07100037 CIT�' OF CUPERTINO n7 ' ' (`� -p,
BUILDING BIV'ISION . �E�v11T �����^^���` ���������� ' '
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_
PERMIT NO.
BUILDI �vG,Ap�R�ssDE ANZA BLVD TBD — T() BE DETERMINED 0 710 0 0 3 7 •
UL
PERMIT L55UE DATE
OWNER'S NAME:
WASHINGTON MUTUAL 10 03 2007
SANiTARY NO. CONTROL NO.
NE:
BU(LD[NG PERMfI'(NFO
ARCHITECT/ENGINEER:
HLDG ELECT PLUMB MECH
� � � �
i p p LICENSED CONTRACI'OR'S DECLARATION IOb DCSCT1pU0il
%� C 1 hcrcby afficm that I am licenscd undcr provisions o[ Chaptcr 9(commcncing
;Z� withScction700U)ofDivision3ofihcBusincssandProfcssionsCodc Rlvj�j EXS `�NG ROOF SYS & INSTL NEW CARLISLE TPO
�� y in full Coree and effe j. ��
�,�z Licensc ��.�+ 0 MEMBR.AN:� ROOF SYS W/1/2 DENSDECK
i E � Datc Contru
� ARCHCI'ECTSDECLARA N UNDERLA'tMENT (CLASS A)
i a a 1 undcrstand my plans shall Ac uscd as public records
)yU
' w� y Liccnsed Profcssional
OWNER-BUILDER DECLARATION
'�� 1 hcrcby alTirm thal 1 am cxcmpt Gum ihc Contractors Liccnsc Law far thc
� p o Collawing rcason. (Sccuon 7(Y31.5. Busincss and Profcssions Calc: Any ciry or county
<,° � which requires a pertnit to consWC4 ��r. improve. dcmolish. or �cpair any sWCtmc �.
°'" y prior to i�s issuancc, alsu ccquires ihc applicant for such permit io filc a signcJ statcmcm
� Z< that hc is Iiccnscd pursuant lo lhc provisions ot �hc Conuacwr �«� ►.aW ccna��� 9 S q. Ft. Floor Area Valuation
,� t �(commencing with Scction 7000) of Division 3 oC Ihc Busincss and Profcssions Codc) o� $16 0 0 0
y�$ that he is exempt theccfrom and Ihe batis (or the allcgcd exempdon. Any violauon o(
Secdon 7031.5 by arry applicant for a permit subjccts the applicant ta a civil pcnalty af p Number Occupaney Type
noc more than fivc hundred dallars (5500). 3 6 9 4 1 � �'�.�
❑ I, u owncr of ttie propecty, or my employcu with waga u the'v solc compensation,
will do �hc work and �he stcuaure is not intendcd or allered (or salc (Sa. 70A4. Bustiness Required Inspections
and Professions Code: The Conuactor's License Law docs not apply m an owrxr of
propeny who builds or improves thercon, and who does such wwlc himseif ar Uuough his
awn emplayces, providcd ihat such improvements are not imend�d or otfeeed far sale. If,
however. �he building or impmvement is sold within one year of caopletion, tlte ownu-
builder will have ihe burden of proving IAat he did not build or improvc [ar puryuse of
sa�.).
❑ I, as awner of the property, am ezclusively conUacting wi�h licensed convactars to
constivct the pmject (Sec. 7044. Businas and Profcssions CodeJ The Cootrattors Li-
ccnse Caw docs aot apply to an owner of property wha builds or imp�nva the2on, and ,
who contracts for sucA projects with a conuactor(s) licensed pursuant to ihe Contne[ofs
License Law.
❑ I am exempt under Sec. , B� P C for ihis rcaton
Owner Dt� _ .. -.
WORKER'S COMPENSATION DECLARATION
1 hereby �rm under penalty o( perjury one o[ �he fallowing declarations:
�J i h:ve and wil! maintain a CertiGcaee of Consent lo xl(-inswe for Warlrcts Compen-
satian, u providcd for by Secdon 3700 af che Labor Code, fw �he performance o[ thc
worlc (or which Nis pertnit is issucd.
❑ 1 havc and will maintain Workcr's Compensation Insurana, u�cquircd 6y Scction .
3700 0( �he Labor Code, for the pertormance ot �he worlc for which �his permit is issued
M Work _ ns�a j n , �insu cc cacricr and Policy numbcr a p:
Cartiu; 7'L�A�.. V� Polity No.: O
CERTIF[CA7'E OF EXEMPI70N FROM ORKERS'
COMPENSATION I?iSURANCE
(Chis scction necd not bc completcd if the permit is foronc hundred dollars (5100)
or Icss. )
I cenify that in �he perforn�ance ot the work for which �his pertnit is issued. I shall not
employ any person in any manncr so aa to bccome subject io the Worlrcrs' Compensation
Laws of California. Datc
Applicant
NOTICE TO APPC.ICAM: If, af�cr making this Ccnitica�c of Excmption, yau shauld
become subject to lhe Worker's Compensacion provisions of U�c La6or Cade, you muu
, O foMwi� comply with such provuions or this pecmit shall be deemed revoked.
z ""' CONS'fRUCCION LENDiNG AGENCY
[.�-i � I hcrcby aCfirm tha� thcre is a constcvcunn Icnding ascnry Cor thc perfortnancc o[ _
a� the wurk Cur which this permit is issued (Sec. 3097, Civ. CJ
W Q Lendcrs Namc �
a z L.cnder's Address
V � 1 ceni[y ihat 1 have rcad this applicaaon and siate U�at the above infoemation is
w � corrcct. I agree to comply with all city and county anfinances and sute Iaws relating �o
0 U building conswction, and hcrcby authome represcntativcs of ihis city lo cntcr u�n �hc
� W abovc-mcntioncd propctty (or inspccuon purpoxs.
a (Wc) agree to save, indcm�ify and kecp harmless thc City o( Cupertino agains�
�� liabilitiu, judgmcn�s, cos�s and expenscs which may in any way accruc against said City
V z in co uence of thc granting of this permit.
�"^ APPL A UNDERSTAND WILL COMPLY WITH ALL NON-POINT ISSllCd by: Date /� - ��J _
SO GUt.6'C�0 � �
� Re-roofs ��/�--
' ature of Appli � � a� ° T e of Rc rof
H ARDO ALS D O E YP
Will Ihc applicant or futu mg occupant storc or handle •ardous matcrial
as dcfined by lhc Cupenino Municipal Cadc. Chap�cr 9.12, and thc Hcalth and Safety
Ca1c. Scction 25532(a)? All roofs shall be inspec[ed prior to any roofing material being installed.
�y� ❑No
Will thc applicant or Cuture 6uilding occupant usc equipmcnt or �viccs which
If a roof is installed without first obtaining an inspection, I agree to remove -
�mii ha•rardous air conwminan�s az cicfincd Ay �hc Bay Arca Air Quality Managcmcnt all new m: �terials for inspection.
Distcict? `_
❑ Yes n�I6
��- v
1 havc rcad the ha�arCous matcrials tcyuircmcros uncicrChap�cr6.95 of Ihc CaliCar-
nia Hcal�h & Safcty Codc, Sections 25505. 25533 and 25534.1 undcrsund �hu iC ihc 6uilding
Jocs not rtcntly havc a tcnan4 �az it ' my responsi6iliry to notify ihc occupant nf �hc —
rcyui ich mus� bc me 'or issuance of a Ccnificaic of Oc - S1g113tUI'e ��f Applicant Date
� b All roof coverings to be Ctass "B" or better
ner or authorircd agcn �� -
��
CITY OF (;UPERTINO
`�` �����(.�E'
������
� U PE�TI I��J PERMIT APPL [CATION FORM
APN # Date:
J �P 1�� 6 C7 � O��oc�.� 3, �, a� �
Building Address:
1� zs� so���. b� A�,zr� �3�.,d. C� ; c.
Owner's Name: Phone #:
���.:� �� ��k( Ko8 Z53- 8�z
Contractor: License #:
�w• et�k( o iA, 8086�..
Contact: Cupertino Business License #:
� i M k►J
Type of Rc�of Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles 0 Wood Shingles
❑ Other (Specify) � Other (Specify) T� �T�
Number of existing coverings J'Y( Provide I.C.B.O. Report #�SQ- lyb3
� To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu �rtino's Tear Off Policy: ❑
Job Description: '(�e�tive �e,c;1+?� w���»brk►�c. r+�> s�s-1e«,, �r i r�.�-t+�'�t µ,ec� Ckr<<S�`T a
�� 5 �e.,� .,�� % `' � U�d�.e� . �rk
Residential ❑ Com ercial �
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De if
there are any restrictions: LJ
Cost of Project: Type of Constructio • Occupancy group:
�� � Op � " �° rz �
Qty. if
A licable Fee ID Fee Descri tion Fee Grou
BPERMFEE B d Permit Fees BUILDING
.�F BENERGY F nergy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC F�usiness License BUILDING
CITY OF �.UPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ......... 36941004.00
DATE ISSUED.......: 10/03/2007
RECEIPT #.........: BS000002880
REFERENCE ID # ...: 07100037
SITE ADDRESS .....: 10250 DE ANZA BLVD
SUBDIVISION .......
CITY .............. CUFERTINO
IMPACT AREA .......
OWNER ............: WASHINGTON MUTUAL
ADDRESS ..........: 10250 S DE ANZA BLVD
CITY/STATE/ZIP ...: CHPTSWORTH CA, 91311-
RECEIVED FROM ....: IMFERIAL ROOFING
CONTRACTOR .......: TBL - TO BE DETERMINED LIC # 00096
COMPANY ..........: TBL� - TO BE DETERMINED
ADDRESS ...........
CITY/STATE/ZIP ...: ,
TELEPHONE .........
FEE ID UNIT QUANTITY �,MOUNT PD-TO-DT THIS REC NEW BAL
------------- ---------- ---------- -------
BENERGY PERMIT FEE 234.36 112.49 0.00 112.49 0.00
BPERMFEE VALUATION 16,000.00 234.36 0.00 234.36 0.00
BSEISMICOM VALUATION 16,000.00 3.36 0.00 3.36 0.00
--�-------- ---------- ---------- ----------
TOTAL PERMIT : 350.21 0.00 350.21 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 350.21 #5709
' ---------------
TOTAL RECEIPT : 350.21
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ------
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
Communiry Development
�' � 10300 Torre Avenue
: '�,
��� � :: ? � Cupertino CA 95014
Telephone (408) 777-3228
C1TY OF Fax (408) 777-3333
'UPEf�TINO
Buildi:n De artment
J � B Q D ;�� - �j , �� � �IfL'�. • PE b I � # � .
1 PHONE # �{08 _ 2 - 2-
OWNER'S NAME: � Ir�, U�'C
GENERAL CONTRACTORCp ' FAX #
I am not using any subcontractors: , � �
Si�, ture Date
Please check a licable subco tractors and com �lete the followin information:
SUBCONTRACTOR BUSIrfESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Fini.shing
IIectrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
� Roofing %G �
Septic Tank
Sheet Metal
Sheet Rock
Tile
� Q
Own / ontr c Signature Date