08080072 (2) CITY OF CUPERTINO 4x+a',roa
BUILDING DIVISIGN PERNUT ' C(]NCI2ACTOR;11 'URMA IQN, ,
BUILDING ADDRESS: PERMIT NO.
1071.5 MTNETTE DR ARMSTRONG INSTALLATION 08080072 -
OWNER'S NAME: PERMIT ISSUE DATE
I'AU1., LE, DOUX 4575 SAN PABLO AVE 08/11/2008
IF NE: SANITARY NO, CONTROL NO.
(510) 777-1234
ARCHITEC AIENGINEER: BUILDING PERMrr INFO
BLDG ELELT PLUMB - MECH
Sop LICENSED CONTRACTORS DECLARATIONO O O O
F 1 hereby affirm tiW 1 an 14eiuun
c l der PMVWGM or Chapter 9(commenting lob Description
,�
M withSadon7BW)ofDlv1Aon�3/a3fdnBusiOu"am�"l1Prypfypoman
, dmyllcmunis RE—RF FOAM OVRLY OVREXT TAR&TRVL RF CLS A 16SQ
t!�3 Lieell fora ane C37 Lk.gContractor 4atuaOly
' p Dem ARCHr1EC1'S DECLARATION
7W< 1 understand my plars,"I be mood as public records
tad Licensed Professional
OWNER-BUILDER
-BUILDER DECLARATION
I hcmby alarm that I nor
Caompt Imm the Contractoh License Law for the
D O following noon.(Satan 7011_5,Business and ProfeYiom Code:My city or county
$ which rtquinu a permit to commum.altar,improve,demolish,or mpoh any structure
3y prior to its issuance.ale requim the applicant for such permit to Ole a signed uammem
�<
that be is licensed pursuant a the providom of the CDnlmctarl Lumem Law(Chapter 9 Sq.Ft. Floor Area Valuation
3 (commencing with Section 70W)ofDivision 3ofthe Business and ProfesdonsCole)w $16000
..
data W is asrmpt thertrom and the basis fes the alcpd ea cupdon My violation of
Section 70113 by airy applicant foc a permit subjects the applicant to a civil penalty of Number - Occupancy Type
not mom than five hundred dollars500).s(5 3 7 5 3 2 0 4 5 .�
I,as ower of Ne prop",or my employes with mW as their sole compensation,
will do the work,and the smumum 4 not intended or offered for ask(Sec.7044,But.
and Protasdom Cadc That Conuamr's Lim.law does set apply m an oumr of Required Inspections
propertyend Wide wimprows Nemsn,ane whodoestachwarthi atm ror through his
own employes,provided tha such Improvements caw sat unusual"offered fnrsale IL
hawewe the building or Improvement k sold within caw leu of eampledon.the own".
builder will law the hard.of proving that he did tet build ar Improve for purpose of
ick.).
C3 1,as owner of the property,iso camuatwly connecting with licensed ennuactmt to
construct the project(SCC.7841,Bushes and Profusion Cade)The Comm m e.U.
cense law does out apply in an ownu of property who builds or Improves memos,and ._.
who contracts for surd projects with a anuacwr(a)licensed Farmers no the ConuctuYs
License law.
❑IarecaermtoxirSee .B&PCfmthkmeson
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby dam under perWly of perjury oro of the fallowing daluamm:
1 hamand will maintain
a Cenlficnm of Consent to self4m rte for Worker's Corepan
mu -
sun, pro hind for by Salon 3700 of des Lab"Code,for the Performance of the
work for which this permit is issued.
0 1 haw and will maintain Worker's Compemation Iruurana,as requirtd by Section
3700 of the Labor Cade.for the Performance of the wort for which this permit is lscmd.
My Worker's Compco m I...carrier and Policy nu rue:
Gartkr. Pen t�.rw, Poliry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This taction mad mtbe completed if De permit le foram hundred dollars($100)
or has)
1 anif,, that in the pwfwmance of the wort for which this permit 6 bound.I small oro
employ any person in any Winner an u e become subject On tre Workmaycompensadom
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If.vier making this Cenifimm of Exemption,you should
Isaacson Object an the Worker's ComPemktion providom of the Labor Cade,you most
Z foMwith comply with such p nfisiom or this permit Shall W dedmed mwkcd.
OCONSTRUCTION LENDING AGENCY
[-t I hereby alfirn that dew ha comaractinn hndiol.,nay for the perfmmmaof
0:i ft wart for which this Permit Is Wood(Sec.3097,Civ.C.)
aQ Lander,Name ,
M Z Lender's Address
U Q 1 a+dfy that I law mad We application and sum that the above infarmauun k
LL^ ratan.l tgme m comply with all city utd aunty oNinamu and swe lava mlatml m
0 SU' Wildingmwmnian.and Waby authorize repesemadwaof Nu city mmmrupnn the
[x7 abow-mendonnd pmpeny for Inspection purposes
�,t y (We)agree to Yes,indemnify and kap harmleY the City of Cupertino against .-
wn Vzl Iiabilide;Judgments.costs and eaPenva which they In any accrue agatrut said City'
V�-+ APPLICum of ERSfANDS Nu pcmtic CO P LTH ALL NON.yo Issued by: Date =— ffZ 1�
SOUR ATIONS. /
Re-roofs
SI IicanuContsseror Dak
HAZARDOUS MAig occ DISCLOSURE Type of Roof
WIII the applicant or(Muni building arupant more w handle hammm matm(al
ss de.Sed by tie Cupertino Municipal Code.Chapter 9.@.roti the Health and Safety
Code.pyre 2553x(.)7 ,�w All roofs shall be inspected prior to any roofing material being installed.
Will that applicant or future building occupant use equipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
At hmamnm tar coomeman s as mma
nby that Bay Area Ab'Quality Management all new materials for inspection.
Q., �N //�,///
❑Yon _Lktha //� �� �-
I have road the hundo us m sr'romirommts unser Cluplca&95 ofde Calif"•
nla Hcafh&SarmyCom,Sodom 25505,25533 and25534.1 utak cities ft Wiluie&
dm roti curmnd Mw a L mu it 4 my ihllity 'fy de arupant n
,equiromenu b�melpiar i of Oc a
Signature of Applicant Date
ownOr a oriaed.ant D All roof coverings to be Class'%W'or better
CITY OF CUPERTINO
• 1. ITEMS OF 2 PERMIT RECEIPT OPERATOR:, patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37532045 . 00
DATE ISSUED. . . . . . . : 08/11/2008
RECEIPT # . . . . . . . . . : BS000005743
REFERENCE ID # . . . : 08080072
SITE ADDRESS . . . . . : 10715 MINETTE DR
SUBDIVISION . . . . . . : `
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PAUL LE DOUX
ADDRESS . . . . . . . . . . : 10715 MINETTE DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : ARMSTRONG INSTLLATI
CONTRACTOR . . . . . . . : MITCH FINE LIC # 22581
COMPANY . . . . . . . . . . : ARMSTRONG INSTALLATION
ADDRESS . . . . . . . . . . : 4575 SAN PABLO AVE
CITY/STATE/ZIP . . . : EMERYVILLE, CA 94608
TELEPHONE . . . . . . . . : (510) 777-1234
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
l.BSEISMICR VALUATION 16, 000 . 00 1 . 60 0 . 00 1 . 60 0 . 00
1REROOFRES SQ FEET 16 . 00 208 . 00 0 . 00 208 . 00 0 . 00
---------- ---------- ------'---- ----------
TOTAL PERMIT 209 . 60 0 . 00 209 . 60 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 209 . 60 #1158
---------------
TOTAL RECEIPT 209 . 60
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
U
CITY OF CUPERTINO
jadwo
REROOF
*CUPERTINO PERMIT APPLICATION
APN # 2-75 Date: B�
Building Address:
I�� ►S� ��r,e � c.
Owner's Name: Phone #:
Contractor: 1 1 Phone #:
1'wAf—,jv\ Fax
Cupertino Business Licej@e #: Contractor License #:
v29 ,Z �'S
Type of Roof Covering:
Existing: Proposed:
-a Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles lo Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles NN
❑ Other (Specify) a\ Other (Specify) g r oar
Number of existing coverings X Provide I.C.B.O. Report# t k U 63 6 .
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: r&~ uVel'l. w aur �° �� ✓��
y u F�. c Ct crr
Residential Commercial ❑
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it-to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation:
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
•
Signature
II
Revised 6/16/08
CITY OF CUPERTINO
REROOF '
CUPERTINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1RER00FC0M Re-roof Commercial B 1COMMLROOF
1BSEISMICO Seismic Commercial B
1REROOFRES Re-roof Residential B 1SFDWLROOF
/6
1BSEISMICRE Seismic Residential B
1RER00FMRES Re-roof Multi-Family B 1MFDWLROOF
1BSEISMICRE Seismic Residential B
1BUSLIC Business License B
Revised 6/16/08
e
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
Fax: (408)777-3333
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance,you must agree to comply with 2007 IBC Standards
and manufacturers specifications on re-roofing. All roofs are Class "A"per Cupertino
municipal code 16.04.080.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City,the following steps are
required:
1) Pre-inspection and/or tear off approval.
2) In-progress inspection approval.
3) Final inspection approval.
• a) Spark arrester installation.
5. If plywood is installed, a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
IMPORTANT:
1. Flat roofs must have a minimum of 1/4 "per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: pu�� Le L• >"
Job Site Address: /v 641
Roofing Company Name:
Applicant's Signature: 7 Date:�D Y
• Greg Casteel
Building Official
Revised 07/30/08
Green Building Plan Check
Index of Green Building Points/Categories
A. Category Example of an Index or Table of Green Plan Sheet or Page Points
Building Points Categories that must be
shown and referenced on the Project
Plansi See below
B. Site 9. Install H.E. Irrigation, (details/spec)' L-1 2 points
11. Permeable Paving, Note L-1 2 points
C. Foundation 1. Use 15 % Flyash Concrete, (note) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) S-2 2 points
6. B. OSB Sheathing, detail S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spec.) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec. A-4 2 points
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11. A 2500 Gal.Tank, Note/Spec) L-1 10 points
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (Note/Spec.) A-3 1 point
3. Ener y Star Refrigerator, (Note/Spec. A-3 1 pollnt
P. Other 1. List Green Features on Plans A-1 1 point
TOTAL POINTS 40 points
•
•
Plan Review Process Work Book Page-12-Revised 3/25/08
Green Points Rating System for Remodeling Projects
Due to the diversity of remodeling project types,assigning a"total points"value to a project to be considered environmentally friendly is
not feasible. However,25 measures have been highlighted to signify that every effort should be made to incorporate them into your
projects. These items have been chosen based upon their impact on the environment and the health of the home in coordination with
ease of implementation and relative low cost. These measures can be used as a starting point for'greening"your project.
INPUT Resources Energy A01H.,13
to
1.Recycle Job Site Construction&Demolition Waste
65%=1 point;75%= 2 points;80%=4 points up to 4 Resource pts 0
2.Salvage Reusable Building Materials _J 4 Resource pts y=yes 0
3.Remodel for Mixed Use,Adaptive Reuse,and
Historic Preservation 4 Resource pts y=yes 0
4.Protect Native Soil 2 Resource pts y=yes 0
5.Minimize Disruption of Existing Plants&Trees 1 Resource pt y=yes 0
6.Implement Construction Site Stormwater Practices 2 Resource pts y=yes 0
7.Protect Water Quality with Landscape Design 2 Resource pts y=yes 0
8.Design Resource Efficient Landscapes and Gardens4 Resource pts y=yes 0
9.Reuse Materials/Use Recycled Content Materials
for Landscape Areas 2 Resource pts y=yes 0
10.Install High-Efficiency Irrigation Systems 2 Resource pts y=yes 0
11.Provide for On-Site Water Catchment/Retention 2 Resource pts y=yes 0
1 1
B.Foundation
1.Incorporate Recycled Flyash in Concrete
25%Recycled Flyash=2 points;Add 1 point for every 10%
increase of flyash,up to 5 points up to 5 Resource pts0
2.Use Recycled Content Aggregate 2 Resource pts y=yes 0
3.Insulate Foundation/Slab before backfill 3 Energy pts y=yes 0
1 1 1
C.Structural Frame
Vii.Substitute Solid Sawn Lumber with Engineered Lumberr _ 3 Resource pts y=yes 0
2.Use FSC Certified Wood for framing
(For every 10%of FSC lumber used=2 points,up to 10) up to 10 Resource pts. 0
3.Use Wood Woists for Floors and Ceilings 2 Resource pts y=yes 0
4.Use Web Floor Trusses 2 Resource pts y=yes 0
5.Design Energy Heels on Trusses 6"or more 2 Energy pts y=yes 0
6.Use Finger-Jointed Studs for Vertical Applications 2 Resource pts y=yes 0
7.Use Engineered Studs for Vertical Applications 2 Resource pts y=yes 0
8.Use Recycled Content Steel Studs for Interior Framing 2 Resource pts y=yes 0
9,Use Structural Insulated Panels(SIPS)
a.Floors 3 Energy pts y=yes 0
b.Wall 3 Energy pts y=yes 0
c.Roof 3 Energy pts y=yes 0
10,Apply Advanced Framing Techniques 4 Resource pts y=yes 0
11.Use Reclaimed Lumber for Non Structural Applications 3 Resource pts y=yes 0
12.Use OSB _ 1
a.SubFloors 1 Resource pt y=yes 0
• b.Sheathing_ _ _ 1 Resource pt y=yes 0
I I 1
. xtenor n s
1.Use Sustainable Decking Materials
a.Recycled content 3 Resource pts y=yes 0
b.FSC Certified Wood 3 Resource pts y=yes 0
2.Use Treated Wood That Does Not Contain Chromium/Arsenic 1 IAQ/Health pt y=yes 0
3.Install House Wrap under Siding 1 IAQ/Health pt y=yes 0
4.Use Fiber-Cement Siding Materials 1 Resource pt y--yes 0
1 1 1
E.Plumbing
1.Install Water Heater Jacket 1 Energy pt Y--yes 0
2.Insulate Hot and Cold Water Pipes 2 Energy pts y=yes 0
3.Retrofit all Faucets and Showerheads with Flow Reducers
a.Faucets(1 point each,up to 2 points) Up to 2 Resource pts. 0
b.Showerheads(1 point each,up to 2 points) Up to 2 Resource pts. 0
4.Replace Toilest with Ultra-Low Flush Toilets
(1 point each,up to 3 points) Up to 3 Resource pts. 0
5.Install Chlorine Filter on Showerhead 1 IAQ/Health pt y--yes 0
6.Convert Gas to Tankless Water Heater 4 Energy pts y=yes 0
7,Install Water Filtration Units at Faucets
(2 points each,up to 4 points) Up to 4 IAQ/Health pts. 0
S.Install On-Demand Hol Water Circulation Pump 4 Resource pts y--yes 0
r.necmcer
1.Install Compact Fluorescent Light Bulbs(CFLs)
(6 bulbs=2 points,10 bulbs=3 points,12 bulbs=4 points) Up to 4 Energy pts. 0
2.Install IC-AT Recessed Fixtures with CFLs(1 point each,up to
5 points) Up to 5 Energy pts. 0
3.Install Lighting Controls(1 point per fixture,up to 4 points) Up to 4 Energy pts. 0
4.Install High Efficiency Ceiling Fans with CFLs
(i point each,up to 4 points) Up to 4 Energy pts.I I 0
1 1 1
G.Appliances
1.Install Energy Star Dishwasher 1 Energy pt Y= as 0
2.Install Washing Machine with Water and Energy
Conservation Features 1 Energy pt y=yes 0
3.Install Energy Star Refrigerator 1 Energy pt y=yes 0
4.Install Built-In Recycling Center 3 Resource pts y=yes 0
1
H.Insulation
1.Upgrade Insulation to Exceed Title 24 Requirements
a.Walls 2 Energy pts y=yes 0
b.Ceilings 2 Energy pts Y--yes 0
2.Install Floor Insulation over Crawl Space 4 Energy pts y=yes 0
3.Install Recycled-Content,Fiberglass Insulation with
No Added Formaldehyde 3 IAQ/Health pts y--yes 0
4.Use Advanced Infiltration Reduction Practices 2 Energy pts y=yes 0
5.Use Cellulose Insulation
a.Walls 4 Resource pts y=yes 0
b.Ceilings 4 Resource pts y=yes 0 •
6.Alternative Insulation Products(Cotton,spray-ioam)
a.Walls 4 Resource pts y=yes 0
D.Uenings 4 Resource pts y=yes 0
INPUT Resources Energy AQ/Healil
mows
1.Install Energy-Efficient Windows i
a.Double-Paned f 1 Energy pt y=yes 0
• b.Low-Emissivity(Low-E) 2 Energy pts y=yes 0
c.Low.Conductivity Frames a 2 Energy pts y=yes 0
2.Install Low Heat Transmission Glazing 1 Energy pt y=yes 0
1 1 1
J.Heating Ventilation and Air Conditioning
Use Duct Mastic on All Duct Joints 71AQ/Health
Energy 0
2.Install Ductwork within Conditioned Space 0
3.Vent Range Hood to the Outside 0
4.Clean all Ducts Before Occupancy 2 IAO/Health pts y=yes 0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy pt y=yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
8.Install Sealed Combustion Units
a.Furnaces 3IAQ/Health pts y=yes 0
b.Water Heaters 31AWealth pts y=yes 0
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEER/11 EER or higher AC with a TXV 3 Energy pts Y--yes 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts y--yes 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes 0
13.Retrofit Wood Burning Fireplaces
• a.Install EPA certified wood stoveslnseds 1 IAQ/Health pt y=yes 0
b. Install/Replace Dampers 1 Energy pt Y--yes 0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15.Install High Efficiency Filter 41AQ/Heallh pts y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes 0
1 1 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts y=yes 0
2.Install Solar Water Heating System 10 Energy pts y=yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts y=yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2A kw=12 points,3.6 kw=16 points) Up to 16 Energy pts 0
�6 Select Safe and Durable Roofing Materiels 1 Resource pt Y--yes 0
7.Install Radiant Barrier 3 Energy pts y=yes 0
1 1 1
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts y=yes 0
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts y=yes 0
3,Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes 0
1 1 1
•
I
INPUT ROSDUICOS Energy MiHeafth
. n oor r ua ty an n s es • .
1.Use Low/No-VOC Paint 1 IAQ/Health pts y--yes 0
2.Use Low VOID,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0 •
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y--yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQMealth pts y--yes 0
7.Seal all Exposed Particleboard or MDF 4 IAQ/Health pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y--yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQMealth pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 1
Total olntsvela e.. 1401 1301 57
Total Points Project Received: 01 01 01e
G:datalprogsrgreenbulldingguidelineslremodelersrgreenpointstinal2.12.04proteoled.xis
e
Community Development
10300 Torre Avenue
Cupertino CA 95014
Y Telephone(408)777-3228
CITY OF Fax(408)777-3333
41f,UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
v 7IS IP. c 4R n �6cfOa7Z
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR FAX # T o , r.s
I am not using any subcontractors:
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date