04040149 (2) CITY OF CUPERTINO
BUILDING DIVISION ni�n m dC0NTRA0IN
T0R FORM
iERMI A,TTON.
,,,,,,� ,•, „ 6^,,;':-
BUILDING ADDRESS: - _ DRAEGER CONSTRUCTION INC PERMIT N%4040149
OWNER'S NAME: PERMITLSSUEDATE
STEPHEN LEE MME 2004
ONE:
SANITARY NO. CONTROL NO.
(408) 536-0420
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 0 0
uoo LICENSED CONTRACTOR'S DECLARATION
u Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing �� !S
W wish Studied 7000)orr ..viol 3 arm.Businexsano Professions ndc,and my liccnu is /ZIg ❑ E®
c.u, in full farce and cffcc{d�] REROOF X11y
�Z LieemerClass Lie.it
nl-� Date Contractor JUL (�� p
ARCHITECTS DECL !.� 200a1
5y 0' I understand my plans shall he used as puhlic 'it, Y'
>au
o'e Licensed Professional ®tt�1�D1�
OWNER-BUILDER DECLARATION �t�l
q a lS I hereby affirm that 1 am exempt from the Contractor's License Low for the
p O following reason.(Section 703 1.3,Business and Professions Code:Any city or county
L eswhich requires a pelmin m construct,alter,improve.demolish,or repair'my strucade
,Ea prior to its issuance,also rcquires the applicant for such permit m file a signed statement
a that he is licensed pursuanuo the provisinnsofthe Cnntraclnr'sLic..Law(Chapter) Sq.F[.Floor Area Valuation
yH (commencing with Section 9000)of Division 3 of the B usiness and Professions Cade)or
y
that he u exempt Nemfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penally of 3 665Q92riberO0 Occupancy Type
not more Nan five,hundred dollar,(5500).
❑I,as owner of the property,or my employees with wages ex their sole compensation,
will do the work,and the mmctuR is nod intended oroffc.d for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.lf,
however,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
salt.).
as owner of the property,am exclusively contracting with licensed contractors to -
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li
cense Law does not apply to an owner of property who builds or improves themon,and,
who contracts for such projects with a comracmr(s)licensed pursuant to the Contractors
License law.
71em exemplt der ee / .B&PC for this..on
caner a ��, Date
/"`\ RKER'S COMPENSATION DECLARATION
1 hereby offrm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-hour for Worker'sCumpen-
117M
wn,as provided for by Section 3?00 of the labor Core,for the perfmmance of the
rk for which this permst is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
of Nc Lab t�6roodde,for Ne,performance of Ne work for which Nis permit is issued.yWorkcr'sC�yp/sati eicourmd Pulicynup,ggf� 41 Y2 7
rtier. .•//�[(( Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crlds scrium need not becumpleted if the Permit is for one hundred dollars($100)
m lass.)
I certify that in The performance of the work for which this permit is issued,I shall not
employ any Person in any manner an M m become subject e the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject In the Worker's Compensation provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall he deemed revoked.
ti CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for performance Of
C(.> the work fur which this permit is issued(Sm.3097,Co,C.)
W�Q Lender's Name I
z Lender's Address
U Q I carry NB(I have Rad this application and male that the above information 1s
e4 F cereal,I agree to comply with all city and county ordinances and state laws relining to
t7U building contraction,and hereby authorim rcpresemanivcs of this city to enter upon the
Uohnm
e- endmad properly for inspection purposes.
gy (We)agree to save,indemnify end keep harmless the City of Cupertino against
,'may fn liabilities,judgments,costs and expenses which may in any way see=against said City
U Z in consequence of the granting of this permit.
"
APPLICANT i%�R 7AJDS WILL COMPLY WITH ALL NONPOINT Issued by: Date
SOURCE
Win.,
�d Re-roofs
Win.,��w pp�aoanUContncmr Data
L HAZARDOUS MATERIALS DISCLOSURE Type of Roof
A�i
Will the applicant or future building occupant store or handle harallous noun ial
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
udc,Section 25532(e)? All roofs shall be inspected prior to an roofing material being Installed.
❑Yea C]NO P P Y g b
Will the applicanl or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
III haxartlous air wnmminan¢as defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yrs 0 N
1 have met the humorous materials i ircmentsunderChapter6.95oftheCalifor-
niaHcalth A Safety Coda,Serious 255115,25533 and 25534.1 undersand Nat ifthe huilding
docs not currentJ ave yraos,+pal it is my rcsponsi hility to nod l y the occupant of
requirere w f Yfie me error N issuance of a Cenificaa:of Ocupancy.. ignatU (Applicant Date
Owe r thorizodagent Date All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: S �n PHO11t # yc6
GENERAL CONTRACTOR: _ FAX# e, 6
I am not using any subcontractors:
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
REROOF �f
CUPERTINO PERMIT APPLICATION FORM
APN# 3 (�, <- -!�—`r a 2 . / Date:
Building Address:
7/5-52 S Qr
Owner's Name: Phone#s
ya — J ?
Contractor: Phone#: *0,5-U-041 zn License#:
Con _ iC 17 6" 1 O
Contact: Phone#: Cupertino Business License#:
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)
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 Description:
o
Residential 0frunercial ❑
Fire Zone: Yes ❑ No E] Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
Qty. if
Applicable 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