06100199 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �IVTRAT�R ' IQ `
BUILDING ADDRESS: PERMIT NO.06100194
19985 PRICE AV
PERMIT ISSUE DATE
OWNER'S NAME:
GEORGE MONK 10/261/2006
SNE: SANITARY NO. CONTROL NO.
ABUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
!00 LICENSED CONTRACTOR'S DECLARATION Job Description
U P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z w with Section 7000)of Division 3 of the Business and Prolessions Code,and my license is
',may in full force and IT .� �- REROOF- TEAR OFF EXISTING TAR & GRAVEL, INSTALL
License 'ass Conti FLINTLASTIC TORCHDOWN CLASS A
ul DamContractor _ r
-RCHITECTS DECLAR
Lu
U I understand my plans shall be used as public records ks�'
,a
O y Licensed Professional
�0, OWNER-BUILDER DECLARATION
<z I hereby affirm that 1 am exempt from the Contractor's License Law for the
in o 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
Z y prior to its issuance,also requires the applicant for such permit to rile a signed statement Valuation
=G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
r t— (commencing with Section 70!10)of Division 3 of the Business and Professions Code)or $5400
i 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 APN Number Occupancy Type
not more than five hundred dollars($500).
❑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 forsale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's 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.).
❑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.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Conscnt to self-insure for Worker's Compcn-
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 Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
section need not be completed if the permit is for one hundred dollars($100)
ss.)
I c 'fy that in the performance of;he wor for which this permit is issued.I shall not
cm loy any person in any ft�Subject to the Workcrs'Compensation
s of Cal Date
Applicant
NOTICE LI is Certificate of Exemption,you should
become subject to the Worker's Compensa' n provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
(~-r C4 1 hereby affirm that there is a construction lending agency for the performance of
pC> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Lender's Address
U 0 I certify that 1 have read this application and suite that the above information is
LL 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
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities^judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
�.
APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL NON-POINT Issued by: 4'
SOURft REGULATIONS
Re-roofs =
Signa f pplic on for Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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.
❑Yes
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yeslu
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 ten nt,that' is my responsihilily to notify a 0 ant of the
require nus Itch must t pno trance of a Certificate of cupan Signa ore of Applicant Date
All roof coverings to be Class"B"or better
Owner r authorized agent Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
F Telephone(408)777-3228
CITY OF
Fax(408)777-3333
"UPEkTINO
Buildin De artment
JOB ADDRUSS:� PERMIT #
OWNER'S NAME: PHONE # S'6 2 `t
GENERAL CONTRACT ( s FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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
.:m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36905041 . 00
DATE ISSUED. . . . . . . : 10/26/2006
RECEIPT # . . . . . . . . . : 36580
REFERENCE ID # . . . : 06100194
SITE ADDRESS . . . . . : 19985 PRICE AV
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : GEORGE MONK
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : STAN SKARBEK
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . .
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - - - - - - - - - - - --- - - - - ---- - - ------ -- --- ------ - --------- - ----- ----- - --- --- -- -
BPERMFEE VALUATION 6 , 000 . 00 126 . 36 0 . 00 126 . 36 0 . 00
BSEISMICRE VALUATION 6 , 000 . 00 0 . 60 0 . 00 0 . 60 0 . 00
BUSLIC FLAT RATE 1 . 00 105 . 00 0 . 00 105 . 00 0 . 00
--- ----- -- ---- - - - --- ------- --- --- ----- --
TOTAL PERMIT 231 . 96 0 . 00 231 . 96 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - - - - - -- - - --- - - - - - - ------- --- - ----- - ----- ------
OTHER 231 . 96 MASTERCARD
TOTAL RECEIPT 231 . 96
--� CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# _ Date:
0122Z 2 6
Building Address: `
Owner's Name: Phone#:
L
Contractor: License#:
Contact: Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
0 Built-Up Roof X Built-Up roof
Asphalt Shingles ❑ Asphalt 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 Policy:
Job Description:--rear C// q�xb daij, F11A
Residential Comm ial ❑ C GU-P' /4,
Fire Zone: Yes ❑ NOConfirmed with Planning DeDt . if
/11 there are any restrictions:
C t of Project: Type of Construction- t Occupancy grou
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
BUS IC Business License BUILDING