07060150 CITY OF CUPERTINO40
BUILDIN.G DIVISION PERMIT '7[tAC ! � MATION,
PERMIT NO.
BUILDING ADDRESS:
19781 AMHERST DR ALL SEASONS ROOFING 07060150
OWNER'S NAME: t PERMIT ISSUE DATE
J. K. LEE1720 SMITH AVE 06/18/2007
SANITARY NO. CONTROL NO.
JE:
(408) 971-4455
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 Z LICENSED CONTRACTOR'S DECLARATION
o lob Description
v I hereby affirm that I am licensed under provisions of Chapter 9(commencing
;zW
with Section7000)ofDivision3ofthcBusinessandProfcssionsCodc,andmylicenscis REMOVE _. LAYER SHAKE ROOF. INSTALL 23 OSB & 230
=y in full force and effeGu v 9
, Lio• LIFETIMI� COMP. ROOF (WEIGHT=4 .8) . CLASS A
�z License
E o Date Q] Contractor
ARCHr1ECTS DECLARATION
i a< I understand my plans shall be used as public records
iyv
tL Licensed Professional
a OWNER-BUILDER DECLARATION
a1 hereby affirm that 1 am exempt from the Contractors License Law for the
:n O following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolLsh,or repair any structure
t-y 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 Contractor's License Law(Chapter 9 q.Ft.Floor Area Valuation
s- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $10700
? 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 V V Number Occupancy Type
not more than five hundred dollars(5500). 3 16 2 9 0 3() .
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure isnot intended oroffered for sak(Sec.7044.Business Required Inspections
and Professions Code:The Contractor's 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec .B&P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury fine of the following declarations:
I have and will maintain a Certificate of Consent to self-insum for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code•for the performance of the
work for which this permit is issued.
❑1 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 Workers Compensation Insurance carrier and Policy number arc: ++
Carrier. �ST4R.A n a- Policy No.D'(V`00 L —041
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars($100)
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 Workeri 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,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z, CONSTRUCTION LENDING AGENCY
Fr C4 1 hereby affirm that there is a construction lending agency for the performance of
tYi> the work for which this permit is issued(Sec.3097,Civ.C.)
[4 Cl Lender's Name
�Cl Lenders Address
U Q 1 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
U building construction,and hereby authorise representatives of this city to enter upon the
ahove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
P.
rn liabilities,judgments,costs and expenses which may in anyway accrue against said City
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURC EGULA IONS. 461
-13-02 Re-roofs A�,;
SignatuicofAppli t/Contractor Dare Type of Roof
HAZARDOUS MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? _ All roofs ;hall be inspected prior to any roofing material being installed.
❑Yes
If a roof i:;installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
-nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
1 have read the hazardous materials requirements undcrChapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
;w4ner
uirements which Ix tnet prior w issuance of Certificate of Occupancy, Signature of Applicant Date
(� l All roof coverings to be Class"B"or better
or a- 'S agent Date
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 31629030.00
DATE ISSUED. . . . . . . : 06/18/2007
RECEIPT #. . . . . . . . . : BS000001686
REFERENCE ID # . . . : 07060150
SITE ADDRESS . . . . . : 19781 AMHERST DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER J. K. LEE
ADDRESS
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2418
RECEIVED FROM . . . . : HAEOLD MORAZON
CONTRACTOR . . . . . . . : GORSHTEIN, VLADISLAV LIC # 21035
COMPANY . . . . . . . . . . : ALI SEASONS ROOFING SERVICES
ADDRESS . . . . . . . . . . : 170 SMITH AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (4(18) 971-4455
FEE ID UNIT QUANTITY 1,MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- -------- ---------- ---------- ----------
BPERMFEE VALUATION 10, 700. 00 180.36 0. 00 180.36 0. 00
BSEISMICRE VALUATION 10, 700. 00 1 .10 0. 00 1.10 0. 00
--------- ---------- ---------- ----------
TOTAL PERMIT 181.46 0. 00 181 .46 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 181.46 MC
---------------
TOTAL RECEIPT 181.46
CITY OF EXPERTINO
RE ROOF
LUPE T NO PERMIT APPLICATION FORM
APN # 3� ( �,q Date:
Building Address: `
Owner's Name: � • \� � � Phone #:'
Contrac or: (� License#:
C�
Contact: ^ `\ � S�tG�S -- Cupertino Business License #:
f�( Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles _6Asphalt Shingles
'< Wood Shakes Wood Shakes
❑ 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.
I Have Read, Understand and Will Comply With Cu])ertino's Tear Off Polic
Job Description: \(2_Q,�-Ap vee \ k cxk,\fT Z 0,S'�
rood - \•Ss
Residential JA tornmercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are any restrictions: U
Cost of Project: Type of Construction: Occupancy gr
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING