05050120 (2) CITY OF CUPERTINO .'
BUILDING DIVISION PERMIT 's&CONTRAC�TQRIN 'URMATI�
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BUILDINGADDRESS: KEVIN SULLIVAN ROOFING PEBMITNob5050120
OWNER'S NAME: PERMIT ISSUE DATE
DNE: SANITARY O. CONTROL NO.
(408) 842-10r)7
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MMH
i on'z LICENSED CONTRACTORS DECLARATION Jobb � o O O
M 1 hereby"Al M.that I am licensed under provide..of Chapter 9(mmmeMing
with Section 700IB of Division 3 of Ne Business and Profession.Cade,and my license 6
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Dem Canlmbr
ARCHITECT S DECLA ATION L_ _
.l undemand my plans shall he used u public mord —w-+ •� .2005
Licensed Professional p
3 Oat lam exempt
DECLARATION BU�I.®I■
I hemhy affirm Net I OWNER-BUILDER
from Ne DECLARATION
License Law for the
a.0 o following moan.(Section IID 1.5,Business and Prefexair..Cade:Any city or county
a�$ which require a permit to consumer.ahem.improve,demolW,or rapelr any structure
Fly prior m its issuance.atm require the applicant foruch permit to file a signed statement
qq
that he 1,licensed pursuant to the provisions or the Commuter's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
2Wg (commencing with Section 7000)of Division 3ofthe Business and Professions Cale)or
that he u emmpt therefrom and the basis for this alleged exempdon.My violation of
Section 7031.3 by any applicant for Permit subjects the applicant to a civil penalty of 3 MN7tifter0 O Occupancy Type
not more than five hundred dollars($500).
❑I,as owner of the property,or my employees with wages Is their sole compcnution,
will do Mc work,and Ne someone is not intended or offered for sale(Sm.7W.Business Required Inspections
and Prefwu..Code:The Contractors License law does not apply to an owner of q P
property v ho builds a tm proves dmmn,and who does such wok himself or Uuough his
own cmploycw,provided than such improvements am n(nimended arairemA forsets.If,
however,the building or Improvement isuld within one yen of mmpIttion,the owner-
builder will have the bwdan of proving than he did net Wild ant Improve for purpose of
said.).
❑1,as owner of the property am exclusively contracting with licensed contractors b
coromco the loneer(Sec.70M,Business and Professions Code)The Conummes Li.
cense law does not apply to an owner of propeny who Wilds or improves themon.and
who contracts for such projects with a contractor(s)licensed punwnt to the Contractors
License Law.
❑lam exempt under Sea ,B k P C fo this moon
Owrur Dam
137." WORKER'S COMPENSATIONDECLARATION
I hereby a(Rrm under penalty of perjury one of the following declantiow.
I heve and will meintaln•CMficateof cement to u16i..um for Wieftes Compen.
.00
ion,u provided fm by Section 3700 of the labor Code,for the performance of the
rk for which this permit is issued.
1 have and will maintain Wokers Compensation Insurance,u required by Section
of the labor Code,Ter the performance of the work far which this pemtit is blued.
Worime,CCormmppensation isss rence carrier and Policy nsummbber arts:rtier.J!/.lG1S I'sM`r Policy No.:C�1�
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thissection need not he completed itthe permit is furore hund drllan({10(B
or kas.)
1 ocnify that in the performance of the work for which Nb permit 6 issued,I abet]not
employ any person in any manner an as to become subject o the Workers Compemadon
Laws of California.Da¢
Applicant
NOTICE TO APPLICANT:If.a0cr making this Certificate of Exemption,you should
become Subject to Ne Worker's Compensation provisions of the Labor Code,yeas mon
,J O faMwith comply with Such prom
visions or this permit shall be deemed asked.
,zt�-" CONSTRUCnONLENDINGAGENCY
IhembY aRnm Met du.6a eonuwtirn kndingagenry for the performance of
a the work for which this permit Is issued(Sec.3097,Civ.C.)
Q Lendeh Name
Z)z Landers Add.
U Q I certify that 1 have mad this application tad sere thin the&how Information 6
Uy^ mom I ager in comply with all city tab county ordinaaea and Sum tam relating to
0 building convection,and hereby subodu representatives of this city in crew upon the
W above-mentioned property for Inspection purposes
fi (we)ager to raw,indemnify and keep humhat the City of Cupertino against
fn liabilities,judgments,cats and expenses which may in any way accrue against mid Cloy
in L) APPLICANTs nch.
e
UNDERof the RISTANfing of I
DS AND WILL COMPLY WITH A NON-POINT Issued by: Date
SOU ECULA
Re-roofs
{nature of Applic HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will Ile applicant o future W Ilding mupentnom orhandle hnudow material
u dfisud by the Cupertino Municipal Code.Chapur 9.11.and ties Health and Safety
Cats,Section 155310? All roofs shall be inspected prior to an roofing material beim Installed.
❑Yea Qa P P Y g g
Wit the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hammous air conuminmis Is defined by the Bay Area Air Quality Management all new materials for inspection.
nrict7
❑Yes Cy T
Ihave mWthe hnaNtims 2555.255 uimmcntsundr Chmtsrd.95ofthe wilding O /
nu HuhhRSntlyhow.Seedan tat it
and155N.1 mnoledthuiftiionotn wilding 9 3
Jove not currently how a unan4 Net Vo 6 my responsibility to nobly ties acupant of the
requl hich most Wrom".facerulk,tsorOcm Signature of Applicant Date
: All roof coverings to be Class"B"or better
Owner o auoharircd agent Dam
Community Development
10300 Torre Avenue
OCF
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408)777-3333
�UPEt�TiNO
Building Department
JOB ADDRESS' PERMTr#
7 KMAJ z W . C>Se Solt 0
OWNER'S NAME: (T W Cr PHONE# !0 3`
GENERAL CONTRACTOR: 4Zn4,jJS, 51Z4,ovAi FAX#
I am not using any subcontractors:
l/ 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
ontracto ignature Date
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# 3G.oI7b" I Date:
Building Address: J
4'x7 &M,4-rE W
Owner's Name: Ph ne#
G e-- 0 936 -4-dol9
Contractor: Phone #: License#:
• 5U444 icor ?d3743'
Contact: Ph' e #: Cupertino Business License#:
i� d -D.P7`Y-cam
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
W"Asphalt Shingles Q.,`Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
0-'Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Num er of existing coverings '7i ❑ 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:
aim way ,. &tf5 30Vk
Residential Commercial ❑ JGc(1
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
gSx�
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
/11 BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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