08080070 (2) CITY OF CUPERTINO 4rrv :R €
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BUILD' 9DIVISION s PERT �kCb�+���1t?��M����v� '
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BUILDItT,A DESS: PERMIT NO.
WILLOWBROOK WAY RESPONSIBLE ROOFING INC 08080070
OWNER'S NAME: PERMIT SUE DATE
CHANG JENQ-SIAM AND SUH- 2882 SPRING ST - 08/11/2008
f4Ep -r n nrn
(650) 969-6151 SANITARY N0, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGO ELECT O PLUMB MECH
D O
�96 LICENSED CONTRACTOR'S DECLARATION Ib Description
ro 1 herens by AMM Nat I am licensed under PMWaof Chapter 9(CommenOaSCrIP
cing
with Section 70(IB)ol'Divislon 3 of the Business And Profossioru Code,and my liceost is RE-RF T/0 EXTNG RF, INSTL 40YR COMP RF OVR 30#FLT
^� in full forte and eff .}J�vl.,-�G,()
514 License `� Us.g W/7/16 OSB BRD CLS A 28 SQ
c r Dem 1�u` Contractor L-.D J/�
LiARCHnECrS DECLARATION
f u I understand my plans shall themed As public records
6
Is G Licensed Professional
OWNER-BUILDER DECLARATION
C 0 1 hereby,(Term mal 11. ,Business
form ant Con ons Co :A n C Law for to
i.O o which re myon.permit
t 7 construct.
Bminms and Proimprove.
a moll Calc:Any oily m county
$ which requires a permit m trims des alms Improve,demolish.orrepaira sig my structure
z y
prior lin its Issuance.dpurse requires lM applicant for such permit to Ole se,Law statement
g (commeslkgwithSssion70timpmviviamofoftheBsinessto IUcetuelesWaCoder9 Sq,Ft.Floor Area Valuation
(commencing dune W Section 70W)tof he Division r to al egad Business and on.PraAny
Cada)of $115 7 0
Q — that M u ammpt therefrom and the bub fm me alleged eanmptiu.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofNumber Occupancy Type
am ream thu Ove hundred dollars(SM. 36922047 tl l7'
❑1,As owner of me property,or my employee,with wages an later um comRnaalion,
will do the work,ud the Suuctum is notimencied oraHered forak(Sec.7014,Business Required Inspections
and Profesaioos Cade:That Conuacmr's Llc nam law does tit apply to an owner of q P
propenywha build,arimprovea Merton,and who doessach amrkhimselres through his
ownemplayen,provided thatueh improvements tie not intended oro@Cod for Wu IL
however.Ne building m improvement b sold within ane year of compleuan,the mvner-
builder ,will have the burden of proving Nat he did not build or improve for purpose of
❑1,As awner of the property,am eadusively contracting with licensed unVacmrs in _
Construct the project(Sec.7014.Business and Professions Cade:)The Contracture U.
a.taw doe not Apply W an owner of properly wind Wilds or lonquo l thereon,end.
who contracts for such projecla with a eannamm(s)licensed pursuant tome Contractor's
Lkems Law.
❑Iamuemptunder Sac. ,B&PCfothlsmsson
Owner Dam
WORKER'S COMPENSATION DECLARATION
' 1 hemby e0ism under penaity of perjury au o(Ihe fallowing declentiatu:
I ham and will maned.A Certificate ofCommrit to self-ivum fmwarkelsCompen-
suion,As provided for by Seeman 3700 of dte labor Code,for rho performance of to
work for which this permit is issued.
❑I have and will merman Workers Compensation Iteunnce,As required by Sermon
3700 of Ne labor Cade,for the performance of the wart fmwhich this permit is lmod.
My Worker,Compenul m Insurance carrier and Policy number art:
Car icr.--- -<4I f,r/i.9 Peliq Na.:,XAY7Jlln—.- A u1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
crids sum.seed tmthe completed irtK permit is fortune hundred dedats(5100)
or lose)
I certify that in to performance of use wart for which this permit Is issued.I aha!not
employ any person in any mannerso as to become subject to the Workeri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after mating this Cenifesto of Emmption,you should
become subject te the Workers Compensation provisions of the Labor Codc,you most
.J O faMwia comply with such proviav m athis permit Shall be demand revoked.
'„�„` CONSTRUCTION LENDING AGENCY
(~ 1 hereby Affirm dal Nem is a construction lending agency,for can performsae of
ai r�-v
to work far which Nb permit is Issued(Sec no97,CW.C.) '
W Q Lauded Name
Z Landers Address
U Q 1 certify mat I have mad this Application And sem Nu the above Information is
w F current.I agree as comply with all city and county aNlpNtta and slam laws Rioting to
0 U building construction,and beroby Interim representatives of this city to enter upon the
W above-menuaned property,far impaction programa
�" py (We)agree to save,indemnify and keep harmless the City of Cupertino against
IiabilitW,judgmcnu,costs and eapecsu which may in any way accrue against sad City
fJ 7 in consequence of the Swung of this permlL i
r1• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGU,�i..AATIONS.
(� E' "(I Dam Re-roofs
Signature ofApplicaHAZARDO Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant in forum Wilding aceupant nam m handle huesNoos malaria
as defmw io tine Cupertino Municipal Cade,Chapter 9.13.Cori the Health end Sorely
ewe,Section 25533(a)7
C]Yen .B Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hun udous air conuminanu u defined by me Bay Area Air Quality Management all new materials for inspection.
District
Oyu ON.
I have mad to h mmiants mamriala requiremeneonder Chapmr6.95 of the Califor.
nIsHosIN&Safety Cade.Smiom 35505,35513 uu1355M.luwvaand thuifine Wilding
does.,,.ad,haws anent.mu iii my rovponaihility m rumil the occupant of the
nquimm�c'lis whichnnmwn metp—riormiuuanccof,Ce rwamof Occupancy. ,Signature Of Applicant Date
owner af:rthariwd,sere Dam� . All roof coverings to be Class'%¢"or better
CITY OF CUPERTINO
•2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN 36922047 . 00
DATE ISSUED. . . . . . . : 08/11/2008
RECEIPT # . . . . . . . . . : BS000005741
REFERENCE ID # . . . : 08080070
SITE ADDRESS . . . . . : 10798. WILLOWBROOK WAY
SUBDIVISION
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER CHANG JENQ-SIAM AND SUH-SHIANG
ADDRESS 10798 WILLOWBROOK WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : RESPONSIBLE ROOFING
CONTRACTOR ELMORE, PAUL M. LIC # 105
COMPANY RESPONSIBLE ROOFING INC
ADDRESS 2882 SPRING ST
CITY/STATE/ZIP . . . : REDWOOD CITY, CA 94063
TELEPHONE (650) 969-6151
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
1.HSEISMICR VALUATION 11, 570 . 00 1 . 20 0 . 00 1 . 20 0 . 00
IREROOFRES SQ FEET 28 . 00 364 . 00 0 . 00 364 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 365 . 20 0 . 00 365 . 20 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ' ------
--------------
CHECK 365 . 20 #12065
---------------
TOTAL RECEIPT 365 . 20
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
----- ----------------------------
----- ----------------------------
601. ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
oazo
CITY OF CUPERTINO
REROOF
a I OF
IWUPEkTwO PERMIT APPLICATION
APN # Date:
Building Address:
I G
Owner's Name: Phone #: !2l
Contractor: Phone #:
Fax#:
Cupertino Business License #: Contractor License #:
V
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles p,'Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
o�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: —T ` -5 A-
r� >-� vve, r 3U '� Ft:1 F � / /eco crSC'� ✓�c���c� .
p'l,�f, o
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:
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
•
Signature
Revised 6/16/08
CITY OF CUPERTINO
REROOF
CUPEkTINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1REROOFCOM Re-roof Commercial B 1COMMLROOF
IBSEISMICO Seismic Commercial B
a� '°
1RER00FRES Re-roof Residential B 1SFDWLROOF
1BSEISMICRE Seismic Residential B
1REROOFMRES Re-roof Mulfi-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/a " 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: —r;
job Site Address: OCA e X
q.
Roofing Company Name: Vis'_-� n-� ' l�(� I� > > (n r}
Applicant's Signature: Date: F,_ I 1 v�
• Greg Casteel
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
R
B. Site 9. Install H.E. Irrigation, (details/spec)' L-1 72points
11. Permeable Paving, Note L-1 points
C. Foundation 1. Use 15% Flyash Concrete, (note) S-1
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2
5. Use Truss with heels, (detail) S-2
6. B. OSB Sheathing, detail S-2
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 POINTS1 40 points
•
•
Plan Review Process Work Book Page-12-Revised 3/25/08
e ,
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 Resouices Energy IAQIHealth
.Site
1.Recycle Job Site Const action 8 Demolition Waste
65% 1 point;75%= 2 points;60%=4 points i up to 4 Resource pts 0
2.Salvage Reusable Building Materials i 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
B.Design Resource-Efficient Landscapes and Gardens 4 Resource pts y=yes D
9,Reuse Materials/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 D
1 1 1
B.Foundation
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 0
2.Use Recycled Content Aggregate 2 Resource pts y=yes 0
3.Insulate Foundation/Slab before backfill 3 Energy pts y=yes 0
1 1 1
C.Structural Frame
1.Substitute Solid Sawn Lumber with Engineered Lumber --? 3 Resource pts y=yes 0
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 Floors 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 0
7.Use Engineered Studs for Vertical Applications 2 Resource pts y=yes 0
S.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 0
c.Root 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
112.USe OSB — ---
a.Subfloors 1 Resource pt y=yes D
• b.Sheathing _ 1 Resource pt y=yes 0
1 1 1 i
INPUT Resources Energy IAQIHealth
xtenor ms -
1.Use Sustainable Decking Materials
a. content Recycled Y f 3_Resource pts y=yesF D •
b.FSC Certified Wood i 3 Resource pts y=yes 0
12.Use Treated Wood That Does Not Contain Chromium/Arsenic j 1 IAO/Health pt y=yes 0
13,Install House Wrap under Siding 1 IAQ/Health pt y=yes 0
14.Use Fiber-Cement Siding Materials _ _ t 1 Resource pt y=yes 0
1 1 1
E.Plumbing
1.Install Water Heater Jacket v _] 1 Energy pt y=yes 0
2.Insulate Hot and Cold Water Pipes 2 Energy pis y=yes 0
3.Retrofit all Faucets and Showerheads with Flow Reducers
a.Faucets(1 point each,up to 2 points) Up to 2 Resource pts. 0
b.Showerheads(1 point each,up to 2 points) i Up to 2 Resource pts. 0
4.Replace Toilest with Ultra-Low Flush Toilets
I(1 point each,up to 3 points) 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/Health pts. 0
8.Install On-Demand Hot Water Circulation Pump 4 Resource pts y--yes 0
r.tiecmcai 1
1.Install Compact Fluorescent Light Bulbs(CFCs)
(6 bulbs=2 points,
10 bulbs=3 points,12 bulbs=4 points) _J 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 pts. 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 CFCs
(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
Conservation Features 1 Energy pt y=yes 0
3.Install Energy Star Refrigerator ! 1 Energy pt y=yes 0
4.Install Built-In Recycling Center 1 3 Resource pis y=yes0
- _-- —_---- — – 1
H.Insulation IMM
1.Upgrade Insulation to Exceed Title 24 Requirements
a.Walls 2 Energy pts y=yes 0
b.Ceilings 2 Energy pis y=yes 0
2.Install Floor Insulation over Crawl Space 4 Energy pts y=yes 0
3.Instal(Recycled-Content,Fiberglass Insulation with_
No Added Formaldehyde ___ 3 IAO/Health pts 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 0
b.Ceilings 4 Resource pts y=yes 0
6.Altemative Insulation Products(Colton,spray-foam)
a.Walls 4 Resource pts y=yes 0
o.t;eilings 4 Resource pts y=yes 0
r
mows 114PUT Resources Energy IAO/Health
1.Install Energy-Efficient Windows –
• a.Double-Paned 1 Energy pt y--yes 0
b.Low-Emissivity(Low-E) 2 Energy pts y=yes D
i c.Low.Conductivity Frames v 2 Energy pts y=yes 0
--
2.Install Low Heat Transmission Gla—zing Energy pt y=yes 0
1 1 1
J.Heating Ventilation and Air Conditioning
Use Duct Mastic on All Duct Joints J 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 IAQ/Health pt y=yes 0
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 7
0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy pt Y--yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
8,Install Sealed Combustion Units
a.Furnaces 31AQ/Health pts y=yes 0
b.Water Heaters 31AQ/Health pts y=yes 0
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 0
13.Retrofit Wood Burning Fireplaces
• a.Install EPA certified wood stovesfinserts 1 IAQ/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/Heallh pts y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes 0
1 1 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts y=yes 0
2.Install Solar Water Heating System 10 Energy pts 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=18 points) _ Up to 18 Energy pts 0
I6.Select Safe and Durable Roofing Materials 1 Resource t -
L----- --- – ------ P Y=Yes 0
7.Install Radiant Barrier 3 Energy pts y=yes 0
1 1 1
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 7Energy pts y=yes2.Install Overhangs or Awnings over South Facing Windows pts . y=yes p
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes D
1 1 1
•
r
n oor r ua Iry an n s es
1.Use LOwMo-VOC Paint 1 IAO/Health pts yryes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAO/Health pts y=yes 0 •
3.Use Low/No VOC Adhesives 31A0/Health pts yryes 0
4,Use Salvaged Materials for Interior Finishes 3 Resource pts Y--yes 0
5.Use Engineered Sheet Goods with no added Urea 0
Formaldehyde 61A0/Health pts y=yes
6.Use Exterior Grade Plywood for Interior Uses 1 AQ/Health pts y=yes 0
7.Seal all Exposed Particleboard or MDF 4 IAO/Health pts yryes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pis y=yes 0
10.Install Whole House Vacuum System 3 IAO/Health pis y=yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts yryes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pis y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAO/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 yryesF 0
1 1 1
Total Points Availablel 140 130 57
Total Points Pro'ect Received: 0 0 _,
G:daialprogslgreenbulldmgguidelinwr=Ddsiowgreenpdntsfnal2.12.04proledehds
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Community Development
10300 Torte Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
WUPEkTINO
Building Department
JOB ADDRESS: PERMIT#
v 08-04 0 70
OWNER'S NAME: PHONE # ;;2;
GENERAL CONTRACTOR: I FAX #
I am not using any subcontractors: Y. t 1 y
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
dim- Gw�
Owner/Contractor Signature Date