06020078 (2) CITY OF CUPERTINO fi^ ' '% AT,IO -'
BUILDING DIVISION PERMIT � A
CONTRACTORINFbN
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BUILDING ADDRESS: WAGNER ROOFING CONTRACTOR "BIWL""o06010078
OWNER'S NAME: PERMUT ISSUE DATE
STRETHER SMITH 12242 SARA 01/13/2006
)NE: SANITARY NO. CONTROL NO.
(408) 777-8331
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION lob Description
O O O
U 1 hereby affirm that I am liaved under provisions of Chapter 9(commencing p
with Seetion 700Bof Division 3 ofthe Businexsard Professions Cods,and my license is
n in lull10,eMddffect. s� 8 REROOF--T/O SHAKE, INSTALL SHINGLES
j Z Liccnm Cl1ass Lie.as p� �^�'
n r� Dale t9l'— CT`S D[tor �8 � �3
pp ARCHTfECI-SDECL9 ATI It[rtJ`�_'..-'iA r��y
ii C-s I understand my plaos shell bo used as public mcn
'Eu
g0G Licensed Pmfcssional
3 OWNER BUILDER DECLARATION JAN
�?(M 1 kmby affirm Nal I am exempt from the ConlrutaYs License law for sbe ry G(7 �oo fi
r 0 O following mason.(Sec4on 7031.5,Business and Pmfexaons Code:Any city or county
'� i which requires a permit to Construct,shot,improw,demolish,or repair any structure ll
— riser m its issuance,also rex use 1'c Ifor such l to rile a signed sucrown An.z --"' "' 1075(]
i t P m to pp b an sorrel g
X othat 1%fcomencingwJpurwao7000)ofDdo ivionofft oftheBuacmr'andNofaw(CTapter9 Sq.Ft. Floor Area � `vlaluation
a;�$ that M is exempt
Uncomfoan nd of bassison3 the al Business endon.Any=
Of LV fi ff �-t7q�gyTs
that he u 31.5 b Nem from and the beer for ube alleged exemption.Any l Pennon of LLLaII i!W U �ry�
not more
them five
airyapplicant for apermit subjects tre applicantbacivil penally of3 AIR
not more dun tiro hundred dollars(SSOD). r Occupancy Type
❑L t awnm of Ne property,m ix employees with wage u their sole compensation,
will do Ne work,and the he Com is nae intended or offered foaale(See TWA,B nor of
and enywhoW code:The wstren on,License law doe,Out apply lf an usurer ar Required Inspections
propertywho Wilds provided unthawsthereon,and who himselfor Ito
awn ver,th eex, inori that such improvements are not ear of
On offered for sale. r- '
builder,llle building or improvement is sold within one year of completion.NCpmee of
builder will have Ne burden of proving that he did not build or improve for purpose of
sok.).
❑1,as owner of the pmpeny,am exclusively conlruting with licensed ronaumrs to
Conswct the pmjeci(Sec.7014,Business and Pmfexdans Code)The Conautm's Li.
cove law docs not apply to an owner of property who builds or improve thereon,Md.
who crot"Cls for such pmjecta with aeon amor(s)licensed pursuant m the Contractors
License law.
[II am exempt under Sec. ,B&P C for this mason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby aRirese under penalty of Perjury one of the following declarations:
I haw and will maintain aCmtifiate of Covent to self-ivum for WorteYsCompen-
13700.1'
on,u Provided for by Section 3700 of the labra Code,for the NiformOna of the
rk for which this permit is issued.
1 have and will maintain Worizes Compensation Imurance,as required by Secdon
Ne labor Code.for theuformTintt of the work fm which Nu permit is issued.
Wohers Com vatioaInn artir and Policy number oto:
rtier: J_�Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This union need not W completed if the Permit is for one hundred unit=(5100)
or ksx)
T certify that in rte performance of she work for which this permit is issued.I about not
employ any permn in any manner an as to hmome subject to the WVrkerl Compessauon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker a Compensation provisions of the I Mor Code,you most
.JO faMwith comply with such provision or this permit shall be deemed revoked.
71 CONSTRUCTION LENDING AGENCY
Ihereby Afro,Nat then is a eonsuuction lending agenry,fm the performance of
C' Ne work for which this permit is issued(Sec.3097.Civ.C.)
{T7 Q Lender's Name
0. Under's Add.
DZ
U0 !lordly Nu 1 have mad this application and sate that the above infortvtion is
D. FCOMM l agree to comply with all city and county ordinances and stale laws totaling m
C)U building construction,and hereby authorim representatives of Nis city in enter upon the
purpo
aharo-es judged propertycosts
fond Ox a rows which ex
F C (We)agree to saw.indemnify and keep harmless the City of Cupertino against
Iq
liabilities judgments.costs and apcnscs which may In any way ucmc against sod City
U z in consequcneo of the granting !this permit.
^ APPLICANT UNDERSTA S AND WILL COM WITH ALL NON-POINT Issued b
SOURCE REGULATIONS. y' Date Q
Re-roofs
SlImatum of Applman, ter Date
DOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building occupant store or handle hvardous material
as deftud by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Codc,Section 25332(a)?
❑Yes irlfNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtainijlg an inspection,I agree to remove
W-1dnm air conumivnu as defined by the Bay Ama Air Quality Management
Disericl7 all new materia for inspection.
❑Yes ` :QNo
I have read llrrdmxm3lmlals rtquimmo underCltapter6.95 olthc Califor. C
ria HZuem Sal od ttormoru235Ds.2531J troy er"md NatiflfM building / / / — M / _!� �D
ddu nal Curt[ y mo i rcnan4 NBl its
y ibililY b IMti(y TIM 0.iupanl of do, (/L-!� (.l l f l3
rcquimmenD hmuRbemelpon'to van a'enifaaorOcapaney. Signatu Of plieant Date
owner autho' dagcnt pato All roof coverings to be Class"B" or better
:x
Community Development
10300 Torre Avenue
114
4W' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEf�TINO
Building Department
JOB ADDRESS: PERMIT#
6131 Dy- OS 0 t-"») 7 0'-'-
OWNER'S NAME: S re er 5yvj'Jj, PHONE # ty&3 — 8331
GENERAL CONTRACTOR: W , FAX #
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
12-21-2005 14:53 PRGE:1
CITY OF CUPERTINO G o
REROOF
DUPE INO PERMIT APPLICATION FORM
APN# � �—/ (/ oQ Date: —�3- 2ooG�
Building Address: a 31 p
rt?.S UtG IL.
Owner's Name: Phone#: 95-7-38o3
/192. - "7.eT Gr Svr,."�l)
Contractor: Phone# License#:
Contact: Phone#: Cupettino Business License#:
sift a ti,, 7y7-'333 1
Type of Root Covering:
Frisking: Proposed:
• Built-UP itocf O ,Built-Up roof
• Asphalt Shingles R( Asphalt Shingles
W
6✓ Shakos u ,.W,oed Shakes
U WmdSkhWa
u Other(S ) p�On (Spoiyesj Sy YrgA_ 451 •'b<rglaSS �.!�45,
Nutahar of esisting covenage I o �raviije
I.C .O.Refit• V L *94 7
T.6e Removed O Provide Mfg.imWlation Specs.
I Have Read,Understand and Will Comply With ino's Tear Off Policy:
JobDescriptitm: &rno e Si"Jte jzw 77iv5 nrec.tr Sv y2 C/abs
,bt, 1'SS 5('+.+� �S #3v ST^) ✓.�>er ,•K• t✓ OS/
Residential V Commercial 0
Fire Zone: Yes ❑ No 2— Confirmed with Planning t.if
there are any restrictions:
Cost of Pmjtxt: Type of Construction: Occupancy group:
9 io 7sro '"
Qty. if
Applicable Foe ID Fee Pescri [ion Fee Grow
BPERMFEE Bl P&adt Fees BUIDING
BENERGY Ener BU"ING
BSEISMICRE Seismic Fee Res BUBAING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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