03100178 (2) CITY OF CUPERTINO
BUILDING DIVISION CONTRACTbR INFORMATION
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BUILDINGADORESS: EL CAMINO ROOFING CO INC PERMITNO03100178
0232 SANTA CLARA AV
OWNER'S NAME: 1650 S 7TH ST PERMIT ISSUE DATE
REUTER STEVEN D AND CAROL C 10/23/2003 .
NE: (406) 292-7644 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
i0o LICENSED CONTRACTORS DECLARATION hap
U 1 hereby e)or the 1 em of the
Business
undo prevision[of Chapter and
mmmense is .IOb>DI tom( LE0
W with Scclion](X)Il)of Division lof Nc Bassi,l¢x end Pmfcssiurts Code,end myliccuc is - rr �R�OJ��
i „ inmBromeaaderect.- L� ( � �� REROOF
2 License 1 Lie.X
G°aR°"ar MAR 2 6 2004
EE� ARCIiTTECI'S DECLARATION
C< I un enuinJ y tans I h used as public records
?eu
.0p LicensedPntressione[ BUILDING
OWNER-BUILDER DECLARATION
IS I hereby alarm that 1 a.1. .Bump(fare the fe mns Co :Anyc Law for the
5 mui following reason,Section]onsm Business and Pr,cvduu colorist.or:Any oily nr county
which its Ws a ..alsoaft to cnnsuua,alter,imposts hemailtor repair signed ahucthn $2500
-Zy poor toiuissuans.alsoatto the the applicant for COMMrmi0uicese Lawdnauimem
u � (commthat he ecing wit putstion7 the of Divionsnf of teBusinssan License Law(Chapmrl Sq.Ft. Floor Area Valuation
$ (commencing with Sectinn]00o)of Division3 of the Business and professions CoJe)ur 32622010 . 00
that he is exempt therefrom and the basis far the alleged exemption.Any=of
Section]031.5 by any apPllc®t for a permit subjects the applicant to a civil penalty of araC APN Number OCCU
.at Mo.danA.<handled doll.(S50o). Occupancy Type
1,as owner of the pmpeny,M my cmployces with wages u their sole Compensation,
will do the work,and are truaurt is nm intended or offered for a.[. maq Business
and Professions Code:The Contractor's Li".Law docs not apply to an uwter of Required Inspections
Partially who builds or improves themon,end who doessuch work himul(or through his
own emp[awas,provided that such improvements ase not intended or offered(orale.If.
hoi the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or Improve for purpose of
sai
❑I.as owner or the property,am exclusively contracting wit licensed contractors to
construct the project(Sec.7W,Business and professions Code:)The Conuaclue.Li-
cense Law does not apply in an owner of Inaptly who Wilda or improve[Ibereon,and
who contracts for such projects with a contractor(s)licensed pursuant to On Conlsmors
License Law.
O 1 am exempt under Sec. ,B At P C for this lesson
Owner Data
WORK ER'S COMPENSATION DECLARATION
ffa
1 hereby an under penalty of perjury one of be following declarations:
1 have and will mainuin a CeniOcole or Canute to self-insure for Worker'.Carrico.
u p.id.d for by Section 37M of the Labor Code.(ar Ne retf°rmance of the
wor for which Nis permit I.issued.
1 have and will maintain Worker's Compensation lou mance,as required by Section
3100 of be labor Code,for the perfoamsuce of the work for which this nnut is issued.
'Y'
Compensation In n artier anJ Polity hr art: _
Cartier. Policy No.: _
CERTIFICATE OPE EMPTION FROM WO
COMPENSATION INSURANCE
(This section need nut becomplesed if the M mil is for one hundred dollars($100)
or loss.)
I ttni(y that in the performance of the work for which this permit is issued,I shall not
employ any person in an manna 5p I pore sob' t to lbe Workeri Com oration
Laws of California.Dafe-`���3�_/ 1rr
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the Lahr Code,you must
�O forthwith comply with such provisions mar this parand"hall h deemed revoked.
Z N CONSTRUCTION LENDING AGENCY
1 herehy affirm that Nen is a convection lending agency tar the Performance of
Ya the ,it for which this permit is issued(Sec.3011,Civ.C.)
Y Q Lender's Name
Lendcr'[Addreu
C) I certify Nal I have read this application and sate that he above information is
y F correct.I agree to comply with all city and county ordinances and suite laws relating 1.
7 V building construction,and hereby authorise mpresennivu or Nis city la color Open the
shove-mjudgcd partiallycosts
fan inspection purposes.
(we)agree to saw,indemnify and keep harmless Be City Of Carolina again.(
N liabilities,Conence rthe Flotsing expenses which may in any way accrue against City
>z A APPLICANT
ND Floating of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
SignasSignatureof ApplicaADem
HAZARDOO US MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant.Chapter
or handle huuduus mumel
C de.Sed Section
the Cupenlno Municipal Code.Chepmr 9.13,and the Health and Safety
Code.Dyes zss32(a)1 o All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it hoaardous oil contaminants u crated by the Bay Area Ail Q°ality Manag<mcnl all new materials for inspection.
aria?
❑Yu
Ihave&Safet Code.Sold ma505. 553terf3 it 25534,
4,1 u ChaundOworthe Calif., v t G
lie Health&Safety Cade,Secdou 25N1 is my 3s'nori3s.1 to adrnd loraifCp .bring
dots nal c Ily haw a ensu(,that it u my reaiwnsi.ility m nndfy the.euparal of the
royuinm nu hick mus be met poonnissuancc ora CcniBcd�P°f Opcu.racy. / Signature o f Applicant Date
agent` IO I TIS U All roof coverings to be Class 'B" or better
Owner or autbarircd.gore pato
CITY OF CUPERTINO
REROOFCITY OF
O ��
• CUPERTINO PERMIT APPLICATION FORM
APN# v Date:
Building ddress:
® CA, G
Owner�1Na>J0 tJ l C7r Phone
.#;, S S � I
` _,,,VV
Contractor: Phone#•S Lice se#:
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
C1Asphalt Shingles halt 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 Comply With Cu ertino's Tear Off Policy: ❑
Job Des cr' tion:
,ver T 3114b
Residential Ur Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plan ' g Dept. if
there are an trictions: LJ
Co of Project: - Type of Cons tmcti Occupancy gro
v
Qty. if
Ay 1' ab] 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
•
'7
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 4
Sec : Twp: Rng : Sub: Blk: Lot :
APN . . . . . . . . : 32622010 . 00
DATE ISSUED. . . . . . . : 10/23/2003
RECEIPT # . . . . . . . . . : 23578
REFERENCE ID # . . . : 03100178
SITE ADDRESS . . . . . : 10239 SANTA CLARA AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : REUTER STEVEN D AND CAROL C
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : SAN JOSE CA, 95129-4040
RECEIVED FROM . . . . : EL CAMINO ROOFING
CONTRACTOR . . . . . . . : CASTILLO, MARK LIC # 21455
COMPANY . . . . . . . . . . : EL CAMINO ROOFING CO INC
ADDRESS . . . . . . . . . . : 1650 S 7TH ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 292-7644
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - - - ------- - ---- -- - ----- - - -- ----- --- - - ----- - -- --- - - -- - - - -
BPERMFEE VALUATION 3 , 000 . 00 77 . 00 0 . 00 77 . 00 0 . 00
3SEISMICRE VALUATION 2 , 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00
- ---- ---- - ---- - ----- - - ---- - - -- - - - -- --- - -
TOTAL PERMIT 77 . 50 0 . 00 77 . 50 0 . 00
A
METHOD OF PAYMENT AMOUNT NUMBER
- - - - - - - - - - - ------ - ----- - - ---- - - ----
CHECK 77 . 50 0008795
TOTAL RECEIPT 77 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
600 PRE-INSPECTION
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