07060217 CITY OF CUPERTINO
BUILDING DIVISION PERMIT c�art�cTOR �� MTI€)N
PERMIT NO.
BUILDING ADDRESS:
10758 MAXINE AV JIM KRAIJSE ROOFING 07060217
PERMIT ISSUE DATE
OWNER'S NAME:
GLADYS KWOK 2310 DIANA AVE 06/25/2007
SANITARY NO. CONTROL NO.
VE:
(408) 773-0704
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
o a 0 0
i p Q LICENSED CONTRACTOR'S DECLARATION Job Description
W
P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z cvu with Section 7000)of Division 3 of the Business and Professions Code,and my license is TEAR OFF EXISTING SHAKE 1 LAYER. RE SHEET W 7/16"
n. in full force and effec(7 "—
) z License Class Lie `� OSB, 301,B FELT, 50 YR ARCH COMP. SHINGLE, 38LB.
Dam Contractor
T'S
ARCHITECDECLAR N
Z C a 1 understand my plans shall be used as public records
)yU
'u.y Licensed Professional
n
a OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Calc:Any city or county
`<m 6� 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 $ Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 �] $12800
Y F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 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 of3 2 6 0 2 0 5 6 ( Number Occupancy Type
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 isnot intended oroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conuactoes License law docs 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 Contractor's Li-
ccnse 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 Contractofs
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I Moe and will maintain a Certificate of Consent to self-insum for Worker's 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 Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workees Compensation Insurance carrier and Policy number arc:
Carrier: -�rIQ r �W�W Policy Nos c oo iV�s
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Chis section need not be completed if the permit is for one 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 Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
a > the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
aLender's Address
U 0 1 certify that I have read this application and state that the above information is
Gk t--t correct.I agree to comply with all city and county ordinances and state laws relating to
rJ U building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
13.
,may V) liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date — ,
r i
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued bl' l�
SOU EGULATIO S. 91.(_.0 "t
Z S 7 Re-roofs w-
Signature pelican Contractor Dam T of]roof
AZARDOUS MATERIALS DISCLOSURE Type
Wi applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cafe,Chapter 9.12,and the Health and Safety
Code,section 25532(a)? All roof: shall be inspected prior to any roofing material being installed.
❑Yes N°
-- If a roof is installed without first obtaining an inspection,I agree to remove
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 all new r;laterials for inspection.
District?
❑Yes No
I have read the hazardous materials requirements under Chapter 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
require c which must met pri to issuance of a Certificate of Occupancy. Signature;of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorize l Dam
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT' RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: B11:: Lot:
APN 32602056 .00
DATE ISSUED. . . . . . . : 06,'25/2007
RECEIPT #. . . . . . . . . . BS000001780
REFERENCE ID # . . . : 07060217
SITE ADDRESS 10'758 MAXINE AV
SUBDIVISION . . . . . .
CITY CU:?ERTINO
IMPACT AREA . . . . . . .
OWNER GLADYS KWOK
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP LO3 ALTOS CA, 95022
RECEIVED FROM . . . . : EDIVARD A GREGORY
CONTRACTOR KR%USE, JIM LIC # 21415
COMPANY JIM KRAUSE ROOFING
ADDRESS 2310 DIANA AVE
CITY/STATE/ZIP . . . : MORGAN HILL, CA 95037
TELEPHONE (48) 779-0704
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- -----
BPERMFEE VALUATION 12, 800. 00 201 .96 0. 00 201.96 0. 00
BSEISMICRE VALUATION 12, 800. 00 1.30 0. 00 1 .30 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 203 .26 0. 00 203 .26 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 203 .26 MC
---------------
TOTAL RECEIPT 203 .26
07v4:) v,,? / -7
CITY OF CUPERTINO
aiV_ RF ROOF
CUPEkTwO PERMIT APPLICATION FORM
Date:
APN#&2�0ao . CT 6 z 6 -v
Building Address:
Owner's Name- Phone#:
6 IQ W s `f-W 3 1_( �, o-- S 6?_ b�
Contractor: License#:
Contact: Ldward Gr® Ory S-10f yy=GE Zl Cupertino Business License #:
North Bay Permit Service Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof _
❑ Asphalt Shingles Asphalt Shingles 5 L Yl-
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings I ❑ Provide I.C.B.O.Report#
To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read,Understand and Will Com ly With Cupertino's Tear Off Policy:
Job Description:—f/z) S s oO�L 1491e,- C6
k .� r 0SO � i .sD fc 4 _SA,.� /,e, 3S-
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of ruction: Occupancy group:
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
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
rUPEkTINO
Building Department
JOB ADDRESS: PERMI #
l() 7T 0 7 6 0 /1/ki 0 "7 O 6 O-Z-( 7
OWNER'S NAME: (y d PHONE # "Z c(Z y
GENERAL CONTRACTO J ` ,S FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSI:4ESS 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 Si"gnRme Date