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07060081 CITY OF CUPERTINO PERMIT 1t,� BUILDING DIVISION " PERMIT Cfi3 `RACTC?R� t� Il * PERMIT NO. BUILG67 ESfiROSPECT RD ABOVE ALL ROOFING 07060081 PERMIT ISSUE DATE OWNER'S NAME: BLUE HILL MEDICAL OFFICE 700 NORTHRUP ST 06/12/2007 SANITARY NO. CONTROL NO. NE- (408) 29� -4188 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 lcd p a LICENSED CONTRACTOR'S DECLARATION Job Description m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing z U with Section 7000)of Division 3 of the Business and Professions Code,and my license is C OMMERC-:AL RE—ROOF, REMOVE EXISTING WOOD SHAKE C m in full force and effect. G AND ,vD Z License lass Lic.$ o Date contractor — ' "'* INSTALL ASPHALT SHINGLES F ARCHITECTS DECLARATION i a< 1 understand my plans shall be used as public records iy0 u.H Licensed Professional a OWNER-BUILDER DECLARATION t� t 1 hereby affirm that I am exempt from the Contractor's License Law ort the jc Oe� 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 t"N prior w its issuance,also requires the applicant for such permit to file a signed statement Valuation Sq.Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 ` q,Ft.Floor Area $31500 tZ (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 366100541 . Number not more than five hundred dollars($500). 1,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 forsale(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 We.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.). ❑I,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- 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 Contractor's License law. ❑lam exempt under e B&P C for this reason Owner Date WORKER'S C SATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure 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. ave 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 Work�ers(Co� nrc ation In nee carrier and Policy number a : Carrier. STT 17, Policy No.: 7 CERTIFICATE OF EXEMPTION FROM ORK COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) 1 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 Workcrs'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 Z forthwith comply with such provision or this permit shall be deemed revoked. z CONSTRUCTION LENDING AGENCY [�rte. I hereby affirm that there is a construction lending agency for the performance of ai> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name Z Lender's Address 1 certify that I have read this application and state that the above information is V.. O correct.I agree to comply with all city and county ordinances and state laws relating to rJ- V building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and exHI ma in anyway accrue against said City V`Z in consequence of the granting of Date ►- APPLICANT UNDERSTANDCOMPLY WITH ALL NON-POINT Issued by: SOURCE RE (: t Vz a Re-roofs I ure of A icanUCon r Dao HAZARDOUS MATERIALS DISCLOSURE Type of F.00f 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 shall be inspected prior to any roofing material being installed. C]Yes AdN0 If a roof:s 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 Arca Air Quality Management all new materials for lnspectio District? Yes ICZNu ,t I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Section 25 , 5533 and 15534.1 understand that if the building does not currently have a Lena a is my responsibility o notify the occupant of the requirements wh'h met ' to issuance of a Certificate of Occup Sign turf of Applicant Date t All roof coverings to be Class"B"or better 0 r or authorized agent Da CITY OF =ERTINO 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: bethe COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36610054 . 00 DATE ISSUED. . . . . . . : 06/12/2007 RECEIPT # . . . . . . . . . BS000001614 REFERENCE ID # . . . : 07050081 SITE ADDRESS 20555 PROSPECT RD SUBDIVISION CITY CUPERTINO IMPACT AREA . . . . . . OWNER BLUE HILL MEDICAL OFFICE ADDRESS 20555 PROSPECT RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ABCVE ALL ROOFING CONTRACTOR KEN SULESKY LIC # 23092 COMPANY ABCVE ALL ROOFING ADDRESS 700 NORTHRUP ST CITY/STATE/ZIP . . . : SAN JOSE, CA 95126 TELEPHONE (408) 292-4188 FEE ID UNIT QUANTITY PMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ------- BPERMFEE VALUATION 31, 500 . 00 384 .48 0 .00 384 .48 0 . 00 BSEISMICOM VALUATION 31, 500 .00 6 . 72 0 .00 6 . 72 0. 00 -- -------- ---------- ---------- ---------- TOTAL PERMIT 391.20 0 .00 391 .20 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 391.20 14286 --------------- TOTAL RECEIPT 391.20 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ----------- 305 FRAME 307 INSULATION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS CITY OF CUPERTINO REROOF CUPEkTINO PERMIT APPLICATION FORM 070 6 COPS d APN# Date: ` Lo Building Address: Owner's Name: Phone Contractor: _ License #: �21 Z4 Z- S Contactn Cupertino Business License #: Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles -Asphalt Shingles )W-Wood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles ❑ Other(Specify) ❑ Other(Specify) Number of existing coverings 1 ❑ Provide I.C.B.O.Report# 16 To be Removed ❑ Provide Mfgr.Installation Specs. I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: Job escription: 1� ko -11/1 LO ds 7 le- l Residential ❑ Commercial 1$z_ —77 Fire Zone: Yes ❑ No Confirmed with Planning Det. if there are any restrictions: LI Cost of Project: Type of Construction: Occupancy group: t o 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 `;UPEkTINO Building Department JOB-2c,5,55 S PERMITD7NOODO I OWNER'S NAME: PH NE # t �t - 10 - GENERAL CONTRACTOR „ ;, t T' r ' " I*•A?C # rr' Z I am not using any subcontractors: ZL2 L7 Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSIINESS 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