06050189CITY 0F,.CUFUK1I.fvu
BUILM•; DIVISION PERMIT
BUILDING ADDRESS:
22283 N DE ANZA CL
OWNER'S NAME:
AUSTIN DONNA M AND L S
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ARCHITEC•rlENGINEER:
1 hereby affirm that I am licensed under provisions of Chaptcr 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect. _ 3 Lie• 3 0 7
Date Class
i - O Contractor r
ARCHITECCS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Conuactoes License Law does not apply to an owner of
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. If,
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
sale.).
0 I, as owner of the property, am exclusively contracting with Licensedraetur�e
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Ui'
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractors) licensed pursuant Contractoes
License Law.
Q I am exempt under Sec B & C for This reason
Owner Date --------
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty or perjury one of the following declarations:
L] I have and will maintain a certificate or Consent to self -insure for Workces Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Com easation Insurance carrier and Policy number are:
Cartier: Va.4d PolicyNo.: DOGS%l b d Y E1
OR FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -1 CO I
(This section need not be completed if the permit is for one hundred dollars ($14)
or less.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code,youmust
,Z forthwith comply with such provisions or this permit shall be deemed revo
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H & W ROOFING
1890 CREWE C
(415) 964 -4 945
PERMITNO- 06050189
PERMIT! ISSUE DATE
05/23/2006
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
GARAGE ONLY. TEAR OFF SHAKE AND REROOF WITH
CLASS A SHAKE
Floor Area
W
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work For which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemn•fy and keep harmless the City of Cupertino against
liabilities, judgments, costs and a uses which may in an y accrue against said City
in consequence of the granting this permit.
APPLICANT UNDERSTA S AND WILL CO LY WITH ALL NON -POINT
SOURCE REGULAaon
y
(, � `,2 7
Signature of ApplitorDatc
OUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstorc or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cock, Section 25532(a)?
Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
Yes ❑ No
I have read the by Dass materials c uincm u under Chapter 6.95 of the Califor-
nia Health JS
Safety Code tions 25505, 25533 25534.1 understand that if the building
does not currently tenant, that it is my risibility to notify the occupant of the
requirements wh' sr' be t or to "u of a Certificate of Occupancy.
Owner or a thorize gent Date
Issued by:
Re -roofs
Type of Roof
W
Required Inspections
i
Type
Date -S---' 2J_v -,
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed W�thout first obtaining an inspection, I agree to remove
all new materials fo nspection.
of A licant Date
All roof coverings to be Class "B" or better
L
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work For which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemn•fy and keep harmless the City of Cupertino against
liabilities, judgments, costs and a uses which may in an y accrue against said City
in consequence of the granting this permit.
APPLICANT UNDERSTA S AND WILL CO LY WITH ALL NON -POINT
SOURCE REGULAaon
y
(, � `,2 7
Signature of ApplitorDatc
OUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstorc or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cock, Section 25532(a)?
Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
Yes ❑ No
I have read the by Dass materials c uincm u under Chapter 6.95 of the Califor-
nia Health JS
Safety Code tions 25505, 25533 25534.1 understand that if the building
does not currently tenant, that it is my risibility to notify the occupant of the
requirements wh' sr' be t or to "u of a Certificate of Occupancy.
Owner or a thorize gent Date
Issued by:
Re -roofs
Type of Roof
W
Required Inspections
i
Type
Date -S---' 2J_v -,
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed W�thout first obtaining an inspection, I agree to remove
all new materials fo nspection.
of A licant Date
All roof coverings to be Class "B" or better
CITY OF
7UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
222 ti A An -L-e, C r
PERMIT #
06 0 S° bt--' gL f
OWNER'S NAME:
PHONE # 1:5F2-
:5F2GENERAL
GENERALCONTRACTOR:t,
#
I am not using any subcontractors:
ignature Date
Please check a nlicable subcontractors and complete the following information:
Owner/ Contractor Signature
Date
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
PERMIT RECEIPT OPERATOR: amyw
:m 1 of 1 COPY # : 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35602024.00
DATE ISSUED ....... 04513/2006
RECEIPT #......... : 06050189
REFERENCE ID # •••
SITE ADDRESS .....: 22283 N DE ANZA CL
SUBDIVISION CUPERTINO
CITY .............
IMPACT AREA .......
OWNER ............: AUSTIN DONNA M AND L S
ADDRESS •••••
CITY/STATE/ZIP
RECEIVED FROM ....: H & W ROOFING
CONTRACTOR .......: HAINES, HARRY LIC # 1173
COMPANY ..........: H & W ROOFING
ADDRESS 1890 CREWE CT
CITY/STATE/ZIP ...: SAN JOSE, CA 95132
TELEPHONE ........: (415)964-4945
UNIT
--FEE ID _
----- ----------
BPERMFEE VALUATION
BSEISMICRE VALUATION
QUANTITY AMOUNT
--------------------
4,000.00 3,600.00 104.76 0.50
____
105.26
PD -TO -DT
----------
0.00
0.00
__
0.00
THIS REC
----------
104.7
0.50
105.26 ----------
--NEW-BAL-
0.00
0.00
---------
0.00
TOTAL PERMIT :
------NUMBER
AMOUNT
METHOD OF PAYMENT ------
-------
CHECK 105_26 6846
TOTAL RECEIPT 105.26
CITY OF CUPERTINO (X05 01bq
REROOF
CUPCITY Of
El�TINO PERMIT APPLICATION FORM
Building Address:
Owner's Name:
Contractor:
Contact:
' Type of Roc
Existing:
❑ Built -Up Roof
❑ Asphalt Shingles
p," Wood Shakes
❑ Wood Shingles
❑ Other (Specify)
Number of existing coverings
❑ To be Removed
I Have Read, Understand and Will Comply With Cup(
r
ob Description: T
esidential Co ercial ❑
Fire Zone: Yes ❑ No
Cost of Project: Type of Construct
J
Qty. if
Fee ID
BPERMFEE
BENERGY
BSEISMICRE
BSEISMICOM
BPLANCHK
BUSLIC
Date:
C;
Phone #:
q6 -e J 6 - 1
License #:
7
Cupertino Business License #:
f Covering:
Proposed:
❑
Built -Up roof
❑
Asphalt Shingles
BUILDING
Wood Shakes
❑
Wood Shingles
❑
Other (Specify)
❑
Provide I.C.B.O. Report #
❑
Provide Mfgr. Installation Specs.
rtino's Tear Off Policy. U
i2t/'�'v�
-r✓ c�� ' .S Ila C/asS s�ia/fir
Confirmed with Planning Det. if
there are any restrictions: LJ
ion: Occupancy group:
Fee Description
Fee Grou
3ldg Permit Fees
BUILDING
Ener
BUILDING
Seismic Fee Res
BUILDING
Seismic Commercial
BUILDING
Plan Check Fee
BUILDING
Business License
BUILDING