07100183 CITY OF CUPERTINO °' '
BIiILDING DiVIS10N PERMIT Gm�TlE� �T:.C?� ��������Q�
;;,
BUILDING ADDRESS: PERMCE NO.
7512 SHADOWHILL LN STONERIDGE ROOFING" 07100183 •
iER'S NAME: PERMIT LSSUE DATE
YUN LIN & DAN MEYBERG 2798 GL ENFIRTH DR
PHONE: SANITARY NO. CONTROL NO.
(408)729-5101
ARCHITECT/ENGiNEER: BUiLDING PERMIT INFO
BLDG ELECf PLUMH MECH
� � 0 �
i p p LICENSED CONTRACTOR'S DECLARATION JOI� DOSCTIptlOp
� v� I hcrcby afGrm that I am liccnsed undcr provisions of Chap�cr 9(commencing
; Z, � with sccuon 7aw) atDivision 3 of ihc Busincss and Protcssiuns Code, and my liccnsc is RE — ROOF , TEAR 0 FF WOOD SHAKE � 2 8 S Q C LA S S A� 1/ Z
�� z Licen Clazs d eff `` �r / L � . � a L,[��
��r IN. OSE(RADIAN BARRIER) 30 LBS, 50 YRS COMP.
: � �p Da� /v �� C J� Contractor ..
� ARCHITECI'S DECLARATION
i a a I undcrstanJ my pians shall 6c uscd as puAlic rccords
)yU
' u. � Licensed Pn�fcssional
� y � OWNHR-BUILDER DECLARATION
� I hcrchy al7rm that 1 am cxcmpt Crom thc Canvactors Liccnsc Law [or �hc
j p O (ollowing rcason. (Scction 7031.5, Business and Profe.csions Code: Any city or coun�y
�°„ �i which requiccs a permit to cnnswct, allcr, improvc, dcmalish, or repair any stmcture
? Z} pnor to i�s issuancc, alw rcquires thc applicant for such permit to filc a signcd s�atemcm �' Ft. Floor Area Valuation
�_ � �ha� hc is liccnscd pursuant to thc pmvisions of thc Con�rrctor's Liccnsc Law (Chaptcr 9 ���] •
� t- (commcncing wiih Scction 7000) of Division 3 of �hc Busincss and Profcssinns Codc) or $ 9 � � �
° 3� that he is exempt thccefrom md the bacis for the allcgcd exempdon. Any violadon o(
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of ��y Number Oceupaney Type
not more �han five hundred daUars (5500). 3 6 2 3 � � 9 4. V V
❑ I, u owncr oC tlie propcny, ar my employces with wages az their solc compensadon,
will do utie work, and shc ssructure is not intendcd or offered for sak (Sec. 7044, Business Re uired Ins CCL10ilS
and Peofessions Codc: The Conuacwr's License Law dacs nat apply w an awner of Q p
property who builds or improves thercon, and who dces such work himseltar �hrough his
own emplayces, providcd that such improvements are not intended or oQercd for sale. If.
however, the building or improvement is sold within one year of compledon, �he owrrcr-
builder will have the burden of proving Wat he did nat build or improvc [or purpose of
sale.).
❑ I. az awner of the propcny. am exclusively conuac�ing with licensed rnntractors w
conswct the project (Sec. 7044. Business and Professions Code:) The Conlrutur's Li-
cense Caw docs aot apply �o an owner o( propeny who 6uilds or improves Ihercon, and ,
who convac�t Cor such projec�s with a convactor(s) licensed pursuant to U�e Convactors
License Law.
' 1 am ezempt under Sec. , B dc P C for ihis reuon
,� Dale _ .
WORKER'S COMPENSA'ITON DECLARAT[ON
I hereby �tm under penalty of perjury one of the following declarations:
❑ I hsae and will maintain a Certificate of Consent lo sel!-insure for Worker's Compen-
sation, u provided for by Secdon 3700 of the Labor Code, for �he performance a[ the
work far which this pertnii is issucd.
�have and wiU maintain Workers Compensaaan insuance, ac �cquired by Scction ,,
3700 0[ the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carticr and Poliry num6cr a Q
Camer: ��'t�L'. `�n � Policy No.: � 6` �� S Y
CER'fIFICATE OF EXEMPI'ION FROM WORKERS'
COMPENSATION INSURANCE '
(This scction necd not bc complctcd i( t4e pecmit is for onc hundred dollars (S I00)
or Icss.) .
I cenify that in thc performancc of ihc wark Cor which �his pertnit is issucd, l�all not
employ any person in any manncr so as lo bccomc subjcct to the Workers' Compensa6on
Laws oC Califomie. Da�c
Applicant
NOTICE 7'O APPLICAM: If, aCtcr making ihis Ccrtificau of Excmption, you should
bccome subject w thc Worker's Compcnsation provisions of �hc Latwr Code, you muu
� O forthwiW comply with such pmvisions or this pecmil shall bc dccmcd ccvokcd.
Z "'" CONSTRUC170N LENDING AGENCY
���-+ I hcrcby a�rm that thcre is a conswcuon Icnding agcncy Cor thc perCurtnarkc uC _
�L, � �hc work Cur which ihis permit is iuued (Scc. 3097, Civ. C.)
W Q L.cndcr's Namc '
� z C.ender's Addrcss
V � I ccnify �hal 1 havc rcad Ihis application and sutc Ihat thc abovc informadun is
w � cocrcc� 1 agrce to comply wiih all city and county ontinances aad state laws relaang w
� U building conswction, and hcreby authori�e rcprcscntativcs of this city to cnicr u�n IAc
� a aM1ovc-mcntioncd property for inspcction purposes.
(Wc) agree to save, indcmnify and kecp harmless ihc Ciiy of Cupertino againsl
N � liabititiu, judgmcnts, casts and expcnscs which may in any way accruc against said City �
V z in cantequcncc oC �hc granting of this permit. D$Le �
►"� APPLICANT UNDERS7ANDS AND WILL COMPLY W1TH ALL NON-POIM Issued by: a � /
SOURCE REGULATIONS.
��s�d t'7r�2rt �Z ! o�2� � Z Re-roofs ��
�
Signa�ure of�Appli n�i Conuacwr Daic
HAZARDOUS MATERIALS DISCLOSURE Type of R� �of
Wi1t ihc applicant or futurc building occupmtstorc or handlc harardous marcrial
:fincd by the Cupertino Municipal Codc. Chaptcr 9.12, and the Health and Safcty
:. Scction 25532(a)? —! All roofs : hall be inspected prior [o any roofing material being installed.
❑ Ycs �yno
Will thc applicant or Cuwrc building occupant usc cquipmcnt or cicviccs which If a roof i: installed. without first obtaining an inspection, I agree to remove •
emi� harardaus air contaminan�s as dcGncd by the Bay Arca Air Qualiry Managcment all nevv m; iterials- for inspection.
Disvict?
❑ Ycs �Ju
1 havc rcad �he ha�ardrnu maicrials requiremcnts undcr Chap�cr 695 0( �hc Cali(or- ^�
nia Ficalih & Safct Codc. Senians 25505, 25533 and 25534. I undcrs�ind that iCtAc buildin � � �� �j q
Jocs not curtenily havc a tcnan4 �at i[ is my responsibility to rrotify thc occupant of the �j_],/ S%�t � YIhZ �'f '~� �O � L � p`
rcyuircmcn�s which must bc met prior w issuancc aC a Ccnificaic of Occupancy. � C� Date
Signat«re �f Applicant
�� �s�7� � �e � O � All roof coverings to be Class "B" or better
Owncr authori•r.cd agcnt ��� —
o� t � � � �,�
CITY OF ��UPERTINO
` '' RE1200F
CUPER�TttVO PERMIT APPL�ICATION FORM
APN # � �� � Q � � r � � Date: � � 2 U �' Q�
Building Address:
� �,
Owner's Name: Phone #:
' � s. C.yQ�) � 2�- 91
Contractor: License #:
,�e r� a r� �6� �1 �
Contact: Cupertino Business License #�
� i � �o� e ..
Type of Roof Covering:
Eatisting: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles L9�Asphalt Shingles
E�W ood Shakes ❑ W ood 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 Cu �ertino's Tear Off Policy: ❑
Job Description: 28�' ���� j S �
� o � w� � �/ ' �> 1Z�,a�w ��,��r 301b� o .� �
Residential [� Commercial ❑
Fire Zone: Yes ❑ No ��' Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Construc-tion: Occupancy grou :
� �� 2 -�
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE I31dg Permit Fees BITILDING
BENERGY Energ BUILDING
I BSEISMICRE Seismic Fee Res BIJILDI�G
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BLJILDING
BUSLIC Business License BUILDING
CITY OF CUPERTINO
3 ITEMS OF 3 PERMI':' RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl}:: Lot:
APN ......... 36�;30094.00
DATE ISSUED.......: 10,'26/2007
RECEIPT #.......... BS(100003085
REFERENCE ID # ...: 07:.00183
SITE ADDRESS .....: 75:_2 SHADOWHILL LN
SUBDIVISION .......
CITY .............. CU]'ERTINO
IMPACT AREA .......
OWNER ............: YITtd LIN & DAN MEYBERG
ADDRESS ..........: 75:_2 SHADOWHILL LN
CITY/STATE/ZIP ...: CUI�ERTINO CA 95014
RECEIVED FROM ....: SEItGIO GONZALEZ
CONTRACTOR .......: SEIZGIO GONZALEZ LIC # 25625
COMPANY ..........: ST()NERIDGE ROOFING
ADDRESS ..........: 27�18 GLENFIRTH DR
CITY/STATE/ZIP ...: SAId JOSE, CA 95133
TELEPHONE ........: (4()8)729-5101
FEE ID UNIT QUANTITY ��NlOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----------- ---------- ---------- ----------
BPERMFEE VALUATION 9,000.00 158.76 0.00 158.76 0.00
BSEISMICRE VALUATION 9,000.00 0.90 0.00 0.90 0.00
BUSLIC FLAT RATE 1.00 107.00 0.00 107.00 0.00
----------- ---------- ---------- ----------
TOTAL PERMIT : 266.66 0.00 266.66 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 266.66 #541
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TOTAL RECEIPT : 266.66