PP 6 p .Air int or devices which p g
mit ba,.amuu,air conaminanm a demmd by me Bay Ama Ah Quality Management all new materials for inspection.
Distdn7
❑Yes No
I have mad me hamNfmmcrodsrequiremors under Chapter 695 of the Cali fon �� C'z_'
/
Dia HcalthffiSafmy Calc,Scc0ons 255(15,25533 and 25514.1 understand mal if the builmr, 1 __ z_''s.� /
does not currently have a tenant,mat iI is my responsibility m ammy the occupant of the V
requoicachaswhich must bemetprionnissuanceofaCenifsided, lccomm,. Signature of Applicant Date
1 t
_I �'
Owner or sumori,ed clam, D„e All roof coverings to be Class "B”or better
CITE' OF CUPERTINO a � z Z
S(Mzv, REROOFCITY Of
3
CUPERTINO PERMIT APPLICATION FORINT
APN # 31fc S' _ U_�_(, Date:
Building Address: %�
/ 0 rl "� M ki\-- 4
Owner's Name: Phone#:
C/M Df 4a20 /10A 80 7/ Cvc7
Contractor: ( Phone#: License#: i
Contact: Phone#: Cupertino Business License#:
Still •�/knLt-/� � 9 �-I -!�•� �
Type of Roof Covering:
Existing: Proposed:
/" 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 Description:
Residential ❑ Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with PI ning-Dept. if
there are anyr rictions:—
of Prgjec CLD Type of Cons Occupancy oup
Qty. if
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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