08120017 BUILDjNGJpIvISION PERMIT �COt'!I, RtfiCTOR Q,,,Mt1'TION,
BUILDING ADDRESS: PERMIT NO.
21979 SAN FERNANDO AAM TBD - TO BE DFTERMINED QR12nnI7
OWNER'S NAME: PERMIT ISSUE DATE
NE: A CONTROL NO.
L'T DTR
ARCHITECT/ENGINEER:
BUILDING PERMITrNF0
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION IObDeSCrI hon
rd UZ 1 hereby affirm Nat f am'"rescd-ods we"'.of Mapmr 9(mmmcaing P
n<5lwird Section7IXIU)ef Diviaian7of NC Butiness antl Profrssiom Cotle.and mylicense is
-tom in m. aandercaL RE-RF RMV OLD ROOF& RPLC W/STNDING SEAM MTL ROOF
L- D�maClus CCoontractor SYS ON EXTNG POOL,HSE BLDG
ARCHITECTS DECLARATION
'f U 1 urMcrsmnd my plans shall be used as public records
g Licensed Professional
j''N� OWNER-BUILDER DECLARATION
�f 1 Met, fl,.Nat I.m exempt fmm the Conlnao'.License Law for the
too following mason.(Section 1031.5,and.and Prefcssium Code:Any city or county
$ which requires a permit m conswct,ser.mea..demolish,Or¢pair any wunum
prior in its issuance.tied nc,uirca Ne xpplinm for such perunitto fiks signed sulemcm
ppxx< NU W is licensed pursuant to the provisions ofdte Conuactori Ucomen Law(OupW9 Sq.Ft.Floor Area Valuation
yF$ (commencing with Section 7000).(Divbion 3 of No Businessand Professions Codc)or
y
that M Is exempt therefrom and Be basis for Ce alkgcd aempdon.Any violatian of so
Section 7031.5 by any application for a Permit subjects the applicant in a civil perully of APN Number Occupancy Type
nm more Nfisc
an hundred dollars($M
01,no uoftiepmperty,mmyemployeeswithedgesutheirmkcompemadon, 35710005 . 00
wflldo Cewmk,and ebe suns.isnatinleMed w offered ruessle(Sa.70U,Business
and Profeemom Cod&-The Conuxmn
eS Litue low does ML apply in an owner of Required Inspections
pr nywhobuildaaimpo Cereon,a whodoeasmhworkhbm fw Nmvghhis -
was employees,ptwided that such imp thements are not inendd oroffered foredo.It,
however,Ne Wilding or impmwmmi iswid within one you of completion.Ne owner-
�btulld will base the padre of proving Nat he did ws Mid or impron for purpose of
W
L as awes of Ce property.a..Business aclusi and wnuazains wird littered enntraet'S ecaushoU La the es ober(Sec.topuna narofand Professions Cade:)Tie Cmhacmfa Li-
who Law dose tot apply m an oweer of propartyxoDi who Wilda ser improves Combos.and.
who contracts[m surd projects wird a enntramOris)licensed purswnt as ted ContsanoYs -
Elan'Law.
❑Iter yips under set .Bd PCfor this moan
Uwrca
WORKERS COM ENSATON LARATfON '
I hereby affirm under Penalty of perjury one of the following dechmdoar:
haw and will maintain aCenifiate of Camem in self-insure fm Workers Compm- _
'm.a provided for by Section 3700 of the labor Code.for the perfonnan¢of the
work fee which this Permit is issued.
❑I hive and will maintain Warkees Compensation Insurance,as required by Sermon
3700 of the Lobar Code,for the performance of Ce work tar which Otis permit is lssutN
My Werk es CompamaGan psunore curia and Policy number ma:
Cartier. Policy No.: ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fids seNm need Out W cmnple ed If the permft is farmehundead demes(SIOD)
m kis)
1 testify Nat in than perfonmurcc of the work for which this permit is issued.)shill am
employ any Person in any
f , maL Wbes
omc subject m Ne Wortrn'Compcmadon
Laws onC �s Dam
Applill
NOTICE
TO APPLICANT:If,after midling this Cpn Rcate of Exemption,you should
hectare subject m Nb Waher'a Compemktion pmol na of Nc Labor Codc,you mese
O faMwith mmPly with such'ervLsl.m or Nu Permit shall bm
e domed mated.
d.
51 CONSTRUCTION LENDING AGENCY
Ithereby aRmm that Nee is a construction lending agency for Inc Performance of
athe work for which this permw
it k ivd(Set091
3 ,Civ.C.)
D3 Q Launois Name
zLandeex Adieus
V 0 1 mortify that I Mw bad this application W sue Cc the stow information u
comsecl I agrce m coroply with all city and county oNina�s and.me lawn;relating m
�0 Wilding concoction,and hereby audomize repmsenutivesof Nis city m enms.0.the
hove-mcaEcd properly fm impomion purposes
4 a (We)agree to saw,indemnify and kap harmlem the City of Cupertino agafmt ,
fn lisplities,Jagmcnts.cosu and expenaeswhich maykany nyamue sgainuseid City
.V Z^ iL
APPL CgANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
Sr. REGULATIONS
S—u/Rnr fermi a —L V I dZ/0K Re-roofs
Sigmuure of AppliantrCon r a�
HAZAR US MA DISCLOSURE Type of Roof
Will the applicant w future building mcupantcom orhandle harudom material
as defined by the Cupertino Municipal Codc.Chapter 9.11,and the Health and Way
code.Secdonn531p)7All roofs shall be inspected prior to any roofing material being installed.
Yes
Will the appltca ll ser future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Nt havndous air conmmirunu u de0oed by the Bay Ams Air Gustily Management all new materials for inspection.
uict7 1/
❑Yes ONO
I haw mW the heusdous materials requirementsunder CluDter G95 of NeCalifor-
nkHcalNkSecty Code Sctiom15505,15533aa1155N.ImN:ms ifde building _
dem not cuecntly Law a natant,Nat it as my reeponeldlity In nudity de oxvpant fit the
mgyiromenu which marc t piortoimuancc 9(a Ccrdfeam of OcapAngO Signature of Applicant Date
t/ T Or WOH w, Ytd 1\I_ I/n'112� All roof coverings to be Class'n"or better
Owen or mdmriuA ager te� g �'
edgy CITY OF CUPERTINO O � 0O1�
REROOF
CUPERT
CITY OF
• INO PERMIT APPLICATION
APN # Date:
2531 00 0!S-? , O�3 Iz -08
Building Address:
2_lq`7q v) l erna,h0LO
Owner's Name: Phone #:
C( +A Of Ct _eQ_V- � vue � 1-1-1 3215
(24 rvvtew
Contractor: -� gD Phone #:
Fax #:
Cupertino Business License #: Contractor License #:
Type of Roof Covering:
l
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
.4 Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
40 ❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) )&- Other(Specify) S-1-ay&4 Seam Me�J
Number of existing coverings ❑ Provide I.C.B.O. Report # SyS
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: R emcg e, a l cA ro and re-.p(ac-e. w, �II S-Izt nd t ny
SP_aw\ Mui%J �� Sys-I--e_w, }Po {'
on is �in�
ol 6Lkse
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:
� L
Signature
Revised 6/16/08
CITY OF CUPERTINO
OF REROOF
1 OF
CUPEkTINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1RER00FC0M Re-roof Commercial B 1COMMLROOF
1BSEISMICO Seismic Commercial B
1RER00FRES ' Re-roof Residential B 1SFDWLR00F
1BSEISMICRE Seismic Residential B
1REROOFMRES Re-roof Multi-Family B IMFDWLROOF
1BSEISMICRE Seismic Residential B •
1BUSLIC Business License B
Revised 6/16/08