06050078 (2) CITY OF SUTE !INO "
BUILbINC DIVISION PERMIT r CONTRA.GTI.t INFAORMA.TIOlY �,'.
BUILDING ADDRESS: s ALL SEASONS ROOFING SERVI ffrTND'06050078
20688 SHELLY DR
OWNER'S NAME: PERMIT MUE DATE
FRIEDMAN KENNETH I AND LYDIA J1720 SMITH AVE 05/09/2006
NE:
SANITARY NO. CONTROL NO.
(408) 971-4455
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
= . 0
.00 LICENSED CONTRACTOR'S DECLARATION l IObDe$CiDescription
mC 1 hereby affirm Nal 1 am licensed under provisions of Chase,9(cammmcing P
tzW with Section 7")of Division 3 ofW Businessand Professions Cade,and my license is
infullraroeand�rp REMOVE EXISTING SHAKE ROOF. INSTALL 20 SQUARES
`i""m°as` ` 7/1611 OSB LC INSTALL 20 SQUARES 50 YEAR COMP
Doth Contractor
ARCHnECfSDECLARATION S V WEIGHT 3 . 4
10:< I understand my plans shall he used as public retards
to
o Licensed Professional
OWNER-BUILDER DECLARATION
if 1 hcrehy xlnrm that I am exempt from Ne Contractors License Law for tM
O O fallowing road...(Section 10 1.3,Business and Pmfessioas Code:Any City ar county
<m which enquires a permit w cnruuuct,slue,,improve,demolish.or¢phi,any structure
iy pdarm its issuance,also requires theapplicant farsuch permi,to fileasigocdsummon,
< Wm he is licensed pursuant to the provisions of W Canuacmr's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
e�O (comae ngwith m7000)of Division3ofthe BusinmaMProfessions Codc)ur $2000
y that he u exempt thucfrom and dm basis far Ne all.,al exemption.Any violation of
Section 7031.5 by any applicant for a permit mbjem the applicant to a civil penalty of APN Number Occupancy Type
m,more than rive buMred dollarn(M3 P Y YP
❑1.u owner of Ne propmy,m my wploycns with wa{d as Wvmk eampensation.
wiBmdrwa .ndheawure notmreMd.r.Bwr.,aae(s«. ou.eas Required Inspections
and Professions Code:The Contactors License Law data Out apply to e ns an owner of q p
Own tnitubonuiprovi id that. Nermn,ve who.not
hendedcnuelfedWaugh his
awn employees,provided or i that such improvements ane not intended marterW for We.If,
budder.the Wilding Waimprovcmvinumldwithin arc year of completion.due.wive.
builder will have Ne burden of proving Net M did not build or improve for purpose of
.1c). /
❑a u awncr Of the properly,,B sin=and contracting with Bcehe Cmnwttms i-
.La d project(Sec.]GOC,Business and property
whoWilds
Code:)The Cammc om.Li-
weve law data out appy to ts owner of t ropers voce sed p or improved thereon,and
who contracts for such projects with s e.nuaaoKs)licensed pursuant in the Contractors
License Law. Q
❑1 am exempt under Sec .B&P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty,of perjury arc of the following declarations:
L]1 havd and will maintain a Certificate of Consent to self-inure for Workers Compen.
moon,
work farr which this
fpe by Section 3]00 of the lobar Code.far W performs.¢of the
which Nis pewit is issued.
❑1 have and will maintain Workers Compenaau.n Inmra.ct,as rryuircd by Section
3700.(the tartar Cade.for da perfmma .fthe work for which the permit t issued '
My Workers Compensations insurance
nns nce carrier and Polity number are-
Grti., L ,r c+l'U\ Policy No.:
CERTIFICATE OF FFIEMFTLON FROM WORKERS'
COMPENSATION INSURANCE
Cfhu section reed mine considered ifthe permit is formic hundred dollar(5100) a
or less.)
1 ctnify that in the performance of the wank for which this pewit is issued.l shall no,
employ any person in any mar mer an as us become mbjw or IM Wolters'Compenmuon
Laws of California Dam -
Applicartl
NOTICE TO APPLICANT:IL order making this CeniGcare or Exemption,you should
become subject in the Workers Compensation plovidimu of W Labor Code you must
.JZ (mMWlth comply with such provisions 0111113 pewit Nall be decreed revoked.
z CONSTRUCTION LENDING AGENCY
F wore
by which
War duertused(Sc.33097,Ch, agercy for lnepuformanct of
C > Le won mr venins Ivo perm.i,idddee(sen.309].civ.ea
a^p Lenders Name
� z Landers Aaareas
U Q 1 certify that 1 basic mad this application and sure that W above informaiu.is
UL E-' cow¢1 agree to comply with all city and county ardinawa and state laws relating to
0U Wilding cmnoodcum.and hereby autharim mpresenmives of this city to cmcr done the J—\��yg�7 //
snare-mendmned nrolseny me inspection pdgwma /�^a!'IUCn./
(We)agree to save,indemnify and kecp harmless the City of Cupertino against
tF".a[aq lianilitins,judgmenu,Costa and expense which may In any way vttmc againsssaidm
V Z in consequence of the grantin{of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURg REGULATIONS.
L)1 A a -A Qat f�)SZ, t Re-roofs
Signature of ApplicanitConua cor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applieau or future Wilding oecupanumre orhandlc havasdons m tow
at de0nM by the Cupcnino Municipal Code.Chapter 9.13.and the HCe1th and Safety
Coda,section 25532(a)] All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
first obtaining an ns
Will the applicant or rumor building occupant use equipment or devices which If a roof is installed without g inspection,I agree to remove P
.mit hdrardoud air couraminantd as defined by the Bay Area Air Quality Management all new materials for inspection.
District
❑Yes u.
1 Mvc read Ne hvardssusmauerials requirement unde'Clurn,6.95 ardor ealirm,
nu Health&Safety Cade,S.U.nM5.25533a 25534.1undcrsund Nuifdue Wilding
does nal cdwmly have a mnanL dao'h u my responsibility us noury W oaupant.r the
my iecmcpu whkh mux be P. i�rance cera ccnirwath or Occupancy. Signature of Applicant Date
Owner or autharir.d agent pa� 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
WUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
ab(o�S�S `jv"e\\ c-- `CSCE\ (j� S6D7�
OWNER'S NAME: y-c rir�_A,^ PHONE #
GENERAL CONTRACTOR: FAX # C y o - _y
I am not using any subcontractorsO(�q
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
om 3 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35915002 . 00
DATE ISSUED. . . . . . . : 05/09/2006
RECEIPT # . . . . . . . . . : 34320
REFERENCE ID # . . . : 06050078
SITE ADDRESS . . . . . : 20688 SHELLY DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : FRIEDMAN KENNETH I AND LYDIA J
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
RECEIVED FROM . . . . : ALL SEASONS ROOFING
CONTRACTOR . . . . . . . : GORSHTEIN, VLADISLAV LIC # 21035
COMPANY . . . . . . . . . . : ALL SEASONS ROOFING SERVICES
ADDRESS . . . . . . . . . . : 1720 SMITH AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 971-4455
4kEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 2, 000 . 00 83 . 16 0 . 00 83 . 16 0 . 00
BSEISMICRE VALUATION 2, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 83 . 66 0 . 00 83 . 66 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ --- --------------
CHECK 294 . 18 19394
TOTAL RECEIPT 294 . 18
Ota05u)
CITY OF CUPERTINO
Sao- REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# 1 5-)q — 15—
WM9L Date: LOU
uildi
Bng Address:
Owner's Name: Phone#:
CRntractor: License#:
�`S So�S �oa�c: Se rJ�Ce -1*�0CA
Contact: C ',� Phone#:
NVC,Ic , 7(�\G\S CMOS%
Applicant/Contractor: Fax #:
AA x-�S pe-s KOC c\
Building Permit Info:
Bldg fG Cook Elect Plumb Mech
Job Description: „
Rew.c�tCAN�s �j svwke covSc .�ns}a�l 20 PJ 7/ib ost3�
Residential: � _ .y Commercial: CRSS
Sq.Ft. Floor Area: a o00 $/Sq.Ft.:
Architect/Engineer: Valuation:
• Type of Construction: Occupancy Group:
-
Qty. if
A licable Fee ID Fee Descril2tion Fee Group
/ BPERMFEE Bldg Permit Fees BUILIDNG
BENERGY Energy BUILIDNG
BSEISMICRE Seismic Fee Res BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
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