03090124 (2) CITY OF CUPERTINOa
BUILDING DIVISION PER jCWN, 1CTC)It.INI''ORM �N
w ,
BUILDING ADDRESS: SECURITY ~ROOFING AIR SYSTE BF'RMITN03090124
OWNER'S NAME: - 677 - KINGS ROW PERMIT MILE DATE
P14ONE: (408) 971-1777 SANITARY NO. CONTROL NO.
HITECVENGINEER: - BUILDING PERMIT INFO
BLDG ELECT' PLUMB MUCH
a 0 0 0
I00 LICENSED CONTRACTOR'S DECLARATION lbDescription
U 1 hereby affvm that l am licensed under provisions of Chapter 9(commencing o
with Section 7ME,of Division 3 of me Business and Professions Code,and my license is
M in full fume and affect. C ratio REROOF
? License Class J' Contractor
.� FINAL I,r�®
Date TS DE LA #I„sptC-m
` ARCHITECTS DECLARATIO
E Iundcnund my plans shall Mused as public records �oOjl
toy Licensed Professional AUG 74
OWNER-BUILDER DECLARATION
aZ1 hereby affirm mat I oro exani the Ii tom-m's License Law for the
my
p o following mama(Secdun]1131.5,Business and PmfessionsCnde:Any city nr county B ILLI ly�
�m which requires a permit m construct,alter,improve,demolish,or repair any structure tLJI g a
zsa prior it)its issuance,also requires the applicant for such Permit to file a signed statement
ass that he is licensed pursuant to the provisions(if the Contractor's License low(Chapter 9 Sq. Ft. Floor Area Valuation
2Fp (commencing with Section 7")of Division 3 of the Business and Professions Cartel or
That he is exempt therefrom and me basis for the alleged exemption.Any violation of 32652074 . 00
Section]031.5 by any applicant for a permit subjects the applicant mNumber Occupancy a civil Penally Of APN NumbType
- nal more man five hundred dollars S5000._ --.-. -- - - -- - - - P Y YP ----
❑1,as owner of the property,or my employees with wages as their sale compensation,
will do the work,and Ne SWcture is not intended or offered for sale(See.II44,Business 3 05 _ qy
and Professions Code:The Carcinoma's License Law does not apply to an Owner or 3 0 7 — INSULARequired
IUN d Inspections -
,impurity who builds or improves thereon,and who does such work himself or mmugh his
Own employees,provided that such improvements rte not intended or offered for=]].If. 601 — ROOF TEAR OFF
however,me building or improvement is sold within one year of completion,the Owner. - ...
builder will have the burden of proving that he did not build or improve for purpose of 602 — ROOF PLYWOOD NAIL
aI`')' 603 - ROOF BATTENS
❑Lasotvaerofine propertyam, StOmesivnd contracting with licensed convenors to - 604 — ROOF IN-PROGRESS
cone La the pmjecl(Sec.]1w4,Business and Professions Code:)Theves thanon,and cense Law dos not m an with
a of property who sed p rs ant to an menton.or's
whocontractsLaw.for Such projects with a contractor(s)licensed pursuant to dm Contractor's
License Law.
❑Tem exempt under See. ,B&PCfar this rcazmn .
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: -
❑I have and will maintain a Certifcate of Consent to self-insure for Wmkcr's Compea-
On,az providipned for by Section 37W of the Labor Code,for the perfmromme of the
for which this mil is issued. ..
F, and will maintain Worker's Compensation Insurance,az required by Section
37W of the Labor Code,for the performance of the work forwhich this pcm,it is issued.
My Worker's Comppeensation Insurance carrier and Policy nu do am:Mai 3�
Carrier. l\*I _ POI icy No.: C 4a` e
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ecction need noW completed if the pcan it is paronc hundred dollam aU00)
Ices)
1 certify that in the perfumanee of the work for which this permit is issued,I shall not
employ any person In any manner sn az to become Subic"to the WOrkeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cent ficam of Exemption,you should
become subject lm the Worker's Com pena cion prevision$of the Labor Code,you must
_ z fordwi lh comply with such provisions or this perm it shall he deemed revoked.
zO CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
Ya , me work for which this permit is issued(Sec.3(N].Civ.C.)
1 Q Under's Name
2, z Leader's Address
1 certify that 1 have read this application and sure that the above information is
Fcorms.I agree Ire comply with all city and county ordinances and stem laws relating to
U building construction,and hereby authorize representatives of this city to enter upon me
a ahovwmeritio od property far inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rA liabilities judgments,costs and expenses which may in any way Secret against said City
;)7 in consequence of the granting Of this permit.
t� APPLICANT UNDERS'T'jA*Nl0$AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIOJJSW' 1 k `
Re-roofs
Signature of APPIKimattonoWum Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building at erre or handle hazardous material
az refined by mM
e Cupertino Municipal Code,e,Chapter 9.12.and the Health and Safety
Code,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
Yes
Will the applicant or future building accupam use equipment or davluas which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air cmumainants as defined by the Bay Area Air Quality Management all new materials for inspection.
15wa�r
itt? +No
❑Yes
I have read the hazan mus materials requirements under Chapter 6.95 of the Califon EfJ
calth&Safety Cade,Sections 25505,25533 and 25534.I understand that if the building �^ tl
not morally have a icnan4 mat it is my mapomibdhy Ire notify me Occupant or me �n I
rements which must or to issuance of a Ccnifcam of Occupancy. Signature of Applicant - Date
(QTII �R
orsummaadagentmm I All roof coverings to be Class "B"or better
CITY OF CUPERTINO
REROOF
CITY OF
CUPERTINO PERMIT APPLICATION FORM
• APN# 3 ,-L/ (,� ` O-4 Date:
lv J /
Building Address: J to ICY\ n_I� r
Owner's Name: a2A 6R I Phone#: p� p�
C/4S4 D� A /� O
Contra tor: C Phone#: License#: i
Contact: Phone#: Cupertino Business License#:
Ste-
Type of Roof Covering:
Existing: Proposed:
X Built-Up Roof � Built-Up roof
El Asphalt Shingles 13Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles Cl 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: t-�rr77
�M oto 4 4 n /evl'rL-!/
Residential ❑ Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det if
there are any restr' ons: LJ
Cost o roje Type of Con Occupancy gr:
if
able 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
ACIFIC
TATES
MANAGEMENT COMPANY.
• 2510 Stevens Creek Boulevard
San Jose,CA 95128
Fax:(408)885-9125
(408)R95-9160 .
September 15,2003
City of Cupertino
Re: Casa de Ama Homeowners Associa tion
Roof Work
Dear Sirs,
This letter serves as confirmation th it the Casa de Anza Board of Directors has awarded
Security Roofing Samoos the contract to pe fo=the roof work.
Please let us know if you have any c uestions or need additional information:
•
Sincerely.
Pacific States Management
S a C.Coffee
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NOTES : MAP SHOWS FIRST FLOOR ONLY - -
L� 3� GPS 6 DENOTES GARAGE LIVING AREA
A !_ L DENOTES MAIN LIVING AREA
F 0 5 Ti S DENOTES INTE9ICR STAIRWAY AREA
t� G N- v ptiti 0 DENOTES DiNEWAY AREA
P S P DENOTES PARRKING AREA
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- _ C 011110 LED IN CONFORMANCE MITN SEC 327
- OF THE REVENUE AND TAXATION CODE
- _ EFFECTIVE DATE MARC" 1,1975
- - _ DWIGHT L. MATH IESEN-ASSESSOR
9UIN G LIPARCEL
NONO NO
0 F F I C E O F t COUNTY ASSESSOR "• SANTA 'C L A R A COUNTY C iA L I FORN ] A
2 2 - O: M4Ry /*i° +bo AlgRY Lw-K PAGE
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