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09030166 CITY OF CUPERTINO BUILDING DIVISION PERMIT `` '' PERMIT NO. BUILDING ADDRESS: 10 9 61, 10 9 6 3, 19 71 10 9 7 3 10 9 81 1 9 8 3 FOUR Z SEAS P1tMIT IssuE DATE OWNIReRgARSKY SQ Sp CONTROL NO. 'ONE: (4-03) 2 7 8-0 3 3 0 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH a p C LICENSED CONTRACTOR'S DECLARATION Job Description i U C 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing _Z, with Section 70(10)of Division 3 of the Business and Professions Code.and my license is RPL,'- EXTNG RF SYS W/NEW GAF GRAND CNYON ° y in full force and effect. �� J -c Z License s Lic. ARCHI EC Date r Contra..... ASP iALT ARCHITECTS DECLARATION R00'P SYS CLS A 76SQ U 1 understand my plans shall be used as public records D u" 4 C y Licensed Professional OWNER-BUILDER DECLARATION r'< I hereby affirm that 1 am exempt from the Contractor's License Law for the 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county mwhich requires a permit to construct alter,improve,demolish,or repair any structure res-'y prior to its issuance,also requires the applicant for such permit to file a signed statement h;q.Ft.Floor Area Valuation Z< that he is licensed pursuant to the provisions of the Contractor's Lit ensc Law(Chapter 9 YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $30000 y 5 2- that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars(5500). 3 1 6 4 0 0 4 7 .PML 0 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 Inspections and Professions Code:The Conuactoes License Law does 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.). 0 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. 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. 0 1 am exempt under SeB&P C for this reason Sec. Owner Dae WORKER'S COMPENSATION DECLARATION 1 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- -non,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 0 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 Worket'srpensagton lnsur4 cc carrier and Policy number Carrier. ` Policy No.:/' CEMly CATE 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 Worker's Compensation provisions of the Labor Code,you must ,J,2' forthwith comply with such provisions or this permit shall be deemed revoked. Z R CONSTRUCTION LENDING AGENCY F.h►V) I hereby affirm that there is a construction lending agency for the performance of p4 5 the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name �Z Lender's Address 0 I certify that I have read this application and state that the above information is U U 2correct.I agree to comply with all city and county ordinances and state laws relating to 1-4 U building concoction,and hereby authorise representatives of this city to enter upon the W above-mentioned property for inspection purposes Q, (We)agree to save,indemnify and keep harmless the City of Cupertino against E" rn liabilities,judgments,costs and expenses which may in any way accrue against said City ._ c� U Z in consequence of the granting of this permit Date P APPLICANT UNDERSTANDS AND WI COMPLY WITH ALL N -PO Issued b): SOUR,CEb0T1 _._.> , ` - L �_ --_.. l/ Re-roofs - Signature of Applicam/Conuactor Dae T Of Roof MATERIALS DISCLOSURE Type Will the applicant or future building occupant store or handle hazardous material as defined by to 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 fur re building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it hazardous air contaminants as defined by the Bay Area Air Quality Management all new r iaterials for inspection. .strict?C]Yes 1 have read the hazardous mahcrials requirements under Chaplet 6.95 of toCalifon- 7 ria Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building r �` _--- does not currently have a tenant that it is my responsibility to notify the Dees ant of the Date reyuirem nes w t or to issuance of a Cert a oc Signaturo of Applicant � - rr rr All roof coverings to be Class or better Owner or authorized agent Date OQ o3a Flo CITY OF (;UPERTINO Iii `;iw REROOF CITY of CUPEkTiNO PERMIT APPLICATION APN # �I � 4<� O q Date3 Building Address: /v q(a Co 13 y F Owner's Name: Phone #: gbly yy47— 3 � 3y HOA: Yes No ❑ If yes, provide letter from HOA Contractor: Phone #: �X* v 3 3 v Fax#: y�X �-7e cv 3 3 3 Cupertino Business License #: Contragtor�� #: Type of Roof Covering: jj• Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles X Asphalt Shingles ❑ Wood Shakes ❑ Wood Shakes ❑ Wood Shinglesii,^&,__ ❑ Wood Shingles X Other (Specify) CAI Sr � ❑ Other (Specify) Number of existing coverings ❑ Provide I.C.C.E.S. Report # To be Removed ❑ Provide Mfgr. Installation Specs. Job Description: /4 c Residential Commercial ❑ Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if Green Building Checklist & attach it to the application or if there are any restrictions: ❑ applicable, include in plan set & the sheet inde�. Valuation: I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy: Signature Revised 02/05/09 CITY OF ("'UPERTINO REROOF CUPLkfINO FEE SCHEDULE Number of Fee ID Fee Deset iption Fee Permit Type Squares Group 1REROOFCOM Re-roof Commercial B ICOM MLR AF 1BCBSC Cal Bldg "'Ptandards B ALL PERMIT TYPES Commissi m Fee IBSEISMICO Seismic CDmmercial B 1REROOFRES Re-roof R--sidential B 1SFDWLR00F 1 BCBSC Cal Bldg ,standards B ALL PERMIT TYPES Commission Fee IBSEISMICRE Seismic Residential B 7(w1REROOFMRES Re-roof Nlulti-Family B 1MFDWLROOF / 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES I Commission Fee 1BSEISMICRE Seismic Residential B 1 BUSLIC Business License B Community Development 10300 Torre Avenue ,y Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CITY OF � UPEf�TINO Buildi n De artment JOB ADDRESS:/ ' 70 q74,.3Z7 /v / - 10jit X PERMIT # Cq co 0 OWNER'S NAME: /y1G PHONE # GENERAL CONTRACT D OR: ar�g FAX # I am not using any subcontractors: ate Signature Please check a licable subcontractors and com Clete the followin 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