03060158 (2) ' CITY OF CUPEW17INO ` ON,r
BUILDING DIVISION PERMITCTR.ACTORINFORMATION"
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BUILDINGADDRESS: ROOFCO OF SILICON VALLEY PERMITNO.03060158
s OWNER'S NAME: 844B EARLE AVE PERMIT ISSUE DATE
MARILYN RECTIPERn
NE: (408) 795-3335 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: _ B IN PERMITINFO
PLUMB MECH
y5�s+� 1
300 LICENSED CONTRACTOR'S DECLARATION M qb DeSCrlptl n
I Wrcby affirm that 1 sec licensed umm,pro,f.i.A..r Chapter 9leommcncing
wife Section]IXXB yr Division fthc Businumancift Iuium Cndr. ylicenanie
in
lPoO mrcemdeT[dyf. ry� '�� REROOF
y�2 Ll. Clu L�c/Y V Iltd U
~ Oafs 4 - Cumnctor O 4)
ARCHRE RATION
L ddcraundmyplans.ballbeuw ublicmcords
ALicensed Professional0
k OWNER-BUILDER DECLARATION
�2 0 1 hereby affirm that 11. exempt from the Contractor's Co License law for the
unty
which followingrerequires
Permit
703 1.5,construct.alter, and Profcemalf Cd le;Any citymroture
which rcquisu•pcmit In mirestealter,improve,demolish,Or repair any structure
-i Sr
pact miu issuance.Also acquires the
sof for such Contrator'to Rleasigned
Law(Chapter
< thMhccricinnseJ pursuant(aof Division
the Contractor's Li censclsw(Caaptery Sq.Ft. Floor Area Valuation
B (commencing with ScNon]OW)nf Division5nf the Business and ProfeuimsCmde)or
Nat he Ie exempt fecmfr.m and the bub for tbe alleged exemption.Any violation of 37525005 . 00
Section 7031.5 by any appliuro for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom Nen raw hundred dollars($500).
❑1,M owner of the progeny,or my employee.with wages as thein.[.margin m.Bon,
will do Ncwork and the Wmcture is not intended m.ffcred formic(Sec.J06a,Business — Re uired Inspections
And Professions Coda:The Contractor's License Law does not apply u an owner of 307 - I NSULAT I ON P
p rpeny who hWlds or impmws feue.n,and who dom.uch work himselforthorugh his
own employees.provided that such improvements are not Intended oroQered formic.If. 601 — ROOF TEAR OFF
h.wawr,Ne building.,improvement is sold within ons year of mmpledon.Neowner-
builderwillhavxJmburdenofprovingOathedidnotWildorimprovefarpurposeof 602 - ROOF PLYWOOD NAIL
MIa.I. 603 - ROOF BATTENS
01,As owner of the propeny.am exclusively commuting with licensed commission to 604 - ROOF IN-PROGRESS
construct be project(Sec.]Dai,Business and Professions Cotler)The Comm aloe's Li
cense taw tlrcs not apply to an owner of Format,who Wilds or improves them.n.red_
who contracts for such ptojecu wife a conmacmr(p licensed pursuam to the Contractor's
License Law.
❑1 Am emmq under Sec. .B&P C fonhls
OwnerDate
WORKER'S COMPENSATION DECLARATION
1 hereby aT m under Penalty of perjury one of Ne following declarations:
I hew And will maintain a Cenificate of Consent m self-inaure for Wallace.Compere
7'C3111
ion,u porvicsd for by Section 5]00 of the Labor Cock.fee me performance of the
rk for which this Permit is issued. _
1 haw and will maintain Worker's Compensation Insurance,M mquimd by Section
00 of the Labor Code,for the performance of the work for which Nb permit is Issed.Workee � ppensix nn .vier and Policy nure :Tu ed CERTIFICATE OF EXEMPOM WORKERS'
COMPENSATION INSURANCE
Crab satins need notWcwnplcwd if dm pemlt Is rnr.achundned dollen(SIM)
or less.)
1 certify that in Ne Permanence or the work for which this permit is issued,l Nall not
employ any permit in any manner an As be become subject o me Workeri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.afar making this Certificate of Exemption.you should
Wo.me subject at be Workers ComPenuuon provisions of the LAWS Code,you muss
.7 0 foMwith mainly with such provisions or this permit shall W Accrued mwked.
„z„ N CONSTRUCTION LENDING AGENCY
Ibemhy.M.that then in masimctinn lending spnxy for tae Performance of
yv r7 me work for which this permit Is issued(Sm.5097,Civ.C.)
�W Q Under',Name
z Lemi Address
V O I sonify that I Mw reed this application and sum that the above information is
it, f" contest.1 agree to comply with atl city and county ordinances and sou laws misting to
O V building construction,and hereby anthoimrepresentatives;ofthis city tocnWupon the
rw above-mendoncd property for Inspection purposes.
.Fa gym (We)agree to save,indemnify and keep harmless the City of Cupertino against
AI liabllides,judgmenu,costs and expenses Which May In any way Accom against Mid City
C) in^+ s peornit.
APPLM A nceof the graming UN ERSTAN ofIMNo WILL COMPLY WITH LL OINT Issued by: Date j
S GULA S. / vS B_J
/O Re-roofs
ignuure afA manVC tractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the app[icam ter future building occupant norc or handle haverdous material
As defined by fee Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Smuma 25552(.)] All roofs shall be inspected prior to any roofing material being installed.
OYet
Will the applicant or future Wilding occupant man equipment or devices which If a roof is installed without firs[obtaining an inspection, I agree to remove
It hatmdous oI,mnuro. as dromal by the Bay Arca All Quality Management all new materials for inspection.
W
❑Yu
I have mad the hazardous meter[atsrequiremenu under Chapter 6.95 ofthe Califor. ,GS�
,
.is Halm@Safety Cotle,Scetions 25505.25555 anJ233Ja.I undcrund ft if the building
!14 � � �/
Vas otmnently how.Want.Out It' rcepe
my nslhility m fee notify am upmt of the
tcy ' n hi muttbe t ' r"uvanccof.CcniOcate pm Signature of Applicant D to
Owner it eulhoriasJe m D. All roof coverings to be Class"B"or better
CITY OF CUPERTINO p
REROOF
CUPEI�TINO PERMIT APPLICATION FORM
APN # �� Date:
Building Address:
g 25A CT
;� AL
Owner's Name: MakiL nl ZECU 6 a 0 �� one
Contractor: / �1 1/aY}eone#: Z c7,..3 53 License#:-7 -7 , /7 v�
�vo�(0 � Sill Gond Y / '-1 7
Contact: '�� Phone#: 93 ���3 Cupertino B sss License#:
/ J
Type of Roof Covering:
Exiting: Proposed:
�— Built-Up Roof Buil[-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ 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 Com 1 With Cu ertino's Tear Off Policy: ❑
Job Description: aFr OlD - /A/( AI&V POP
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed withPl De t. if
—,there are an re fictions:
Cost of Pro' ons ct: v 0 Type of Ccoon: cupancy gr p:
Qty. if
A h ble 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
# z2v61'
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