08080144 (2) CITY OF CUPERTINO
BUILD1,NC DIVISION PERMIT DONT U'OTORWORMA"L N -?
BUILDING ADDRESS: PERMIT N0,
21.567 ROSARIO AVE WESTSHORE ROOFING INC 08080144
OWNER'S NAME: FBRNOT ISSUE DATE
CHENG WIN S AND REI J 2814 AIELLO DR C 08/19/2008
lipNE: SANITARY NO, CONTROL NO,
ARCHRECOENGINEER: BUILDING PERMMINFO
RE—RF RNV 1LYR WDSHK &INSTL BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTORS DECLARATIONISERARB
O O O O
1 hereby affirm than I an Essential under proNsiov of Chapter 9(commencing - ,-- Job Description
whhifice .def DiNdon Ja(the Business and Profesdov Code.and my hcerdau
�Zd LI ern r Cis er d. 2Z
LloevcC — � Uc.N U '
ICE ARCHITECTS DECLARATION
eeZZ I unticrsunJ my plw shill be taxed as public raortla
yo Licensed PmfessionAl
a OWNER-BUILDER DECLARATION
1 hereby alum Nat 1 am exempt from the Conuanoes License Law far No
E O O fallowing reason.(Section 70313,Budmss and Piefessf ms Calc:My city or roomy
$ which mqulres A Permit us cmrsuuct.Alter,improw,demolish,or repair my structure
iy prior A,its Issuance.also Acquires the applicant for such permit to file a signed statement
`o that he islicensed putau,nttothe provisions ofthe comaxwesLicanseLaw(Chapter 9 Sq.Ft. Floor Area Valuation
$ (commencing with Section 7000)m Division 3 of the Business And Professions Code)or
r3.. that he is exempt therefrom and the basis for Alto Alleged exemption.Any violadon of
Section 70313 by any applicant fm a Permit subjects the applicant to A dull penalty of APN Number Occupancy Type
ml mom than nvw hundred dollars ISM
P Y. YP
❑1,a owner of the propraty,or my employees with urges as their sok eampevadm,
will a.the wak And the suunum is not Intended or offered for ale(Sec.Via Emotions
an4 Prefesdov Code:The C.nuectors came Law ands Act apply to an owner of Required Inspections
papery who bullda a Improves dheman.end who does Cuch wart himself m through his
oars employees,praNded Nst such impmwments Am AM intended mo0cred fmsale U.
bawew,the building or improvemml Is said within aro Year of mmpholon,the ownv-
builder ,will haw the bmden of proving dust the did Act build or Improve far P.M.of
sale.).
I]1,As owner of the property.Am eaclosivety contracting with licensed momma.to
m.Met the pmjM(See.7041.Business And Professions Code:)The Contractor'.W.
cave law does not apply to an owner or property who builds or improve moem.ami
who contracts far such pmjcm with a mnuactorts)Ilcemed pursuant to the Conmerora
License Law.
❑Iamnemptundersec. ,BdPCfordhisaaon
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby,f@a under Madly of perjury am of Ne fallowing declarations
low and will mdnW n ACaNOdsto of Conant At self-insure fa WmkersCompen.
m,As provided for by Section 37M of the lahm Code,for the pedamtaa of the
aeric for which this permit is issued.
EyfluoM and will maintain Workers Compensation Insurance,As mqumcd by Section
700a1'the labs Code•far the pedarmaa of the work for wblch his permit Is Issued.
My W.rkers CCompensation 1rigga nce came W Paltry: �num o
Cartier Z�I L- r✓n d Polity No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This renter mmeed AclbC mmpleud Uthe permld lsfaomhunNed deRN(5100)or Iona) ,
I certify Wt in the pufarmance of Ne work for which this Permit Is issued,l dull and
employ any pervn In any ma.mrse As to became abject to dw Worims'Compingu m
4w of Califamia.Data
Applicant
NOTICE TO APPLICANT.1f,eller making this Certincato of Exemption,you should
become abject to the Workers Compensation provviov of the Labor Code,you mum
vJ Z forthwith comply with such provisions or Nu permit shall be deemed matte.
Z O
FDi N
CONSTRUCTION LENDING AGENCY
5 IaffirmNa Hartus construction
for me performance of
than war's for whichthis pmtit B issued(Sec.30 .Civ.C.)
W�Q Lenders Name .
7 Z Lender,Aeares,
U O I certify that I haw road Ws,pplicition and mo,that du show Information 4
D. correct.I unce to amply with All City and county ardiwuv am sur law milang at
SV^ Wildingconstruction,and hereby auNada¢pmenuUws of this city to cruor upon the
W show.mentioned propeny for inspection Purpves
G (We)Agra to ave.indemnify and kcep harmless the City of Capers..against
y liabilidv,judgments,costs and expenses which may in any way acer , S.Inst said City
U Z in consequence of the stating of this armb. �' y
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE WLATIONS.
lY
4iRe-roofs
muaafAppramncontacmr ts
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant am.rhandle haalloos material
As defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Suety
Coda.Sc yuus3zU)]
❑Yds RTN. All roofs shall be inspected prior to any roofing material being installed.
Will Ne.ppfiaan r forum building tLLLpint tax cqulpmat car deHaa which If a roof is installed without first obtaining an inspection,I agree to remove
I heardov all cmtaminats as derimd hy,Ne Bay Area Air Quality Management all new materials for inspection.
cis
❑Yds Ifo
I haw read the bund/taus m,mnabmquimmonu under Chapter G95 of the Califar-
not
Hvl"Safety Cade,Savor 255U5.25533 And 25534.1 undnmarb thu ifthe Wilding
don Ac,Currently haw A unam.Na II u my maponsibility to edify rime occupant of the
requlremc es which most be mm pier anceo eCenirmamora P.O. Signature of App cant Date
ane car caw risa,gcm DidAll roof coverings to be Class'W!'or better
CITY OF CUPERTINO
• 7. ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35619029 . 00
DATE ISSUED. . . . . . . : 08/19/2008
RECEIPT # . . . . . . . . . : BS000005832
REFERENCE ID # . . . : 08080144
SITE ADDRESS . . . . . : 21567 ROSARIO AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHENG WIN S AND REI J
ADDRESS . . . . . . . . . . : 21567 ROSARIO AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4756
RECEIVED FROM . . . . : BEN FOWLER
CONTRACTOR . . . . . . . : PAUL FOWLER LIC # 21417
COMPANY . . . . . . . . . . : WESTSHORE ROOFING INC
ADDRESS . . . . . . . . . . : 2814'-AIELLO DR C
CITY/STATE/ZIP . . . : SAN JOSE, CA 95111
TELEPHONE . . . . . . . . : (408) 694-0060
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
7.13SEISMICR VALUATION 15, 081 . 00 1 . 60 0 . 00 1 . 60 0 . 00
1REROOFRES SQ FEET 23 . 00 299 . 00 0 . 00 299 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 300 . 60 0 . 00 300 . 60 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 666 . 10 MC
---------------
TOTAL RECEIPT 666 . 10
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
080 �q .
CITY OF CUPERTINO
REROOF
ITY OF
�CUPERTINO PERMIT APPLICATION
APN # 67a / () U Date:
Building Address: 2 ( 5 6pvP-
l
�o5ari o
Owner's Name: U./(yl Cit q Phone #:
`1`16 — 1331
Contractor: V�/SSt5�10✓� �o�F _Phone #:Lu,o4 qS'6 -o.Zoo
J Fax #: `log) 5Z, — oz-33
Cupertino Business License #: / L/1 7 Contractor License #:
'778 7Zz
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood?Shingles
❑ Other(Specify) Other,(Specify) 5fov,4 - Cociietl WV}r O
Number of existing coverings X Provide I.C.B.O. Report# eSr- I`(q I
)k, To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: )e move I 16k yf y wood s kak e NSR 1I Cie ra rd
c&( vT h SVla K 2 Z C.(a, f4
Residential Commercial
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation: 5 I U$1
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
•
Si ture
Revised 6/16/08
CITY OF CUPERTINO
REROOF
CUPER,TINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1REROOFCOM Re-roof Commercial B 1COMMLROOF
1BSEISMICO Seismic Commercial B
Z� 1RER00FRES Re-roof Residential B lSFDWLROOF
/ 1BSEISMICRE Seismic Residential B
1REROOFMRES Re-roof Multi-Family B 1MFDWLROOF
1BSEISMICRE Seismic Residential B
1BUSLIC Business License B
Revised 6/16/08
Community Development Department
Building Division
City of Cupertino
• 10300 Torre Avenue
Telephone: (408)777-3228
Fax: (408)777-3333
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance,you must agree to comply with 2007 IBC Standards
and manufacturers specifications on re-roofing.All roofs are Class "A"per Cupertino
municipal code 16.04.080.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City, the following steps are
required:
1) Pre-inspection and/or tear off approval.
2) In-progress inspection approval.
3) Final inspection approval.
a) Spark arrester installation.
• 5. If plywood is installed,a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another insvection can be scheduled.
IMPORTANT:
1. Flat roofs must have a minimum of 1/a "per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with thelI_above stated policy on re-roofing.
Homeowner's Name: W 1 Y\
Job Site Address: S�DT ()Sarl'ib Ave .
Roofing Company Name: Ps�S�1Orf O
Applicant's Signature: 0 =� Date: g I d g
• Greg Casteel
Building Official
Revised 07/30/08
Green Building Plan Check
Index of Green Building Points/Categories
A. Category Example of an Index or Table of Green Plan Sheet or Page Points
Building Points Categories that must be
shown and referenced on the Project
Plans as below
B. Site 9. Install H.E. Irrigation, (details/spec)" L-1 2 points
11. Permeable Paving, Note L-1 2 points
C. Foundation 1. Use 15 % Flyash Concrete, (note) S-1 5 points
D. Structural 3. Uses Wood I-Joist (See( e Spec.) S-2 2 points
5. Use Truss with heels, (detail) S-2 2 points
6. B. OSB Sheathing, detail S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spec.) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec. A4 2 points
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11. A 2500 Gal. Tank, (Note/Spec L-1 10 points
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (Note/Spec.) A-3 1 point
3. Energy Star Refrigerator, (Note/Spec. A-3 1 point
P. Other= 1. List Green Features on Plans A-1 1 point
TOTAL POINTS 40 --
Plan
0poPlan Review Process Work Book Page-12-Revised 3/25/08
r
Green Points Rating System for Remodeling Projects
Due to the diversity of remodeling project types,assigning a'total points'value to a project to be considered environmentally friendly is
• not feasible. However,25 measures have been highlighted to signify that every effort should be made to incorporate them into your
projects. These items have been chosen based upon their impact on the environment and the health of the home in coordination with
ease of implementation and relative low cost. These measures can be used as a starting point for'greening'your project.
INPUT Resources Energy AWHealth
de
1.Recycle Job Site Construction 8 Demolition Waste—
65%=1 point;75%= 2 points;80%=4 points ( up to 4 Resource pts 0
2.Salvage Reusable Building Materials 4 Resource pts y=yes 0
3.Remodel for Mixed Use,Adaptive Reuse,and
Historic Preservation 4 Resource pts y=yes 0
4.Protect Native Soil 2 Resource pts y=yes 0
5.Minimize Disruption of Existing Plants&Trees 1 Resource pt y=yes 0
6.Implement Construction Site Stormwater Practices 2 Resource pts y=yes 0
7.Protect Water Quality with Landscape Design 2 Resource pts y=yes 0
B.Design Resource-Efficient Landscapes and Gardens 4 Resource pts y=yes 0
9.Reuse Materials/Use Recycled Content Materials
for Landscape Areas 2 Resource pts y=yes 0
10.Install High-Efficiency Irrigation Systems 2 Resource pts y=yes 0
11.Provide for On-Site Water Catchment/Retention 2 Resource pts y=yes 0
1 1 1
B.Foundation
1.Incorporate Recycled Flyash in Concrete
25%Recycled Flyash=2 points;Add 1 point for every 10%
• increase of fiyash,up to 5 points up to 5 Resource pts0
2.Use Recycled Content Aggregate 2 Resource pts y=yes 0
3.Insulate Foundation/Slab before backfill 3 Energy pts y=yes 0
1 I 1
C.Structural Frame
1.Substitu a Solid Sawn Lumber with Engineered Lumber _� 3 Resource pts y=yes 0
2.Use FSC Certified Wood for framing
.(For every 10%of FSC lumber used=2 points,up to 10) up to 10 Resource pts. 0
3.Use Wood I-Joists for Floors and Ceilings 2 Resource pts y=yes 0
4.Use Web Floor Trusses 2 Resource pts y=yes 0
5.Design Energy Heels on Trusses 6'or more 2 Energy pts y=yes 0
6.Use Finger-Jointed Studs for Vertical Applications 2 Resource pts y=yes 0
7.Use Engineered Studs for Vertical Applications 2 Resource pts y=yes 0
8.Use Recycled Content Steel Studs for Interior Framing 2 Resource pts y=yes 0
9.Use Structural Insulated Panels(SIPS)
a.Floors 3 Energy pts y=yes 0
b.Wall 3 Energy pts y=yes 0
c.Roof 3 Energy pts y=yes 0
10.Apply Advanced Framing Techniques 4 Resource pts y=yes 0
11.Use Reclaimed Lumber for Non Structural Applications __ 3 Resource pts y=yes 0
12.Use 0SB
a.Subfloors 1 Resource of y=yes 0
I'' b_Sheathing 1 Resource pt y=yes 0
• 1 1 I
iter or m s
1.Use Sustainable Decking Materials
a.Recycled content 3 Resource pts y=yes 0 •
b.FSC Certified Wood 3 Resource pts y=yes 0
2.Use Treated Wood That Does Not Contain Chromium/Arsenic 1 IAO/Health pt y--yes 0
3.Install House Wrap under Siding 1 IAO/Health pt y=yes 0
4.Use Fiber-Cement Siding Materials 1 Resource pt y=yes 0
in
1 1 1
E.Plumbing
1.Install Water Heater Jacket 1 Energy pt y=yes 0
2.Insulate Hot and Cold Water Pipes 2 Energy pts y=yes 0
3.Retrolit all Faucets and Showerheads with Flow Reducers
a,Faucets(1 point each,up to 2 points) Up to 2 Resource pts. 0
b.Showerheads(1 point each,up to 2 points) Up to 2 Resource pts. 0
4.Replace Toilest with Ultra-Low Flush Toilets
(1 point each,up to 3 points) Up to 3 Resource pts. 0
5.Install Chlorine Filter on Showerhead 1 IAO/Health of y=yes 0
6,Convert Gas to Tankless Water Heater 4 Energy pts y=yes 0
7.Install Water Filtration Units at Faucets
(2 points each,up to 4 points) Up to 4 IAO/Health pts. 0
6,Install On-Demand Hot Water Circulation Pump 4 Resource pts y--yes 0
1 1
r.erecmcai
1.Install Compact Fluorescent Light Bulbs(CFLs)
(6 bulbs=2 points,10 bulbs 4 points,12 bulbs=4 points) Up to 4 Energy pts. 0
2.Install IC-AT Recessed Fixtures with CFLs(1 point each,up to •
5 points) Up to 5 Energy pts. 0
3.Install Lighting Controls(1 point per fixture,up to 4 points) Up to 4 Energy pts. 0
4.Install High Efficiency Ceiling Fans with CFLs
(1 point each,up to 4 points) Up to 4 Energy pts. 0
I 1 1
G.Appliances
1,Install Energy Star Dishwasher 1 Energy pt yryes 0
2.Install Washing Machina with Water and Energy
Conservation Features 1 Energy pt y=yes 0
3.Install Energy Star Refrigerator 1 Energy pt y=yes 0
4.Install Built-In Recycling Center 3 Resource pts y--yes 0
H.Insulation
1.Upgrade Insulation to Exceed Title 24 Requirements
a.Walls 2 Energy pts y=yes 0
b.Ceilings 2 Energy pts y=yes 0
2.Install Floor Insulation over Crawl Space 4 Energy pis Y--yes 0
3.Install Recycled-Content,Fiberglass Insulation with
No Added Formaldehyde 3 IAO/Health pis y=yes 0
4,Use Advanced Infiltration Reduction Practices 2 Energy pts y=yes 0
5.Use Cellulose Insulation
a.Walls 4 Resource pts y=yes 0
b.Ceilings 4 Resource pts y=yes 0
6.Alternative Insulation Products(Cotton,spray-foam) •
a.Walls 4 Resource pis y--yes 0
o.t;euings 4 Resource pts y=yes 0
1 1
mows INPUT Resources Energy A01Health
1.Install Energy-EfibienlWindows - j
• I a.Double-Paned 1 Energy pt y=yes p
b.Low-Emissivity(Low-E) 2 Energy pts y=yes p
C.Low.Conductivity Frames � 2 Energy pts y=yes 0
2,Instaw Heat TissnnransmGlaring 1 Energy pt y=yes 0
ll Lo
1 1 1
J.Heating Ventilation and Air Conditioning
r.UseDuct Mastic on All Duct Joints _j 2 Energy pts y=yes 0
2.Install Ductwork within Conditioned Space 3 Energy pts y=yes p
3.Vent Range Hood to the Outside 1 IAQ/Health pt y=yes p
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy pt y=yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
B.Install Sealed Combustion Units
a.Furnaces 31AQ/Health pts y=yes p
b.Water Heaters 3 IAQ/Health pts y=yes p
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEER/11 EER or higher AC with a TXV 3 Energy pts y=yes 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts y=yes p
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes 0
13.Retrofit Wood Burning Fireplaces
• a.Install EPA certified wood stoves7nserts 1 IAO/Health pt y=yes 0
b. Install/Replace Dampers 1 Energy pt y=yes0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydropic Radiant Heating 3 Energy pts y=yes 0
15.Install High Efficiency Filter 4 IAQ/Health pts y=yes p
16.Install Heat Recovery Ventilation Unit(HRV) 51AQ/Health pts y=yes 0
17,Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes p
1
K.Renewable Energy and Roofing 1 1
1.Pre-Plumb for Solar Water Heating 4 Energy pts y=yes p
2.Install Solar Water Heating System 10 Energy pts y=yes p
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts y=yes p
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=1 B points) Up to 16 Energy pts 0
LSelect Safe an'Du Durable Roofing Materials 1 Resource pt y=yes 0
7,InstalhRadiant Barrier 3 Energy pts y=yes 0
1
L.Natural Heating and Cooling 1 1
1.Incorporate Passive Solar Heating 5 Energy pts y=yes p
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts . y=yes p
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes 0
1 1 1
. n oor r ua ry an n s es ,
1.Use LowlNo-VOC Paint 1 IAO/Health pts y--yes 0
2.Use Low VOC.Water-Based Wood Finishes 2 IAO/Health pts y=yes 0 •
3.Use Low/No VOC Adhesives 3 IAO/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts Y--Yes 0
5.Use Engineered Sheet Goods with no added Urea 0
Formaldehyde ' 61AO/Health pts y=yes
6.Use Exterior Grade Plywood for Interior Uses 1 IAO/Health pts y--yes 0
7.Seal all Exposed Particleboard or MDF 4 IAO/Health pts y=yes 0
8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 31AO/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAO/Health pts y=yes 0
5,Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1
ota olnts Avaflablfl 1 1401 130 57
Total Points Project Received: 01 01 0 •
G:datalprogsrgreenbulldingguidelineslremodelerslgreenpointsfinal212.04pmtected.xls
— Community Development ,
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
qjUPEI�TIN0
Building De artment
JOB ADDRESS: Z � 5G } `-o5cvri o i(U• PERMIT # O n y
OWNER'S NAME: W j v1 (,keyA PHONE # qtl$ 5(o -O Z
GENERAL CONTRACTOR: W)e5{5jkc , FAX # dE c15-6 - OZ 33
I am not using any subcontractors: U /!:/s V 1 .1 /0'r
Signature D" ate
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
T' 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