06100043 CITY OF CUPERTINO �p h
BUILDING DIVISION PERMIT F0 R�C. �Jk4 I F RMATTO_
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BUILDING ADDRESS:
OLD COUNTRY ROOFING PERMIT NO.06100043
11698 OLIVE SPRING CT
OWNER'S NAME:
PERMIT ISSUE DATE
RAM GUPTA 125-B GROBRIC CT 2006
INE: SANITARY NO. CONTROL NO.
(707) 864-5557
BUILDING PERMIT INFO
ARCHITECI?ENGiNEER: BLDG ELECT PLUMB MECH
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�
p LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
i Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
<o in full force andc REROOF-T O SHAKES ADD 50 YR COMP SHINGLES
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j r�Z License Class_�_ i.ic.M_ 2' 7 3
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Date tractor
ARCH S D6 N •
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U� ' I understand my plan;a
y LLO H Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
ZOO 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 $9000
a Z y prior w its issuance,also requires the applicant for such permit to rile a signed statement
i =< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
n I- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 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 rU Occupancy Type
not more than five hundred dollars(S500).
❑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 �l 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 U-
cease Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a comractor(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:
j]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
700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker' C,oppm�j rasa on Insursn mer and Polity umber am:
Carier✓/Lt7�T.Y Policy No.: 17 S's 7 ':---
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,I 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 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 i1. 1 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 A Lender's Name
z Lender's Address
U C) I certify that 1 have read this application and state that the above information is
I3.►-" correct.I agree to comply with all city and county ordinances and state laws relating to
0 U 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 expenses which may in any way accrue against said City
U ,'z in consequence of the granting of this rmit.
r" APPLICANT DERSTA S WILL PLY•WITH ALL ON-POINT Issued by: Date
SOURCE LATE
Re-roofs
Signature of Applicant/Contractor 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)?❑Yes � All roofs shall be inspected prior to any roofing material being installed.
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 -
1 have mad the hazardous materials requirements33 nd55 under Chapter fi.95 if the Califor-
nia
aldi g /O
ria Health&SafetyCode,Sections 25505.25533 and 25534.I understand that if the building
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docs not currently h ve a tenant,that it is responsibility to notify the occupant of the
10
requirements wh' ust be me 'or r once of a niricats of Gccupan . Signature of Appl ieant Date
Owner ora thorirsd agent All roof coverings to be Class "B"or better
CITY OF CUPERTINO
2 of 2 PERMIT RECEIPT OPERATOR: suem
COPY # : 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36654101.00
DATE ISSUED. . . . . . . : 10/06/2006
RECEIPT #. . . . . . . . . 36338
REFERENCE ID # . . . : 06100043
SITE ADDRESS 11698 OLIVE SPRING CT
SUBDIVISION
CITY CUPERTINO
IMPACT AREA
OWNER RAM GUPTA
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP CUPERTINO CA, CA 95014-5141
RECEIVED FROM BONITA JENKINS
CONTRACTOR FOLK, DIETER LIC # 20389
COMPANY OLD COUNTRY ROOFING
ADDRESS 125-B GROBRIC CT
CITY/STATE/ZIP . . . : SUISUN, CA 94585
TELEPHONE (707) 864-5557
SEE 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
---------- ---------- ---------- ----------
TOTAL PERMIT 159.66 0.00 159.66 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
OTHER 319.32 VISA
TOTAL RECEIPT 319.32
I
Community Development
10300 Torre Avenue
Cupertino CA 95014
' Telephone(408)777-3228
Fax(408)777-3333
r, IPEkTINO
Buildin Department
�, jos ADDREss.�!G ��d� �y,�-�-� cam-- r # c
OWNER'S NAME: 6' PHONE # 2-!?q -3,1Y7
GENERAL CONTRACTOR PZW FAX#
I am not using any subcontractors:Olaf
Si tore 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
��A f a 6
Own ontractor Signature Date
CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# Date: � 6
Building Address:
Owner's Name:/� �^ Phone#: Z� R —3 g 7
Contractor: License#: / Z Z7 /
l
Contact: Cupertino Bud License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles 'V Asphalt Shingles
Wood Shakes ❑ Wood Shakes
Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ) ❑ Provide I.C.B.O. Report#
XTo be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read,Understand and Will Comply With Cupertino's Tear Off Policy:
Job De ription:
D
Residentia Commercial 'E]-
Fire
❑Fire Zone: Yes ❑ No ❑ Confirmed with Planning D t. if
there are any restrictions:
Cost of roject: o j Type of Construction: Occupancy group:
ado 2la
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