08090068 (2) CITY OF CUPERTINO
8UnA1NG DIVISION PERMIT �kCON TRAC M NFO t1TION �:
BUI 1 0��DORESS: PERMIT NO.
SEPTEMBER DR PRINCIPLE ROOFING & 08090068
OWNER'S NAME: PERMIT ISSUE DATE
BENJAMIN WU 10160 STERN AVE 09/12/2008
• PHONE: SANITARY NO. CONTROL NO,
AacxITECT/ENc1NEER: RE—RF RMV EXT WDSHK INSTL 'BLDG BUILDING
E �PERELECTMIT MECH
am,$ LICENSED CONTRACTOR'S DECLARATION
IbembyafrrmwtIamliccmedunder pma,;aesofChopmr9(commencing ------ Job Description
with Secdan7Or/l)of Dividonloftie Basal• aMProfessiam Code.aMmylicenseu
n in full farce and effect.
License Clam �tt��Lj�2 Lmm 8/635r
swe
ARCHITECTS DECLARA ON
1 understand my Plate Nall be used as public records
Dm,U
g C t Licensed Pmfessioul
3 OWNER-BUILDER DECLARATION
ji2 1 hereby aRmm that I am a emyt from tho Contractor's License Law for ftp o following mason.(Section 101.5.Business and Professions Cade:My city or county
ZOO
S_ which memose a Permit to cnnslncL alter. mpram.dem.iivh,or repair any structure
Lz> prior ut its issuance.also requires Neappliennt forsuch permit in file a signed uanoment
f `o that In,talicensed pmsuammthe pmvislomnrthe Contractors LiccmeLaw(Chapmr9 Sq.Ft. Floor Area Valuation
3 (.Nmmcmckg with Sectio.700)),dDivulmn s.fthe Busimasmd Profeasi.m code).,
.. that he Is exempt therefrom and the basis for also alleged exemption.My violation of
Section 703 1.5 by any applicant for a permit subjects the applicant in a civil penalty of APN Number Occupancy e
not mom Nan five hundred dollars(S500R P Y TYP
❑I,uowneroftiepmpeny,wmymmploMwithmgumthekwke pemadon,
will Prdewarlt and NeswctumiscotIntended Law deforaak(Sec,ye owncra
and Ptywhe,m leader The Canaacten,uecme law daas Out apply lf rt ower a Required Inspections
Progenywho buildsA i d do each improvements
and who does such weals hinmsedfortlwugh his
awn emgloyca.P Wilding
or(dist each impmsemenu tae not imeMe4 oranertd for sale tL
builder .the,dtilNng mhnprovemmt4coldwidid one year ofc improve
dK owe of
builds will have Ne WNem of proving that k did rer Wild or improve far purpose of
tele.).
❑1.u owner of the property am exclusively co mucting with liumed contractors to
mt
comct the project(Sec.7044.Business and Profusion,Cade:)The Coo.aemr's U.
mmun law doer not apply to an owner of property who builds or improves theme ,and,
who contests for such projects with a conuactor(s)licenaed pursuant N IW Contractor's
Licence Law.
❑lamuemptundm See .B&Pc Wthismachn.
Owner Data
, WORKERS COMPENSATION DECLARATION
1 hereby a.under penalty of Perjury arc of dm following declarstiostc
❑1 haw aM wEl maintain a Catifimno ofComent b self-imam(or Warku'a Compcn-
anden,u provided for by Section 57M of time labor Code,fm the perform.of the
work for which this permit is issued.
❑I have W will maintain Worker's Compensation Insurance,an required by Section
5700 of Ne labor Code.far Ne performance of the wart forwhieh NU Permit is issued
My Workers Compensation bourmen carrier and Policy number are:
Canner. C ±M Policy No.: GOU
CYAMON �CC(�
FROM WO ERS'
COMPENSATION INSURANCE
(Thin action reed not be completed if de patent is forme handed dol4n(SIUO) '
Or Inas)
I co tifr that Or the performance of de work for which this Permit Is issued 1"I cot
employ any Person in any mummer so is to became subject to the Workers'Compematiort
Laws of Califomia Due
Applicant
NOTICE TO APPLICANT:If,after making Nis Cenifimm of Eaemption.you should
become subject m the Workers Compensation previsions of Ne labor Code,you mud
.J O forthwith comply with such provisions or this Permit shall W accrued revoked.
Z N CONSTRUCTION LENDING AGENCY
F^� Lnereby N'um lWtuereis.oonnnctimn knaimg agercy ter de Performance ar
tY.�-, Nle work fm which this Permit u issued(Slee,7097,Civ.QUj Q Lender's Name
=Z lenders Address
U O 1 cmtify 0.11 have mad this application and auto,that ono above iNorm ahm i.
IT. correct.I agree to comply with all city and county or immes and slam laws relating N
.� Wilding construction.and hereby authodu repommutives of this city to now upon the
� W .hove-mentioned property,for inspection purpose.
" fY (We)agree to save,indemnify and keep harmkm the City of CuPcnina against
(n IiaNlidu,judgments.casts and..K.which may nn any way Kane against said City
U Z in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date _� Z�u
SOURCE I+EGULATIDNS.
VZ� ee�rta./eb Re-roofs
sgnunre ar PpEun✓Conammer Dam 1 �
IINARDOUS MATERIALS DISCLOSURE Type of Roof
Will de wpdc cot m roam Wilding occoPant armor nark h.-mdmn manorial
as dcRned by tie Cope timer Murdcipal ode.aspect 9.12 and the Heald and Safety
Code,Schen 231520)t
❑tns ❑ All roofs shall be inspected prior to any roofing material being installed.
Will thea licant of future building emor oL use ff a roof is installed without first obtainingan inspection,I agree to remove
pP d W equipment aT Juices whim P
Di trice? dam alt monummants as ed by the Bay Area Air Qtrwly Man,cem=ort all new materials for inspection.
❑Yu No
I haveread Nehaurduum5505. regvirtmc S5unCert7tsperh.e,ofNeinumug-
nkHnoth&Safcty avo aSecvmu Iti myr5533 ssW2SAs.l WraniuM NatRdebuikkj
don not emmndy haws uman.Nat it u sm responsibility m n, ry time aaupant of the
requiremen hkh musth met priorm issuanm ora Catifcam of Osco
w_ a5�1-(i'id Signature of Applicant Date
owmn,or mth.hend ager D,m All roof coverings to be Class';W'or better
CITY OF CUPERTINO
2 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
• COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36214014 . 00
DATE ISSUED. . . . . . . : 09/12/2008
RECEIPT # . . . . . . . . . : BS000006066
REFERENCE ID # . . . : 08090068
SITE ADDRESS . . . . . : 882 SEPTEMBER DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . .. BENJAMIN WU
ADDRESS . . . . . . . . . . : 882 SEPTEMBER DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4127
RECEIVED FROM . : DERECK LOI
CONTRACTOR . . . . . . . .. DERECK LOI LIC # 27564
COMPANY . . . . . . . . . . : PRINCIPLE ROOFING &
ADDRESS . . . . . . . . . . : 10160 STERN AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . : (408) 898-7298
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- - ------ ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 12 , 000 . 00 1 . 20 0 . 00 1 . 20 0 . 00
1REROOFRES SQ FEET 27 . 00 351 . 00 0 . 00 351 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 352 . 20 0 . 00 352 .20 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
•
CITY OF CUPERTINO
iaq- REROOF
• CUPEkTINO PERMIT APPLICATION
APN # / !i0 , / � U Date: �� l GY
`j y /
Building Address:
Owner's Name: � w„L Phone #:
Contractor: Phone #:
(/ Fax#:
Cupertino Business License #: j Contractor License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ ilt-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.
Job Description:
¢ Wao`O. Si/,44:j
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: w
/,2, a ad
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Signature
Revised 6/16/08
CITY OF CUPERTINO
wtodx, REROOF
CUPEkTINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1REROOFCOM Re-roof Commercial B 1COMMLROOF
1BSEISMICO Seismic Commercial B
1RER00FRES Re-roof Residential B 1SFDWLROOF
1BSEISMICRE Seismic Residential B
1RER00FMRES 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 inspection can be scheduled
IMPORTANT:
1. Flat roofs must have a minimum of 1/4 "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 the above stated policy on re-roofing.
Homeowner's Name: O E� Wyj
Job Site Address: 2-
Roofing
Roofing Company Name: d"'Y'Ci
Applicant's Signature: Date: p 9 7Z/p
• Greg Casteel C
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 See 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 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. A-4 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 points
•
Plan'Review Process Work Book Page-12-Revised 3/25/08
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 Resoulces Energy IAD/Heafth
A.Site
1.
Recycle Job Site Construction&Demolition Waste
65%=1 point;75%= 2 points;BO%=4 points up to 4 Resource pts 0
r2.Salvage Reusable Building Materials 1 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
6.Design Resource-Efficient Landscapes and Gardens_ j 4 Resource pts y=yes 0
9.Reuse Materlals/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
B.Foundation 1
1.Incorporate Recycled Flyash in Concrete
25%Recycled Flyash=2 points;Add 1 point for every 10%
• increase of flyash,up to 5 points up to 5 Resource pts F1 0
2.Use Recycled Content Aggregate 2 Resource pts y=yes 0
3,Insulate FoundatioNSlab before backfill 3 Energy pts Y--yesp
1 1 1
C.Structural Frame
1.Substitute Solid Sawn Lumber with Engineered Lumber _J 3 Resource pts y=yes o
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 Floor 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 a
7.Use Engineered Studs for Vertical Applications 2 Resource pts y=yes 0
B.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 p
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.UseQSB — --- - ----
a.Subfioor 1 Resource pt y=yes 0
b.Sheathing 1 Resource
• L — ---- -- - — -- — --- --- of Y=Yes 0
1 1 1
D.Extenor Finish ,.
r1.Use Sustainable Decking Materiels I'
a.Recycled content 3 Resource pts y=yes 0 •
b.FSC Certified Wood 3 Resource pts y--yes 0
12.Use Treated Wood That Does Not Contain Chromium/Arsenic i 1 IAO/Health pt y=yes 0
&Install House Wrap under Siding 1 IAQ/Health.pl y=yes 0
4.Use Fiber-Cement Siding Materials 1 Resource pt Y--yes D
1 1 1
E.Plumbing
1..Install Water Heater Jacket _ _J 1 Energy pt y=yes 0
2.Insulate Hot and Cold Water Pipes 2 Energy pts y=yes D
3.Retrofit all Faucets and Showerheads with Flow Reducers
a.Faucets(1 point each,up to 2 points) i Up to 2 Resource pts. D
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 3points) Up to 3 Resource pts. 0
5.Install Chlorine Filter on Showerhead _ 1 IAQ/Health pt 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 IAQ/Hsalth pts. 0
B.Install On-Demand Hot Water Circulation Pump 4 Resource pts y=yes 0
1 1 1
r,tiecmcar
1.Install Compact Fluorescent Light Bulbs(CFLs) T f
(6 bulbs=2 points,10 bulbs=3 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 pis. 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
1 1 1
G.Appliances
1.Install Energy Star-Dishwasher 1 Energy pt y=yes 0
2.Install Washing Machine with Water and Energy
[Ccnservation Features 1 Energy pt y=yes 0
nstall Ene gy Star Ref gerator1 Energy pt y=yes 0
Install Built-in Recycling Center _ ` j 3 Resource pts y=yes 0
1 1 1
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
rInstall Recycled-Content,Fiberglass Insulation with
o Added Formaldehyde 3 IAQ/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 D
b.Ceilings 4 Resource pts y=yes 0
6.Alternative Insulation Products(Cotton,spray-foam) •
a.Walls 4 Resource pts y=yes 0
o.Cenings 4 Resource pts y=yes D
1 1 1
I.Wmi INPUT Resources Energy IA01i
1.Install Energy-Efficient Windows -
a.Double-Paned 1 Energy pt y=yes p
• i b.Low-Emissivity(Low-E) 2 Energy pis y=yes p
c.Low.Conductivity Frames _ 2 Energy pts Y--yes p
2.1 n stal I Low Haat Transmission Glazing 1 Energy pt y=yes 0
1 1 1
J.Heating Ventilation and Air Conditioning
C.Use Duct Mastic on All Dud Joints _ _ _^� 2 Energy pts y=yes 0
2.Install Ductwork within Conditioned Space 3 Energy pts y=yes 0
3.Vent Range Hood to the Outside 1 IAQMealth pt y=yes 0
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 0
5.Install Solar Attic Fan 2 Energy pis Y--yes p
6.Install Attic Ventilation Systems 1 Energy pt y=yes0
7.Install Whole House Fan 4 Energy pts y=yas 0
6.Install Sealed Combustion Units
a.Furnaces 3 IAQMeaflh pts y=yes p
b.Water Heaters 3 IAQ/Healti is
P Y=Yes D
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 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes p
13.Retrofit Wood Burning Fireplaces
• a.Install EPA certified wood stoves/inserts 1 IAO/Health pt y=yes 0
b. Install/Replace Dampers 1 Energy pt y=yes 0
c.Install Airtight Doors 1 Energy pt y=yes 0
14,Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15.Install High Efficiency Filter 41AQ/Health pis y=yes p
16.Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pts y--yes p
17.Install Separate Garage Exhaust Fan 3 IAQMealth pts y=yas 0 .
1 1 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts Y=yes p
2.Install Solar Water Heating System 10 Energy pis y=yes 0
3. Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts y=yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=16 points) Up to 16 Energy pts 0
6.Select Safe and Durable Roofin Materials
6_�_. _ _ _ 9 __ _ _ 1 Resource pt y=yes p
7.Install Radiant Berner- - - 3 Energy pts y=yes p
1 1 1
L.Natural Heating and Cooling
1,Incorporate Passive Solar Heating 5 Energy pts y=yes 0
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts y=yes 0
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes p
1 1
•
INPUT Resources Enerq� IAQ/Hnith
M.In oor Air Quality and Finishes _
�.Use Low%No-VOC Paint 1 IAQ/Health is es 0
_ P YY
2.Use Low VOC,Water-Based Wood Finishes — — 2 IAQfHealth pts y--yes 0
3.Use Low/No VVOC Adhesives 31AQfHealth pts y--yes 0
4.Use Salvaged Materials for Interior Fnishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 1AQ/Health pts y=yes 0
7.Soat all Exposed Particleboard or MDF _ __ ' 4 IAO/Health pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes D
9.Use Finger-Jointed or Recycled-Content Tim 1 Resource pts y=yes D
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
r2.Use Rapidly Renewable Flooring Matedals _ !I 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles J 4 Resource pts y--yes 0 r
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/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–y as 0
1 i 1
Total Points A 1 1401 130 57
Total Points Project Received: - 1 0 0 0 .
c-0/1 2,1
G:dataWprogs/greenbuildngguidellneshemodeleNgmenadmsfins1212MprrneMed.Kls
A
Community Development
CuTorre Avenue
pOertinoCA 95014
- Telephone(408) 777-3228
CITY OF Fax(408)777-3333
• CUPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
z OdOO 006�-
OWNER'S NAME: PHONE #C4ai) FgF- izi91
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following ' ormation:
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