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06100122 CITY OF CUPERTINO BUILDING DIVISION PERMIT C{1RACQiNF J. RM4rn��LN• BUILDING ADDRESS: PERMIT NO. WOODS ROOFING . 06100122 10460 IMPERIAL AVE OWNER'S NAME: PERMIT ISSUE DATE INISAM PATI MITRA 2179 SNE: SANITARY NO. CONTROL NO. (831637-5576 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH O p LICENSED CONTRACTOR'S DECLARATION v I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description Z w with Section 7000)of Division 3sof the Business and Professions Code,and my license is =y in full force andefr� 3 e/ L;c.1 3 z5/ 3 J T/O SHAKES . RESHEET. OSB, ADD 30YR COMP SHINGLES r ? License Class t p Date / A Contractor. 0. ARC CPS T N a� I understand my u : h a� u.l- Licensed Professional 1 OWNER-BUILDER DECLARATION j<2 1 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 m 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 =o 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 . that he is exempt themfrom and the basis for the alleged exemption.Any violation of Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of G 0 0 Occupancy Type 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 for sate(Sec.7044,Business ns Required Inspections and Professions Code:The Contractor's License Law docs not apply to an owner of q 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.). ❑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- 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. ❑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]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 f.0 rkfor which this permit is issued. Ihave and will maintain Worker's Compensation Insurance,as required by Section 0 of the Labor Code,for the performance of the work for which this permit is issued. My WorkeeCompensation Insurance carrier and Policy number arla : U ' / Carrier. J �'" � Policy No.: S 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.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workcr's Compensation provisions of the Labor Code,you must ,J O forthwith comply with such provisions or this permit shall be deemed revoked. ""' 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 z Lender's Address U 0 1 certify that I have read this application and state that the above information is LI." correct.I agree to comply with all city and county ordinances and state laws relating to O V building construction.and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. W (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 U z in consequence of the ranting of this perm: Date �+ ►r APPLICANT UN STANDS N L COMP WIT} ALL N N-POINT Issued by: SOURCE REGU ONS., r ' Fl at D L Re-roofs .� Signature of Applicant/Contractor Datd 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 9LbI­_ 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 Gpkl 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 t7 does not currently have a tenant,that it is my responsibility to notify the occu ant of the requirements which t be met prior w i ce of a c ficae of Occupan . Signature of Applicant Date �� j �' All roof coverings to be Class B or better Owner or aur z age Date CITY OF CUPERTINO .m 1 of 2 PERMIT RECEIPT OPERATOR: kiersaw COPY # 3 Sec : Twp: Rng: Sub.: Blk: Lot : APN 35719088 . 00 DATE ISSUED. . . . . . . : 10/16/2006 RECEIPT # . . . . . . . . . : 36465 REFERENCE ID # . . . : 06100122 SITE ADDRESS . . . . . : 10460 IMPERIAL AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER INISAM PATI MITRA ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : BONITA JENKINS CONTRACTOR WOOD, LAWRENCE E LIC # 20810 COMPANY WOODS ROOFING ADDRESS 2179 STONE AVENUE STE 22 CITY/STATE/ZIP . . . : SAN JOSE, CA 95125 TELEPHONE (831) 637-5576 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL - - --- --- - - --------- ---- ---------- ---- ----- - ---------- ----- --- -- ---------- BPERMFEE VALUATION 13 , 000 . 00 201 . 96 0 . 00 201 . 96 0 . 00 BSEISMICRE VALUATION 13 , 000 . 00 1 . 30 0 . 00 1 . 30 0 . 00 ------- --- ---------- -- -------- ---- ------ TOTAL PERMIT 203 . 26 0 . 00 203 . 26 0 . 00 CITY OF CUPERTINO Otol 00 l a REROOF CUPEkTINO PERMIT APPLICATION FORM APN# -359- 16) Date: !al/6 l D 6 Building Address: /01/ 60 Ow 's Name: n Phone#: ZSS — o / S o Contractor: ` �ZQ License / .3 l (�J r Contact: Cupertino Business License #: D Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles 7C 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 n p c��� JL �i � D S A6. Residential 1Z Commercial ❑ Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if there are any restrictions: Ll Cost of Project: h ype of Construction: Occupancy group: y©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 Fax(408)777-3333 ri TEkTINO (25-10)5-3-a - 3z8 z - ►�N«, Building Department JOB ADDRESS: • � Gam_ PERMIT# 2 ,� OWNER'S NAME: C.., PHONE # S s-v 5 u GENERAL CONTRACTOR: LAD&md 'r FAX# I am not using any subcontractors: s �. i d4,1d G ignature 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 �C Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ ontrfor Signature Date