09060144 CITY OF CU•PERTINO p
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
10411 CASTINE AVE R E ROOFING & CONSTRUCTION
OWNER'S NAME: INC PERMIT ISSUE DATE
T ATTRA N—IR^
)NE: SMIYA CONTROL NO.
(408) 626-9320
ARCHriECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�o 00 LICENSED CONTRACTOR'S DECLARATION lob Description
U p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z m with Section 7000)of Di'si q�the Business and Prof ns C and my license is
7=y in full force and effect. ��J CI `�z �� RE—RF RMV EXT 1 LYR OF CEM WOOD INSTL 1/2" CDS
? License Cl Ltc..
y c Date Co. rT
30#
T1 I ARCHITECT DECLARA
a 1 understand my plans shall be rrs�as Publi<< FLT & CLS COMP 2 9 S Q
IL H Licensed Professional
A y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's Liccnsc Law for the
in 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
n Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
=G that he is licensed pursuant to the provisions of the Contractor's License Caw(Chapter 9 Sq.Ft.Floor Area Valuation
X t- (commencing with Section 7000)of Division 3 of the B usincss and Professions Code)or $14000
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 AIN Number Occupancy Type
not more than five hundred dollars(M). 32641038. 00
❑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 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.).
❑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 contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec B&P C for this reason
OwnerDate
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 workces compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
w for which this permit IS issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
3 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Laurance carrier and Policy number am:
Carrier Sz&ia� AA I PolicyNo.:
CERTIFICATE OF CEMPTION FROM WO ER
COMP E SATION INSURANCE
(This section need not be completed if the permit is foronc 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 Workcrs'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 hereby a(lirm that there is a construction lending agency for the performance of
fY. the work for which this permit is issued(Sec.3097,Civ.C.)
W
Q Lender's Name
Z Lender's Address
V C) 1 certify that I have read this application and state that the above information is
4L► correct.1 agree to comply with all city and county ordinances and state laws mlating to
0 V building construction,and hereby authorize rt:presentatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
rF-t liabilities,judgments,costs and expenses which may in any way accrue against said City
U,� in the granting of this permit.
AND WILL COMPLY WITH A L N POINT Issued by: Date v
!71C:AJUNDERSTANDS
�� Re-roofsuf 'Contrlcter' Datc
RDOUS
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
Cede,Section 25532(a)7 All roofs shall 3e inspected prior to any roofing material being installed.
❑YesNo
Will the pplic t or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
a
it hazardous air contaminants as defined by the Bay Area Air Quality Managemeq}. - &1 new materials for inspection.
.,txtriet7
_....._.._
❑Yes �cii
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Codc,Sections 25505,25533 and 25534.1 understand that if the building
d of cu nA have a tenant,tater it is nsibiliry m notify the occupant of the /
uircme .1musbc met tss o Certificate of an
y ., �`�'Z ,1� Signature of AF plicant Date
own0rrnantliarized agent—.-- (� Daae TU All roof coverings to be Class" `'or better
CITY OF CUPERTINO 09 ( 4q
RER OOF
CUPEkTINO PERMIT APIPLICATION
APN #
q ( o �g 00 Date: Z 6
Building Address: /, ( � I
tip, ,
Owner's Name: M l I c� Phone #:
r\ , 2
HOA: Yes El No If es provide letter from HOA `T ��
Contractor: r Phone #: 2�
aff I CN � I oj, � C , I"
Fax #:
Cupertino Business License 2-o( 1� Contractor License #:
Type of Rooi'Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
>21 Other (Specify) � ❑ Other (Specify)
umber of existing coverings ❑ Provide I.C.C.E.S. Report #
i To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description:
11 M o I lr� % `'�L,-A- (f 1 L�N1 wo U� I N W A'A---
'W
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 index.
Valuatio
Iuv,
I Hav Understand and Will Comply with Cupertino's Tear-Off Policy:
Signature`!
Revised 02/05/09
a
CITY OF CUPERTINO
REROGF
CUPEkT1NO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1REROOFCOM Re-roof Commercial B 1COMMLROOF
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICO Seismic Commercial B
1REROOFRES Re-roof Residential B 1SFDWLR00F
1BCBSC Cal Bldg Standaids B ALL PERMIT TYPES
Commission Fee
' 1BSEISMICRE Seismic Residenlial B
1REROOFMRES Re-roof Multi-Family B 1MFDWLROOF
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICRE Seismic Residenlial B
1 BUSLIC Business License B
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Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: t� , I ` ( /'�,��- � .�� PERMIT #
OWNER'S NAME: I I L� PHONE # U -
GENERAL CONTRACTOR: 12, L FAX# q4 - 6 -
I am not usingan subcontract rs: 2�I d
Y
_._._ -SLgnature Date
Please check applicable subcontractors and core. lete the following information:
SUBCONTRACTOR BUSI]4ESS 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