06100096 -7-777777777777
77777
CITY OF CUPERTINO
BUILDING DIVISION PERMIT C. RMATIO
BUILDING ADDRESS:
SMS ROOFING PERMIT No. 06100096
1161 HUNTERSTON PL
OWNER'S NAME:
PERMIT ISSUE DATE
MELVIN JUBB 1900 DOBBIN IM 101/12/2006
NE: SANITARY NO. CONTROL NO.
(408).254-7904
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
O p LICENSED CONTRACTOR'S DECLARATION
'w I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
U� with Section 7000)of Division 3 of the Business and Professions Code,and my license is
;may in full force and e grt.3 � � w REROOF- TEAR OFF COMP SHINGLES (2) ADD 30YR COM
z Liccnx C LM �..rds
CLASS A
t-w
D. CogtracR ��I',S LwUI understand my pla f{�e�bS b
:. 0
y Licensed Professional
y rA OWNER-BUILDER DECLARATION
3< 1 hereby alTirm that 1 am exempt from the Contractor's License Law for the
p 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 to prior its issuance,also requires the applicant for such permit to file a signed statement 16 8 8 6
_< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuatit
a F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
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). 36221017 . 00
❑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 for sale(Sec.7044,Business Required Ins ections
and Professions Code:The Contractor's License Law docs not apply to an owner of fl p
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 contractors)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
I hereby affirm under penalty of perjury one of the following declarations:
❑1 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
;,k 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 Ne performance of the work for which this permit is issued.
My Worker onr don surance carrier and Policy nupt4er are: O
Carrier. ' ` 4: Policy No.. (• ~ 6 d d S 5
CERTIFICATE OF EXEMPTION FROM WORKERS'
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 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
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
pr> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
=Z Lender's Address
U 0 I certify that 1 have read this application and state that the above information is
Lt.0-4 correct.I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction,and hereby authorize representatives of this city to enter upon the
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
fJ z in consequence of4DA
ng of this permi 1 —G' L
r� APPLICANT UNDS D COMP WITHALL NO -POINT Issued by: Date
SOURCER GU ' _ /�
7/A Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle ha•/Ardous 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
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 materials for inspection.
District?
❑Yes B#k-- /
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- y all
�O
nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building ///
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements h must be et p' issuance o a Certificate of e. Signature of Applicant Date
°tb1/iJo t
- All roof coverings to be Class B or better
0.0for authorized agent Date.
10/11/2006 22:23 5105383282 LEGALITIES IMC PAGE al
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SURCONMACrOR BUSINESS NAM Bi1SI��ESS L,�CENSE #
Cabirieti do M�7lwor�C ••-
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Lirwleua�/Wood -
Claas/Coming
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iruulatiott .._
Vital Sheet Metal .._
Pahft4/ Wallpaper
. Pavia •
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Sheet M"
Sheetodc
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CITY OF CUPERTINO
em 2 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36221017 . 00
DATE ISSUED. . . . . . . : 10/12/2006
RECEIPT # . . . . . . . . . : 36421
REFERENCE ID # . . - : 06100096
SITE ADDRESS . . . . . : 1161 HUNTERSTON PL
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MELVIN JUBB
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : BONITA JENKINS
CONTRACTOR . . . . . . . : GRAEME BLACKBURN LIC # 27125
COMPANY . . . . . . . . . . : SMS ROOFING
ADDRESS 1900 DOBBIN DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95133
TELEPHONE . . . . . . . . : (408) 254-7904
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--- --- ---- - ------- ----- ---------- ---------- --------- - ---------- ------- ---
BPERMFEE VALUATION 7, 000 . 00 137 . 16 0 . 00 137 . 16 0 . 00
BSEISMICRE VALUATION 7, 000 . 00 0 . 70 0 . 00 0 . 70 0 . 00
------ ---- ---------- --- ------- --------- -
TOTAL PERMIT 137 . 86 0 . 00 137 . 86 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- --- -- - ---------- ------------ ------------- -----
OTHER 221 . 88 VISA
TOTAL RECEIPT 221 . 88
O U10009 U
CITY OF CUPERTINO
' `- REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# J Date:
�d t 2 0
Building Address: � f ,� r _ � L
Owner's Name. Phone#:
��- ZS Z -2-7 7-3
Contractor: / D License#: �js 3 3 L{
Contact: Gv( Cupertino Buusiness License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Asphalt Shingles �4 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 De�ption;el
�2 �G�� 3� ', �/ -7
Residential Commercial ❑
Fire Zone: Yes ❑ No rJ_ Confirmed with Planning Deft. if
there are any restrictions: LJ
Cost of Project: Type of Constru tion: Occupancy grow
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