04060010 (2) CITY OF CUPERTINO �• y 11
BUILDING DIVISION PERMIT CUN`.C. 1.C1?�gR'f.Nk'UXtMt1•'I'.TOI`'";
BUILDING ADDRESS: CONRAD ROOFING SERVICE PERMITNO040 is 0010
WTC'14 AV
OWNER'S NAME: PERMITISSUEDATE
RAJ RAJASI
E: SANITARY N0. CONTROL NO.
(408) 294-7615
ARCHITEL17ENGINEE0.:
BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 0
>! LICENSED CONTRACTOR'S DECLARATION
0,
0s p 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
[u{ MMSeci n7 ))of Divlslon3of Ne Businu d Professions Cade,and my license is
r � mmum dame - t� 2 t REROOF TEAR OFF INSTALL 7 16"RADIENT BARRIER
j�Z License Lk.g � r
cmmeseut OSB PAY 30 LB FELT, V10EDII$�NV 'L�HINGLES
ARCHrfECI'S DECLARA Qtll - x s
1 understand my plans ehAl he used as Puhu rdt
W
o� Licensed Professional JUN 21- 2004
3 OWNER-BUILDER DECLARATION
q 1 hereby offirm that I am exempt from the Contractor's License Law for the
00 following mann.(Section 7031.5,Business and Pat essione Code:Any city or county
k$ which requires mit n a perconala,l alma Improve,demolish.or rean
pair- y motor.IZi primal its ismance.31macquires the applicant(mruoh permiuofite a,igncd Rakment
€o that he is licensed pursuant to the provisions of the Conuacmri License law Whapar9 Sq.Ft.Floor Area ValuPCYR 3 0 0
(commencing with section 0000)or Division 3 of the Businessand Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars($500). P y Typ
I,as owner oftheProperty.oro em Io with wages Nebsole compensation,
31629094 . 00
❑ tanm Y employ=w' ge pe
will dothework,ands: he monism's Liam
Lawdo(orale(Sec.In as Business
and Professions code:The Camremon, ndwho law deet or apply lf an owner of Required Inspections
owneaywhebuilds ori dthat such improvements
sedwho doesouchwork himselfedthough his
ownemployees,provided that such improvementsamne year ofrorleered for comar.
builder,the building or improvement is seld within one year ore prove f r the owner-
bal..). will haw the burden mf proving thm he did not build or improv for purpose of
se1eJ.
❑1.as manor of the property,am exclusively contracting with licensed m"mwm m
conswd the projan(sec.7144,Business and Professions Code:)The Committee,Li-
cense law docs not apply to an owner of property,who build,or improv doctor,and
who contacts for such projects with a contractor(s)licensed pursuant to the Conuactora
License Law.
❑I ran exempt order Sr. .B k P C for thia mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby ailimt under penalty of perjury ane of Ne following d.1.6mos:
ase and will maintain a Cmificare mlConsem la azlf-insure for WorkeesCompen-
on.ax provided for by Section 37W of the labor Code,for the performance of the
work for which this Permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of to work for which this Permitl,issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier Policy Nr p0 _
CERTIFICATE OF EXEMPTION FR KERS'
COMPENSATION INSURANCE
(This section need not In completed if the Permit is for one hundred dnllam(SIM)
or less.)
1 MMUY that in the performance of Ne work for which this Permit is issued,l shall not
employ any Person in any another so n in become subject to the Workers''Compens tion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compamad on provisions of the Labor Code,you must
.�. 0 forthwith comply with such provision or Nis Permit mailbe dimmed rewkcd.
Z""' CONSTRUCTION LENDING AGENCY
[ti 4 I hereby alarm that thea is a construction lending agency for the perfurmance of
Ci> Ne work for which this permit is issued(Sec.3097,Ci,C.)
Q Lender's Name
0.
0.z Lander'.Address
U C 1 certify that 1 have mad this application and sum that Ne above inforeadon is
L4 P correct.1 agree to comply with all city and county ordinances and state laws relating to
�U building conatmction,and hereby authories mpmacntativ of this city to enter upon the
W above-mentioned property for inspection purposes
fyt y (We)agree m save,indemnify and keep harmleu the City of Cupertino against
i-t W liabilities judgments,costs and c.pcnsn which may in any way seems against mid City
f�Z in consequence of the granting or this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: -Dat
SOrE& LA N . / Y
G -0 Re-roofs
Sig ore of ApplicuNComrumr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant acre or handle haaedmus marerlal
as dcEned by the Cupeninm Municipal Crede,Chapter 9.12,end the Health and Safety
Cade,Section 25532(,)? All roofs shall be inspected prior to any roofing material being installed.
IdLr, ❑Yea [yNO
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
havardous air contaminants as tkfined by the Bay Area Air Quality Management all new materials for inspection.
ia?
❑Yes
I have mad the bo ardcus materials requirements umler Chapserb.95 of the Califor-
not
eallhA SaletyCode,Sections 25505,25533 and 25534.1 undeatand Oil ifthe building
currently haw a mnam that it is my responsibility m notify the occupant of Nemmcros the atprior W issamiza aCcrdfcmc mf cupancy. nature of Applicant [e
Ow�ier or ammrirctl opera
' — �'�� All roof coverings to be Class"B"or better
Dam
0q060010
CITY OF CUPERTINO
41TREROOF
CUPkTINO PERMIT APPLICATION FORM
* APN# Date:
Building Address: ? e {
Owner's Name: Phone#:
9 7 1,
F9 f�4jq S�� h,4C4 b ..
Contractor: Phone#: License#:
_04--705- 'Ll I6sZ
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles e 'Asphalt Shingles
e Wood Shakes ❑ Wood Shakes
Cl 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 Polic :
-7/A"
Job Description: 'I U.t- S .k . t e t.rf+�l R-r4 ,.,,f /s Kr ti o sa p r r.o
30lb. t G�Xt,A.,-z_a
Residential [ Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with P mg e if
there are an r trictions:
Cost of Project: 'z.? 300 Type of C n tru All Occupancy roup:
y
QtY
A tc 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
a -
/�8 .30
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: christya
COPY # 2
Sec : Twp : Rng: Sub: Blk: Lot :
APN . . . . . . . . : 31629094 . 00
DATE ISSUED. . . . . . . : 06/01/2004
RECEIPT 4 . . . . . . . . . : 25677
REFERENCE ID # . . . : 04060010
SITE ADDRESS . . . . . : 10332 NORWICH AV
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER RAJ RAJASIKHARA
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2446
RECEIVED FROM . . . . : POH
CONTRACTOR . . . . . . . : KEITH CARNAHAN LIC # 22297
COMPANY CONRAD ROOFING SERVICE
ADDRESS 332 PHELAN AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 294-7615
WE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------- ------ ----------- ---------- - --------- ---------- -------- --
BPERMFEE VALUATION 13 , 000 . 00 187 . 00 0 . 00 ' 187 . 00 0 . 00
BSEISMICRE VALUATION 13 , 000 . 00 1 . 30 0 . 00 1 . 30 0 . 00
---------- --- ------- ---------- ----------
TOTAL PERMIT 188 . 30 0 . 00 188 . 30 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- -- - - - - - ------- -- - ----------- ------------------
CHECK 188 . 30 10276
TOTAL RECEIPT 188 . 30
i
# Community Development
_ 10300 Torre Avenue
Cupertino CA 95014
TM� Telephone(408) 777-3228
WCITY OF Fax(408)777-3333
UPEkTINO
Building De artment
JOB ADD Ess: 1033 -2- -4ocx,3 1 cl, 4v,,, PERMIT # o
OWNER'S NA q y` t PO4fM # 2,*
GENERAL CON CTOR: 6 -.4o , FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
21 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 a��
Septic Tank
Sheet Metal
Sheet Rock
Tile
O Contractor Signature Date
10/28/03