07100059 CITY ClF CUPERTINO � ':> '
BUILDING DIViSION pER1VIIT V������� �����T�Q�' '
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PERMIT NO.
BUILD �N��n�e�'ssAVENIDA LN MARCO R�OFING 07100059 .
OWNER'S NAME: PERMIT LSSUE DATE
DAVID & D P MGMT P 0 BOX 1691 � 10/05/2007
�NE: SANITARY NO. CONTROL NO.
(510)65j-6400
ARCHITECC/ENGiNEER: BUILDWG PERMTCINFO
BLDG ELECT PLUMB MECH
� � 0 0
i p Q LICENSED CON7RACCOR �ECURanoN Job Description
�� C I hcrcby aCfirm that I am liccased undcr provisions oC Chaptcr 9(rnmmencing
,Z wiui5cctian700o)aCDivision3oCihcBusinessandProtcssiunsCodc.a n�+ nylicentcis 'j'�Q EXI�TING SHAKE ROOF, RESTRT 0�'B� 3�LB FELT
�< a in full foree an�, e f�ct . G► Z � 6
j�? LicenscClus�'-���-�/ � Lic.# ` 30YR COKP CHARCOAL BLEND COLOR, 4:12 SLOPE, 22
��,,, i p Datc /i4 �—i O p Contractor
� ARCHITECI'S DECLA AT ON SQ
i
7 a a i undcrsunJ my plans shall bc uscd as public rccorcis C LA S S A
)4U
' u. y Liccnscd Pn�Ccssional
� y � OWNER-BUILDER DECLARATION
I hcreby atTirtn thn� 1 am ezcmpt Crom �hc Contraaors Liccnsc Law Cor thc
� p O Collowing reason. (Scctian 7031.5, Busincss and Profccsions Codc: Any city ar county
�,°, � which rcquires a permit to cnnswct, altcr, improvc, dcmolish, or repair �ny s�ructure
° Z� pnor to i�s issuancc. also rcquires thc applicant for such permit to Gk a signcd statcment „
�= 0 that hc is liccnscd pursuant to thc provisions oC ihc Convacar �«�� r�W ccn��� 9 ,>q. Ft. Floor Area $ 8 5 2 5 Valuation
� F� (commencing with Sccuon 7000) M Division 3 of �hc Busincss nnd Profcssions Codc) or
L �.. �hat he is exempt Neicfrom and the basis Cor the allegcd eumption. Any violation of
Secdon 7031.5 by arry appiicant for a permic subjccts the applicant to a civil penalry of A Number Oeeupaney Type
noc morc than 6vc hundrcd dollars (5500). 3 4 2 4 5 0 4�:'D �
❑ I, as owncr o[ ttie propecty, ar my cmployces with wages as the'v solc compensaGon,
will do �he work, and �:e suucture is not intended or o:Teced forsale (Sec. 7044. Business Re uired Ins ections
and Professions Code: The Contrutor's License Law docs not appty w an owircr of Q p
praperty who builds or improvu thercon, and who daes such worlc himxlCar ttuough Ais
own emplayccs, providcd that such improvemenis are not imendeA or ottered for sale. If.
however, the building or improvement is sold within one year of completion, t6e owner-
builder will have the burden o[ proving �hat hc did no� buld ar improvc far pmpo,x of
saleJ.
� I, as awner oC the propeny, am ezclusively conuacting wi�h liansed cronitactors a
constn�ct the pmjett (Sec. 7044. Business and Protessions Cade:) The Contracwrs Li-
ccnse Law docs no� apply to an owner of property who buiids or improvrs �haeon, and ,
who contwcLt for such projects with a conuactar(s) licensed pursuant to �he Cantrxtots
Lic�nse Law.
❑ I am uempt under Sec. . B dc P C for ihis icuoa
Ownu Date
WORKER'S COMPENSATION DECLARATION - � ,
I hercby affirm under penaity ot perjury one af the folbwing declarations:
❑ I hare and will maintain a Cectificate of Consent ta x1C-insure for Woricers Compen-
sation, as provided for by Sectian 3700 af tlu Cabor Code, for We performance of the
worlc for which Ihis pertnit is issucd.
pQ l navc and wil! maintain Worker's Compensation Insurance, u raryired by Scction
3'160 0[ the Labor Code, Cw the performance of tAe work for which this permit is iseued.
My Workers CompensaGan [n ra carticr and Poliry numbc arc: /
Cartier. `� �� Poliry No.: L �
CERTIFICATE OF EXEMPTION FRO WORKERS'
COMPENSATIONINSURANCE
('Ihis scctioa necd not bc completed if the permit is for anc hundmA dallars (S 100)
or Icss.) '
I cenify that in tt�c perfortnancc of ihc work for which �his permit is issucd. 1 shall not
employ any person in any manncr so az to bccomc wbjcct io �he Workcrs' Compensation
Laws ot Califomia. Datc _ .
Applicant
NOTICE TO APPLICAM: If, aftcr making Wis CcrtiGca�c of Excmption, you sfauld
become suAjcet to the Worker's Compensation provisions of thc Labor Codc. you must
� O (oMwi�h comply wi�h such provisions or this permit shall hc dccmcd revokcd.
z '"'' CONSTRUCI'ION LENDING AGENCY
F + � I hcrcby af[irm �hat thcre is a conswcGon Icnding agcnry Ibr thc performancc of
pl, � ihc wurk far which this permit is issucd (Scc. 3097, Civ. CJ
� A Lcndcls Namc '
= z Lcnder's Address
V � 1 certify �hat 1 have rcad this applieation and su�e ihat the above informauun is
w ► - � cortcct. I agree to comply with all city and county ortlinances and state laws relating a
� U building conswction, and hercby authori�e represenutives of �his city to enter u�n �c
� W abovc-mcntioncd property for inspccuon purposes.
(Wc) agrce to save, indemni(y and kecp harmless thc City of Cupcnino against
�� liabiliues,judgmcros, costs and expenscs which may in any way accruc againsl said City
J z in consequencc aC thc gnnting of �his permit. � "r
�"� APP ANT UNDERSTANDS AND WILI. COMPLY WITH AI.L NON-POINT Issued by: Date "�� �
S R REGULA ONS.
� / S ` v Re-roofs
Signaturc o pplican nuactor Da�e ���
RDOUS MA R1A DISCLOSURE Type of R ��f
W� plicant or fumrc building occupant storc or handle ha•rardous ma�crial
as dcfincd by the Cupenino Municipal Codc. Chap�cr 9.12, and ttic HcalU� and SaCety
c«� Section 25532(a) All roofs : hall be inspected prior to any roofing material being installed.
❑ Ycs
WiII thc applicant or futurc building occupant usc eyuipmcnt or devices w6ich If a rOOf 1 installed without first obtaining an inspection, I agree to remove
cmit harardous air con�aminants az cicfincd by thc Bay Area Air Quality Managcmcnt all new m; iterials for inspeccion.
District?
❑ Ycs No
I havc rcad the ha�arCous ma�crials requircmcn�c umlcrChap�er6.95 of thc Califor• � � J 7
nia Hcalth & Safcry Codc, Sections 25505, 25533 and 25534.1 undcrstand �hu if du build"uig i C�, '`
docs no� nUy havc a �cnan4 �at it is my rcsponsibiliry �o noul'y �hc occupant of �hc i
rcyuirc hich musi met pri �uu�� ar � c�r�8� ora��P�ry. Signature �f Applicant Date
�
ownerorauthori� a���� o„� All roof coverings to be Class ° B�� or better
' . �����
CITY OF CUPERTINO
���'' REIZQ�F
CUPE�TINO PERMIT APPLICATION FORM
APN # Date: /� _ �� � �
Buildin Ad ess: /
l � T � � Ue✓��d� l� �t
Owner's Name: ( J 1 Phone #:
I�c') , � �j V Y'J �` cw J� �� �' � ���/� �
Co t ctor: License #:
c� � � �� � c : �� �� �
Conta t: f Cupertino Business License #:
��i ��� /�l`"P(2 �vt ' /
Type of R �of Covering:
E�sting: Proposed C Gr GD� �
❑ Built-Up Roof ❑ Built-Up roof VL �`�� L
/� v
❑ Asphalt Shingles � Asphalt Shingles � 3� l�! V'� l�'�
� Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
� inber of existing coverings ❑ Provide I.C.B.O. Report #
To be Removed ❑ Provide Mfgr. Installation Specs.
�....� .. .... :.:. -,_._.. . . . ..
"` I Have Read, Understand and Will Com ly With Cu �ertino's Tear Off Policy: "
Job Descriptionif/p ,G,�is : rtS S�c�� /�ao � e s t�e.� ,C�S6� 3�/� �!�-� 4�/�-
, ..._ . . r �a �`E�cl p� r �l-l2 .sla e__ _ .. . � � ���.
. Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De�t. if
there are any restrictions: U
Cost of Project: �� � Type of Construction: Occupancy�roup: s ��
� '�,1 �Z - S
Qty. if
A plicable, Fee ID Fee Description Fee Group
BPERIVg'EE F�ldg Permit Fees BUILDING
BENERGY �nergy BUILDING
BSEISMICRE 3eismic Fee Res BUILDING
BSEISMICOM 3eismic Commercial BiTILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
CITY OF CUPERTINO
2 ITEMS OF 2 PERMI'I' RECEIPT OPER.ATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk.: Lot:
APN ......... 34�45044.00
DATE ISSUED.......: 10/05/2007
RECEIPT #.........: BSCt70002911
REFERENCE ID # ...: 07100059
SITE ADDRESS .....: 10937 AVENIDA LN
SUBDIVISION .......
CITY .............. CUF'ERTINO
IMPACT AREA .......
OWNER ............: DA�"ID & DAVID PROPERTY MGMT
ADDRESS ..........: 10937 AVFNIDA LN
CITY/STATE/ZIP ...: SAI�f CARLOS CA, 94470
RECEIVED FROM ....: EDV�'ARD A. GREGORY
CONTRACTOR .......: CRF;EDEN, MIKE LIC # 21317
COMPANY ..........: MAF.CO ROOFING
ADDRESS ..........: P C� BOX 1691
CITY/STATE/ZIP ...: FRE;MONT, CA 94538
TELEPHONE ........: (5]0)656
FEE ID UNIT QUANTITY �,MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 8,525.00 158.76 0.00 158.76 0.00
BSEISMICRE VALUATION 8,525.�0 0.90 0.00 0.90 0.00
- T - - - - - = -�- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
TOTAL PERMIT : 159.66 0.00 159.66 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 159.66 MC
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TOTAL RECEIPT : 159.66