06100197 CITY OF CUPERTINO
BUIL[iiNG DIVISION -ONT
PERMIT
BUILDING ADDRESS: rJ OO F ING CO. PERMIT NO.06100197
10518 GASCOIGNE DR
OWNER'S NAME:
PERMIT ISSUE DATE
TAUFIK & AUGUSTINE ARIFIN 929 BERRYESSA RD 10/26/2006
.ONE: SANITARY NO. CONTROL NO.
(408) 452-0960
BUILDING PERMIT INFO
ARCHfrECT/BNGiNEER: BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
?2 LU with Section 7000)of Division 3 of the Business and Professions Code,and my license is
<o, in full force anderfict REROOF- REMOVE EXISTING ROOF, AND REPLACE
;n? License Class = I Conti or �i �- WITH BUR MODIFIED CLASS A 21 SQUARES
3 F"O Date ;�r"'1- ?. Contractor 7__r� t ,:r t' i h- � � �
ARCHMC79 DECLA TION
C U I understand my plans shall be used as public records
.a
G
H Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county 0
am ff 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 file a signed statement
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $8450
L 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 rive 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 for sale(Sec.7044,Business Re uired Inspections
and Professions Cote:The Contractor's License Law does not apply to an owner of q p
property who builds or improves thereon,and who flexes 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,die 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 themon,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 Date
WORKER'S COMPENSATION DECLARATION
I 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.
❑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 Polity number am:
Cartier. ';:{ e Policy No.: !` C f,1. z1 "
tL r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This 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,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Dam
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
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lcndees Address
U Q 1 certify that I have read this application and state that the above information is
CL -.
correct.I agree to comply with all city and county ordinances and state laws relating to
O Ubuilding construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
CL (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. S4tQ�
., APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �
SO JCE RFGUL TION .
E 14 _ 10 1!4 I'l: Re-roofs
Signature of ApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Use 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)?❑Yes All roofs shall be inspected prior to any roofing material being installed.
1po
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?
Cl Yes Q No
1 have mad 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
m menu whit ust t prior to issuance of a Certificate of Occupancy.
qy� l'("' °c��` PSignature of Applicant Date
I , 411^VI All roof coverings to be Class"B"or better
Owner or authorized agent Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
''UPERTINO
Building Department
JOB ADDRESS: PERMIT #
06 <0® -7
OWNERS NAME: PHONE # -� Z
GENERAL CONTRACTOR -- , FAX #
I am not using any subcontractors: 6
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
LA �h, Z�' N
Owner/Contractor Signature Date
CITY OF CUPERTINO
3m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 37523012 . 00
DATE ISSUED. . . . . . . : 10/26/2006
RECEIPT # . . . . . . . . . : 36586
REFERENCE ID # . . . : 06100197
SITE ADDRESS . . . . . : 10518 GASCOIGNE DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : TAUFIK & AUGUSTINE ARIFIN
ADDRESS . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : JB ROOFING
CONTRACTOR . . . . . . . : BOB SMITH LIC # 27262
COMPANY J.B. ROOFING CO.
ADDRESS 929 BERRYESSA RD
CITY/STATE/ZIP . . . : SAN JOSE, CA 95133
TELEPHONE (408) 452-0960
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - - - - - - -- - -- - - --- - ---- - ---------- -------- -- ------- - - - ---- ----- - -- ---- --- -
BPERMFEE VALUATION_. 9, 000 . 00 158 . 76 0 . 00 158 . 76 0 . 00
BSEISMICRE VALUATION 9, 000 . 00 0 . 90 0 . 00 0 . 90 0 . 00
BUSLIC FLAT RATE 1 . 00 105 . 00 0 . 00 105 . 00 0 . 00
------ ---- -- - ------- - -- ------- ---- - --- --
TOTAL PERMIT 264 . 66 0 . 00 264 . 66 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - - - - --- - --- - --- - - ------ ----- -- - - ----- ---------
OTHER 264 . 66 AMEX
TOTAL RECEIPT 264 . 66
001MC11
CITY OF CUPERTINO
CCS- - EROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# n v3 f Oiz Date:
Building Address:
Owner's Name: 0 0 Phone#:
:L Aa Z - Z (�f
Contractor:6 License#:
Cont ct: Cupertino Business License #:
SY
Type of Roof Covering:
Existing: Proposed:
J K Built-Up Roof Q( Built-Up roof
)1_ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ;k Other(Specify) _
Number of existing coverings ❑ Provide I.C.B.O. Report 41
❑ To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cupertino's Tear Off Policy: ❑
J"escription:
Residential Conitifercial ❑ 2 S�, ` cI r
Fire Zone: Yes ❑ No Confirmed with Planning Deft. if
there are any restrictions: LJ
Cost of Project: Type of Construction: OccupancytC�roup:
—
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
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