04050070 (2) CITY OF CUPERTINO PERMIT
BUILDING DIVISION PERMIT ,CSN'CRAI-G�TURTNf�SStM�. 'I+01�1�g
BUILDINGADDRESS: WAGNER ROOFING CONTRACTORS PgtN904.050070
OWNER'S NAME: PERMIT ISSUE DATE
LINDA WOOD
ONE: SANITARY 2 CONTROL NO.
(408) 777-8331
ABUILDING PERMIT INFO
RCHITECT/ENGINEER:
BLDG ELECT PLUMB METH
p
YOC LICENSED CONTRACTOR'S DECLARATION Job Descri tion
u 1 patchy affirm Net 1 am licensed under provisions of Chapter 9(commencing P
Zly wiNSe tion7W0)o(Division3o(Nc Busimsand Pmfcssimu Coda.andmylicen¢u
T<L Data
a
affect. omN 7292.$ I REROOF
j Lice rt
CQ� 1RCHITELTS RATION
Ny'+y understand my plans shall be used a tic records
Dg,U
Licensed Professional
S OWNER-BUILDER DECLARATION
+� 1 hereby arrom that I am exempt form the Contractor's License Law for the
3:0 following reuon.(Scetion 7031.5,Business and Professions Cale:Any city or county
+�$f. which requires a permit ser ennstuci,alter,improve,demolish,or mpair'My StructurefZe prior to its issuance.also requires the applicant for such permit to rile a signed statement
£z thals,isliccnsedproposal wtheprovisions oftheConlostor'sLiccnseLaw(Chapter9 Sq.Ft. Floor Area Valuation
e( Rommencingwith Section 7")of Division J oftbe Businessand Professions Cak)or
i $
that he is exempt Ihemfrom and the bels for the snuffed exemption.Any violator,of
Section 7031.5 by any applicant for a permit Subjects the apphesnuo a civil penalty of 3 2eOGIlibiberO 0 Occupancy Type
not mom dun five hundred dollen(5500).
❑I,asowuer at property,in myamploych with wages as two sola ampenution•
will so the workens theawcmre is not intended oroRemd forane(Sec.7oaa,Busines+ Required Inspections
and any wh ono Cade:The Contractor's License law doh not apply lf an owner is 9 P
pwn em who,.provided dust
men limp and who saes Suchuma ended.,.ff or Wough his
Own employ.,.the
dmot wchimprovemCuts arcant aroftlmpleeres for owner-
builder
me building burden
a(pmentlahathwithinott year of completion,meowner- .�
builder will have the burden of proving Nn he Oitl not build or improve for purpose of
wid
0 1. l
❑1,as owner ej the property.am exclusively esand Profession
ng with licensed contractors m V /
Construct La the project(See.o an Business and property
ho Wi Code:)The Conuereon,Lt.
Close Law docs not apply je an owner of property who sed p or s antvves Corton,and
who contracts for such projects with a conwcwrtU licensed pursuant to the Contrwwra
License LA-
0 1 so
aw.❑lam exempt under Seo. ,B&PCfor this..on
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aBlon under penalty of perjury ON of the following de 1motimer.
Ihave ons will for byneCervriag of the
Labor Code,for the Wformancompcm
7F3_-'.'
lon u provided for by Section.)700 of me labor Code,for me performance:of the
rk for which mica permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
00 of the Labor Codc•for de Performance of me work for which this pe_rmiljslaced.
yWorker'sCo reach wmuee trio andPolicynumberare: Taus?er�Pollcy No.:s S'-oY pDnJ$J
CERTIFI ATEOF •(EMPTION ORKERS'
COMPENSATION INSU NCE
(TLIs.,IN uead notNcompkwd if the fermi,iaforoae hundreddollars(SIM)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any pmron in any manner an u to become subject to the Workeri Compensation
Laws of California.Dem
Applicant
NOTICE TO APPLICANT:IL after making this Ccnificala of Exemption,you should
become subject to the Wrnkera Compensation provisions of the Labor Cade.you must
Z frMwith comply with such provisions or this Permit shall M deemed mvoked.
ti h CONSTRUCTION LENDING AGENCY
(—i (hereby affirm that them is a construction lending agency par the Performance or 1
('1t? Le work fur which this permit is issued(Sec.)097.Civ.CJ
W Q Lender's Name /`—/—
]z Lancer's aaamns
V I comfy that 1 have road Cis application end sue ren IN above information Is
W F' correct.1 agree to comply with all city and county ordinances and state laws mining w
O V building arnswction,and hereby authodea mpraentstiven of this city in enter upon the
W above-mnndoued property for inspection purports
(We)agree to neve,indemnify it keep harmless me City of Cupertino against
it , liabilities,judgments.costs and expenses which may in any way scene against and City a�
V Z in consequence of the granting of this permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date —(f
SOURCER UL ONS.
O Re-roofs
Si or Applica/Contracror Data
HAZARDOUS MATER( LS DISCLOSURE Type of Roof
Will the applicant or future building occupant now or handle haardous material
as defined by the Cupertino Municipal Code,Chapter 9.11,and de HCaW and Safety
Code.seetionss531(a)? All roofs shall be inspected prior to any roofing material being installed.
El Yes p u
Will the applicant or mtare building occupant us,equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit h iardous air con eninants u derincd by the Bay Area Air Quality Management all new materials for inspection.
Disvict? —/
Thaw Igftvu
Ih&S.fmt C h,ar d. 25505lsmquirements under.dM33.lu Bermanhapter thmi.95 rdm Wilding
nit Health&Safetyhe.. csovhe,it its myrsnd7S534.l to Not the aicup Wilding
data not c §paha a enen4 Nat it k my responsibility w notily Ug occupwl of the
myuimm whi must bem priorwivvncaofaCerdficateofOccup cy S' eofApplican Dat
r euthan nagem Q am All ro coverings to be Class"B"or ester
Community Development
10300 Torre Avenue
Cupertino CA 95014
Its Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
#UPEkTINO
Building Department
JOB ADDI E,rS:
d6 D R #I - /�bS-DO �d
OWNER'S NAME: 4 PHQNE #
GENERAL CO CT R: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin 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
.4 Roofing alaire G7Z9 2
Septic Tank
Sheet Metal
Sheet Rock
Tile
/Con actor igna;: 7L
ate
CITY OF CUPERTINO
REROOF
CU INO PERMIT APPLICATION FORM
�[ Date:
APN# �z�JT qQI
Building Address:
Owner's Name: ooO •` Phone#.
Mk, 8' MtiS Gv
Contractor. Phone#: -7-2-9331 License M. 6 7a 9 Z77
Phone# Tal G Cupertino Business License#:
Contact: s �- ?7 7-9 3 3 J
-Type of Root Covetiagt
Exbg:tla �O
u Built-Up Roof
posed:
roof
t7 halt Shingles a Asphalt Shiogles
C nod Shakes u Wood Shakes
Wood
Shingles o Wood Shingles y2 /Ass/) 6
o Omer(Specify) O-Orher(Specify) iii mi qq7 --F.(a
Number of existing coverings t] Provide I.C.BA.R r o SA wj
u To be Removed O Provide Mfgr.Installation Specs.
w/058
Y Have Read Understand and Will Com I With Cu rtino's Tear Off Policy:• =/K Job Description: Pr.rr<oe s,%*ft/Z-1'. T+ sT ii ^ `+,r s° Yt t/�.Ss 'I
Sti. v 14,s 3o 95%ra
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with P ug.
.�� them are an atrictions:
Cost of Project: Type of Cons Occupant group
ca a Fee ID Fee Description Fee Grotto
BPERMFEE Bldg Permit Fees BUILDING
ENERGY Energy BUILDING
SEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUELDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING