04100140 (2) CITY OF CUPERTINO *
BUILDING Orns1oN PERMIT CONTRAGT,OR INFCIRNIATION`"`
BUILDINGADDRESS: WINTER ROOFING INC PERMIT"®4100143
' 19945 PRICE AV _
W NER'S NAME: PERMIT ISSUE DATE
SHIRAN CHEN 151 WYANDOTTE DR 10/21/2004
[ONE: SANITARY NO. CONTROL NO.
4083638052
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
a�ioo LICENSED CONTRACTOR'S DECLARATION .
uI hereby affirm Poet 1 am licensed under provisions of Chapter 9(commencing lob DI:SCrIpIlOn
wins�o.nt^�o 7000) DivisionJof NC Businces and Professions Cndc.end myliccnu is
��d Infml nd erfet ,
_mayfY REROOF-REMOVE WOOD SHAKES
4,gor�t ice" -- dor AD 40 YR SHINGLES
m actor
e p d A C I-s_t 6 RA ION
y r2 1 untle. my plans shall be used as public records
DyV
Licensed Pn+(cssional
OWNER-BUILDER DECLARATION
Contractor's
DN
aS 1 Ocaro affirm that I pm exempt from the Cnnuactm'a :License Law for me
o O which
re reoeon.Permian 711]1.5,Business and Pndee moll Cade:Any city Or county
m which rcyuires a permit reconstruct,almn improve,demolish,or repair any sbunum
prior to its issuance,also requires the applicant for such permit to thea signed statement (*8 0
Vis¢ thatheitcing it mounint to provisionsnl the Contractor'snd Prof Law(C Code)
Sq. F[. Floor Area Valu
4e*
(commencing axe exempt
Section Ilandth(Divisiofr the
the
egedCasa.d Professions Calc)or
that he u exempt therefrom and the basis for Ne 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 mare than five hundred dollars 4500). 36905036 . 00
Lo the work,the property,mmyentntended with wagesumei(Sec,eo Buixi ass
will Prthework,and the The
isnotimm�deJ or offered for sale(Sec,to aBusiness
end Professions Code:The Csthemon,License Law does not apply to an owner is Required Inspections
property who builds vi improves thereon,and who des such ennd hied r offered
for sgh his
howOwn ever,the
ebuiprovided provemat such improsoldwisarene year of
sate.IL FIIVALED
however,the have
the
or den of proving
is sold within one year of improv for Ne owe of
builder will have the burden of provin6 Nat he tlitl not build ser improv for purpose of
sale.).
❑ I.as owner of the property,am exclusively cmpmuing with licensed contractors to
consumer the project(Sec.7094,Business and Professions Codef The Contractor's Li NOV
10,1 yaoo4
cense law door not apply to an owner ofpmpcny who builds or improves themon,and ry V L
who contracts for such projects with a conBamons)licensed pursuant to the Contractor's
License Law. BUILDING❑1 am exempt under Sec. ,B&P C for this reason I L®I I�� '
wr Date ®1 I■U
WORKER'S COMPENSATION DECLARATION
1 hereby a0trm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insum for Worker's Compere
satinn,as provided for by Section 37W of the labor Cara.for the performance Of the
work for which this Permit is issued.
ve and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Code.for me performance of the work for which this permit is issued.
Workers Cnm nsa'on its u ec .�/anddP7Putmy number am:
Ca r: krDrNY No.: a O
y CER (FICA �OF E)(MHIONFROM W KERB'
COMPENSATION INSURANCE
(This section need not be completed if me permit is Intone hundred dollars($100)
nr IcssJ
1 eenify that in the gufmmanee Of the work for which this permit is issued,1 shall not
employ any person in any manners.as In become subjecua the Workers''Cnmpensadmi
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If after making this Cer iticam of Exemption,you should
become subject to the Worker's Compe^amion provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this perm its shall Mev
deemed roked.
„E,r CONSTRUCTION LENDING AGENCY
"rr r l hereby affirm that mere is a construction lending agency l m the performance of
(Yime work or which this permit is issued(Sec.3W7,Co.C.)
WU C) Lender's Name
= Z Lenin's Address
O Q I certify Nat 1 have ithJ this application and Stam that the Shaer information misting is
ly F building 1 agree ic comply with all city and county ordinances of and atom laws relating to
�U abovengcotioned mNrLyhcrebyeefimnmrepresentmives ul this city to enter upon the
W above-mentioned pmpcny for inspection purposcx
fy (We)agree to save,indemnify and keep harmless the City of Cupertino against
fq liabilities,judgments.costs and expenses which may in anyway seemo against said Cib '
C.)Z in cnnuqucnco of the gr ami ng of this P U.
^' APPLICA UNDERSTA SA WILL COMPLY WITH ALL NON�POINT Issued by: Date
eOURC _ULA"
-a Re-roofs
rbfic16v a Dam
NAZ OUS MATERIALS DISCLOS Type of Roof
ill the applicant or future building Occupant entre or handle hamrdous material
az in',by the Cupertino Municipal Code.Ch be 9.12,and the Health and Safety
ode,Section 25532g),
��✓// All roofs shall be inspected prior to any roofing material being installed.
❑Yea
Will the applicam or fuwrc Wing occupam use nluipment or devices which If a roof is installed without first o taining an inspection,I agree to remove
I mit Numerous air cora minmae r defined by thc Bay Area Air Quality Management all new materials for inspection.
Disuin?
❑Yea ill
I have read the havanlous materia yuircmcnu under Chapter 6.95 of the Califon
^ias no our thouns 255f 255]7 and 25534.1 undcrs fo flow building
does no ntly have a meant,m is my responsibility m n.dly the occupant I
icy ' meuwhichmu met runissuanccofaCcroics fOccu-arcy. Si a OAPP Date
e raamnrirc agent Dine All roof coverings to be lass "B" or better -
.� Community Development
,t 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
UPEI�TINO Fax(408)777-3333
Building Department_
JOB ADDRESS: PERMIT #
L — y` VL 4��-T PIP/2F9
OWNER'S NAME: / PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: 42
"Signature Date
Please check a ors d c
applicable subcontractom fete the followm* 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