07100177 CITI' OF CUPERTINO ' '
BUILDING DIVISION PERMIT ���k� �T�� Z������TION ` :
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BUILDING ADDRESS: PERMiT NO.
912 ROSE Br,o���rr DR �
ER'S NAME: PERMIT LSSUE DATE
PHON :
� S . CONTROL NO.
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ARCHiTEC'i/ENGiNEER: BUILDING PERM[T INFO
BLDG ELECI' PLUMB MECH
� 0 0 ��
i p LICENSED CONTRACTOR'S DECLARAT[ON JOb DOSCrIpt1011
� F I hcrcby afGrm that [ am liccnscd undcr pmvisions of Chaptcr 9(commcncine •
:� wi�h Scction 7000) o(Division 3 of �hc Busincss and Profc 'ons Codc my liccnsc is
� y in full Corce and eff� � � RE—ROOF ; T/ OF EXSTNG SHAKES � INSTL 7/ 16 " OSB � 3 �
� ? Licensc Ciazs Lic. S
� o Da�c ConlracWr � LB FELT & ARCHITECTURAL SHINGLES � 2 8 SQ � CLASS A
: � ARCHITECI'S DECLA ATION
%-� I undcrs�and my pians shall bc uscd as public rcrnrds .
:a
'U
N Liccnscd Profcssional
� � OWNER-BUILDER DECLARATION
I hcrehy aClirm tha� 1 am cxcmpi Crom �hc Contractor's Licensc Law for thc
j O following rcuon. (Scction 7031.5, Business and Profc.ssions Codc: Any city or county
; Pi which rcquires a permit to conswc4 altcr, impmvc, dcmolish, ar rcpair any swcturc
; y priar ui its issuancc, alsu mquircs ihc applican� for such permi� to filc a signcd statcmcn� � Ft. Floor Area Valuation
�< that hc is IiccnseJ pursuant to thc pmvisions o( ihc Contractur's Liccnsc faw (Chaptcr 9 q•
-� (commencing wiW Scction 7000) of Division 3 of �hc Busincss and Profcssions Codc) or
C.. tAat ho is exempt Nerefrom and �Ae basis for the a►Iegcd eumption. Any violauon o[
Section 7031.5 by any applicant for a pumit subjcc�s ihe applicant to a civil penalty of APN Number Oeeupaney Type
nat more U�an fivc hundrcd doliars (5500).
❑ i, as owncr of the prvperty, or my employc�s with wages as their solc compensation, 3 5 9 0 6 0 3 1 , � 0
will do the work, and ihc suucture is not intended or ofTered for salc (Sec. 7044, Business Re uired In s ecti o ns
and Professions Code: 'i7ie Cnnuactor's License Law docs not apply to an owner of 9 P
property who builds ar improvcs thercon, and who does sucA work himself or through his
own emplayces, provided that such improvemen�s are not imcnded orotfered for sale. I[,
howevu. �he building or improvement is sold within one year of complction. the owner-
builder will have the burden of proving that hc did not build or improve (or purpose ot
salc.).
❑ I, as awner of the properiy, am ezctusively conuacting wiih licensed rnnvactors to
wnswct the projea (Sec. 7044. Business and PcnCcssions CodeJ Tf�e Conuacwr's Li-
ccnse Law docs not apply �o an owner o( propcny who builds or improves Ihereon, and ,
who contrac�s for such pmjec�s with a conlractor(s) licensed pursuant w thc Convactor's
License Law.
❑ I am uempt unda Sec. , B& P C tor �his rcason
.� Da(e �
WORKER'S COMPENSATTON DECLARATION
I 6ereby aftim under penalty of perjury onc of �lu following declarations:
❑ I h:+e and will maintain a CeniGcatc of Consent to ulf-insure for Workcr's Compen-
sation, as provided frn by Section 3700 0( the Labor Code. for �Ae performance of the
worlc for which this pemiit is issued.
❑ I havc and will maintain Workcr's Compensation Insurance, as rtequired by Scction
3700 oC the Labw Codc. Cor thc perfortnance o( �he work for wAich �his permit is issued.
My Wor � om ensau rinsuran carticr and Poli �r,�rc: �
Cartier v Policy No.. Y
CERTIFICAIE O (EMPI'fON FROM WORKERS'
COMPENSAT[ON INSURANCE
(this sectian necd not Ac complc�ed if the permit is far onc hundred doAars (S 100)
or Icss.) '
I certi(y that in thc performancc of fhc work for which Ihis pertnit is issucd, I shall not
employ any person in any manncr m as W bewmc subject �o lhe Workcrs' Compensation �
Laws of Califomia Datc
Applicant
NOTICE TO APPLICAM: If, aftcr making this Ccrtilica�c of Faccmption, you should
bccome subject to thc Workcr's Compcnsstion provisions of the LaAor Cnde, you must
� O foMwi�h comply with such provisions or this permit shall be dccmcd mvokcd.
"'' CONSTRUC7'ION LENDING AGENCY
��—�. I hcfeby aftirm U�at thcre is a conswctinn Icnding agcncy for thc perfortnancc of
;� thc wurk for which this permit is iuucd (Scc. 3097, Civ. C.)
7 Q Lendcr's Namc '
� z Lcnder's Address
)
) 0 I certi[y Iha� 1 havc rcad this application and statc �hm thc abovc info�mauun is
�+ cortec� 1 agrce to rnmply with all city and county onlinances and sute laws rclaang io
j U building conswction, and hcrcby authori�e represcntativcs of ihis city to cn�cr u�n ttic
t W abovc-mcnuoncd propertyforinspccdon purposes I
� a (Wc) agrce �o save, indcm�ify and kecp harmlcss ihe Ci�y af Cupcnino against
�� liabilitiu. judgmcn�s, costs and expenscs which may in any way acccuc against said City
) z in consequencc oC Uic g ti f this permit.
i
�"� APPWCANT UNDER D AND OMPLY WITH ALL NON-POINT Issued by: Date ��- 2?j( .e�i�.
5 RE L �� `
��' Re-roofs �
s���ar� � °° of Rc�of
RDOUS MATERIALS DISCLOSURE T}�pC
Will plic t or futwc building occupant storc or handlc harardous matcrisl
-� dcfincd by thc ctino Municipal Codc, Chaptcr 9.12, and thc Hcal� and Safcty
e. Scction 25532(a)1 � All roofs s�all be inspected prior to any roofing material being installed.
❑ Ycs
wll the applicant or futurc building occupant usc cq�ipmcnl or Jcviccs which If a roof is installed without first obtaining an inspection, I agree to remove
cmii harardous air contaminan�t u dcfincd M1y the Bay Arca Air Quality Management all new m� terials for inspec*ion.
Disvicc?
O Y� 1�° '
I havc read the ha�ardous matcrials requircmcnL� undcr Chapicr 6.95 of thc Cali(or• ___��� �� ��
nia Hcal�h & Safcty Codc, Sections 25505, 25533 and 25534. ! undcrstand �hat iC ihc twilding -
docs not curtently have a icnan4 a ' my rcsponsibility to noufy the occupant of ihc
rcyuircmc chmust t'osw�srA{tC�j(aCcrtitk Signature pli ❑t Da[e
���
Owncr or authori�c cnl „� � , All roof coverings to be Class ��8�� or better
�-� i ��� �� �
CITY OF ��UPERTINO
A�' RE:[�OOF
CupE�T»►o PERMIT APPI,ICATION FORM
APN # Date:
'� � � Cp �� e o O 1 d ` ��
Building Address: ` ��� �
1��
Owner's Nam�e�. ��� � Phon� : �� � �� �
Contractor: ^ License #: „�
� � n S�IG rl 1�c��i "�� t� gC��' 7�.�
Conta : Cupertino Business License #:
�� �� . �3�
Type of P.00f Covering:
E�sting: Proposed:
❑ Built-Up Roof 0 Built-Up roof
0 Asphalt Shingles '� Asphalt Shingles
� Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
Number 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 Cupertino's Tear Off Policy:
Job Descri tion: • ,
U k� h�s w�s�ll � t� �`' � k�n ,-1� �
esidential Commercial ❑ �'� � ( /�
7�
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are any restrictions: L�
�st of Project: Type of Constru�;tiol� Occupancy grou�p:
�f � � �
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE 31dg Pertnit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISNIICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BLTILDING
CITY OF CUPERTINO
2 ITEMS OF 2 PERMI`� RECEIPT OPER.ATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl::: Lot:
APN ......... 35:306031.00
DATE ISSUED.......: 10.�24/2007
RECEIPT #.........: BS�)00003072
REFERENCE ID # ...: 07:L00177
SITE ADDRESS .....: 91:? ROSE BLOSSOM DR
SUBDIVISION .......
CITY .............. CU:?ERTINO
IMPACT AREA .......
OWNER ............. BA:�A JI
ADDRESS ..........: 91:? ROSEBLOSSOM DR
CITY/STATE/ZIP ...: CU:?ERTINO CA, 95014-4216
RECEIVED FROM ....: RO�)FSERV ROOFING
CONTRACTOR .......: KE'TIN E. SULLIVAN LIC # 23810
COMPANY ..........: KE'TIN SULLIVAN ROOFING
ADDRESS ..........: 16'a6 VALLEY OAKS DR
CITY/STATE/ZIP ...: GI':�ROY, CA 95020
TELEPHONE ........: (4�)8)842
FEE ID UNIT QUANTITY .�MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 10,000.00 169.56 0.00 169.56 0.00
BSEISMICRE VALUATION 10,000.00 1.00 0.00 1.00 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 170.56 0.00 170.56 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 170.56 #4376
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TOTAL RECEIPT : 170.56
�;.�'K,;< Community Development
s{ � : 10300 Torre Avenue
'� �'s' '` Cupertino CA 95014
Telephone (408) 777-3228
C1TY OF Fax (408) 777-3333
CUPE�TINO
Buildin De artment
J � � � �5��?iM �- PERMIT # � ,
�CC�O t7 �
OWNER'S NAME: � �. , PHONE # �{-� �t� �'
GENERAL CONTRA OR: FAX # — �
v �..- �, , ��9�_ ,,.� � '
I am not using any subcontractors: - �� ._�
Si;, ature Date
Please check a licable subcontractors and om �l e the followin information
SUBCONTRACTOR BUSI SS 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
•• ,
_ �Q '
ontractor Signature Date