07100095 I CITY OF CUPERTINO ` ` -p ' ��{
BUILDING DIV1S10N PERMIT ���� ����`�"����� '
PERMIT NO.
9UILDIN ADDRESS:
1�798 BROOKWELL DR ABOVE A�L ROOFING 07100095 �
PERMTf LSSUE DATE
OWNER'S NAME: ,
MERCER SHERRYL E 700 NORPHRUP ST 1 12 7
SAMTARY NO. CONTROL NO.
NE:
(408)29Z-4188
BUILDiNG PERMIT INFO
ARCHITECi/ENGINEER: BLDG ELECT PLUMB MECH
� 0 0 �
� p � LICENSED CONTRACTOR'S DECLARAT[ON JOb D8SCr1pL10❑
� v"' I hcreby aCfirtn that I am licensed umkr provisioas oC Chaptcr 9(commcncing
: z� with Scction 7000) of Division 3 of �hc Busincss and Profcssiuns Codc. and my license is RE — ROO F � `I' � � EX S TNG ROO F C �vE''�Ci s I N S T L 3 �#
�� y in full forec and eff t, �
��z LicenscClass 1--���# S UNDRLAY�II�TT. INSTALL MONIER TILE� CLASS A COLOR
p Datc_ �J..Z.jL2�- Convacior -� � �L �" ,,,
a o
: � � � ARCHITECI'S DECLARA N CAMOUFL ,�
j a .-7
� 1 undcrswnd my plans shall bc uscd as public rccor�ls
)yU
' a y Licenscd Pmfcssional
: � < OWNER-BUILDER DECLARATION
�N.]
1 hcrcby a(�rm that 1 am cxcmpt Gam thc Conuactars Liccnsc Law far �hc
� p o lollowing reuon. (SccGon 703I.5, Busincss and Profcssions Calc: Any city or county
�^� which rcquires a pccmit to conswct, altcr, improvc, dcmolish, or repair any suucturc
prior ui i�t istuance alsu rcquires thc applicant [or such permi� to filc a sigrrcd su�cmeni , Ft. FIOOt AI'CS Valuation
�?< �hat hc is Iiccnsc J pursuan t to t h c p ro v i s i o n s a f t h c C o n u a c w r' s L i c c n s c L a w ( C h a ptc r 9 '� q $15 0 0 0
Y F� (commencin g wiih Scction 7000) of Division 3 of Ihc Busincss and Profcssions Codc) or
i�� that he is uempt the�cfrom md Ihe basit Cor the allegcd ezemption. Any violation o[
Section 7031.5 by a�ry applicant Cor a pertnit subjects ihe applicant to a civil penalty a( Number Oeeupaney Type
n o t m o r e t h a n f i v e h u n d re d d o l l ar s ( 5 5 0 0)• 3 6 9 2 1 0 3 3��
❑ I, u owner oC Uie property, ar my employces with wages az their solc campensation,
w:ll do Ihc work, and the steuctum is not intendcd or otieccd forsale (Sec.7044. Busincss Required Inspections
and Professions Code: The Conuacwr's License Law docs not apply to an owner of
propeny wha builds or improves thereon, and who does such wark himultor Wough his
own emptoyces, provided that such improvements are not in�ended or oRered for sala I[,
hawever, the building or improvement is sold within one yesr oC compleGon. �he ownu-
builder will have U�e burden of proving �hat he did not build w improvc for pu�pose of
sa1cJ•
❑ I, ss owner of the properry, am exclusively conlracting with licensed conuactors lo
rnnstruct the project (Sec. �044. Business and Professians Code:) 7he Contncwrs Li-
ccnse Iaw docs oot apply io an ow�r o( propeny who builds or improves the�eon, and ,
who contracu for such projects with a conuactor(s) licensed pursuant w the Contractof's
License Law.
❑ I am eacempt undu Sec. . B R P C for �his mason
Owner Date _.. _.
WORKER'S COMPENSA7'ION DECLARATION
16ercby atTi�m under penalry of perjury onc o( �he following declaralions:
❑ I hsve and will maintain a Certi�cate of Cansent to self-insure for Workers Compen-
sation, as providcd for by Secdon 3700 af the Iabar Code, far thc performance o[ the
work for which Ihis permit is issucd.
❑ I havc and will maintain Workels Compcnsation insurana, u rcquircd by Scction .
3700 0( �hc Labor Codc, Co� thc performancc af �he work for which this permic is issued•
My Worker's Campen tion In uranc carticr and Policy number are: �»
Cartier. Policy No: '�� �r���Jn�
ER'fIFTCATE OF EXEMP'I70N FROM WORKERS'
COMPENSATION INSURANCE
(This sccdon necd not bc complcted if the permit is ku onc hundred dollazs (E100)
ar less.)
i cenify that in thc performancc of thc work for which �his pertnit is issucd, I shall not
e�ploy any person in any manncr so as io bccomc wbject ta the Workcrs' CompcnsaGon
Laws of Cali(omia. Datc
Applicant
N07TCE T'O APPC.ICAM: If, af�cr making ihis Ccrti(icatc of Excmption, you shouki
become subject lo �he Worker's Compensation provisions o( �he Labor Code. you muu
� O forthwith comply with such provisions or this pccmit shall bc dccmcd revokcd.
z ""' CONSTRUCTION LENDING AGENCY
(.~-� � I hereby �rm �hat there is a construction Icnding agenry for the performance of
R! � ihc work for which this permit is issucd (Scc. 3097. Civ. CJ ,
W Q Lendcr's Namc
� � C.cnder's Address
U � ( ccrtijY that 1 havc rcad ihis applica�ion and staic thal thc a6ovc informatiun is
w � cortcct. ! agree to comply with all city and county ortiinances and sute laws ccladng to
O U building conswction, and hercby authori�t reprcscnta�ivcs of �his city to cntcr upon Nc
�� ahovc-mcntioncd property for inspccuon purposes.
(Wc) agrce to save, indcmnify and kecp harmless Ciiy of Cupcnino against
�� liabitities, judgmcn�s, costs and expcnscs whic ay i" way accrue agtinst said Ciry
U z in conuquence of the grenting o( ihis �. Date �
►�+ APPLICANT UN D ILL PLY WITH ALL N N- INT Issued by:
SOURCE
' � Z- v -�- Re-roofs
si rcofApplicantlConlrac _ D° T ofF.00f `
HAZARDOUS MATERIALS DISCLOSURE YP
Will �he applicant or Cuwrc building occupant store or handle ha•rardous ma�crial
az dcfined by thc Cupertino Municipal Codc. Chap�cr 9.12. and thc Health and SaCcty
c«�, s���o� zssszca�� / ' All roofs shall be inspected prior to any roofing material being installed.
� y� ,(7 No ,
� If a roof is installed without first obtaining an inspection, I agree to remove
wll thc applicant or futurc building occupant usc cquipmcn� or dcvices which
cmit harardous air conuminants az dcfincd by Ihe Bay Arca Air Quality ManagcmcM all new rr,aterials for inspec�ion.
District? /
❑ Ycs Xl No
/ / j
1 havc rcad the ha�ardcws mauerials rcqu' mc u rChapter 6.95 o(�he Califar-
niaHcalth&SafctyCodc,Scctions75505, 3 .Iundcrstv�dthatiC�cbuilding .
docs noi eurrcntly have a an � i' my ility to noafy thc occupani o( �hc
rcyuircmcnls whi i f a Ccrtifica� of P� � Signature of Applicant Date
�"� �° All roof coverings to be Class "B" or better
O r or au�hon .ed agcnt J '- ���
CITY OF CUPERTINO
3 ITEMS OF 3 PERMI'[' RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl.c: Lot:
APN ......... 36'�21033.00
DATE ISSUED.......: 10�12/2007
RECEIPT #.........: BS�)00002975
REFERENCE ID # ...: 07:L00095
SITE ADDRESS .....: 10'798 BROOKWELL DR
SUBDIVISION .......
CITY .............. CU:?ERTINO
IMPACT AREA .......
OWNER ............: MEItCER SHERRYL E
ADDRESS ..........: 10'�98 BROOKWELL DR
CITY/STATE/ZIP ...: CU]�ERTINO, CA 95014-4609
RECEIVED FROM ....: AB()VE ALL ROOFING
CONTRACTOR .......: KEI1 SULESKY LIC # 23092
COMPANY ..........: AB()VE ALL ROOFING
ADDRESS ..........: 70() NORTHRUP ST
CITY/STATE/ZIP ...: SATd JOSE, CA 95126
TELEPHONE ........: (4()8)292
FEE ID UNIT QUANTITY E�'IOUNT PD-TO-DT THIS REC NEW BAL
BPERMFEE VALUATION 15,000.00 223.56 0.00 223.56 0.00
BSEISMICRE VALUATION 15,000.00 1.50 0.00 1.50 0.00
BUSLIC FLAT RATE 1.00 107.00 0.00 107.00 0.00
----------- ---------- ---------- ----------
TOTAL PERMIT : 332.06 0.00 332.06 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 332.06 #14831
---------------
TOTAL RECEIPT : 332.06
Community Development
�`�" "� 10300 Torre Avenue
� • , �;�,. Cupertino CA 95014
Telephone (408) 777-3228
` C(TY OF Fax (408) 777-3333
'UPEI�TINO
Buildi�n De artment
JOB ADDRESS: PERMIT #
( i'; � �� � f� �r � r: �. � .��� - �' � f)dC� f
� OWNER'S NAME: � �� t � �, `t �.�� � ; ,, _ � ��_-4-�. ; PHONE # �( c� � �(�' -- � 1
� GENERAL CONTRACTOR � ' i � c e � � _ FAX #
,, j � / - j , .
I am not using any subcontractors: - % /�f � � _ ' �' � �� �� �
� ` ��;nature ate
Please check a licable subcontractors and com �lete the followin information:
SUBCONTRACTOR BUSIr�ESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
IIectrical
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
v � o 0 0 �.�
��CITY O�' CUPERTINO �, ; ���
. R�EROOF �.�.�
CUPEI�TINO PERMIT APP'LICATION FORM
APN # G� � �� 3� . �� Date: '� l Z C �
Building Address:
' � C: * „ . � ` , �- � � � �'�
�.
Owner's Name: - � Phone #: �
��- i ~ �� �: r1S� ��.;, �- � ' . � 1 � S
Contrac or: License #:
'�-=-X_; �- '�� - -�
Contact: _ . ,._..� Cupertino Business License #:
i� l ����- ,� � ��� �_ � �� 3 o q Z-
, Type o1' Roof Covering:
Existing: Proposed:
O Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles O Asphalt Shingles
,� Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles � 1
O Other (Specify) ,,� Other (Specify) 1`��� L v1 � Y-� �, i\-�--
Number of existing coverings v ❑ Provide I.C.B.O. Report #
� To be Removed O Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Com 1 With (;u ertino's Tear Off Polic :
Job Description:
; - - ' •• r. ' , ,
� 1 � ' L"" , " i lC•<7 - ' �<'� - � . ._ ' " • _ �.
t ulf CC � � ,.4-. �"" �t � ,- . l.;•,c c ( !�- c,L._,,'l� �
esidential Comm cial ❑ � t'i-'te � � � c � '1 + _
,
�, � �C�S % r l� � . �a �r, tC, , �` ���.
Fire Zone: Yes ❑ No Confirmed with Planning D�t. if
there are an restrictions: L�
C st of Pro ect: e, Const�uction• Occu anc� roup:
j �p � P g
�"j '� � ' � '_E, �,-�- �� i � ,
�- � � � $ � � �� ,
Qty. if
A licable Fee ID Fee Descri tion Fee Grou
' BPERMFEE Bld Permit Fees BUILDING
BENERGY Ener BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK , Plan Check Fee BUILDING
' BUSLIC Business License BUILDING