07110061 CITY OF CUPERTINO ` � :
BUS'!,DING DIYISION PERMIT ���TR�.�(?�. ���' �'����
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BUILDING ADDRESS: PERMIT NO.
7520 KIRWIN LN GROMO F'OOFING INC 07110061 .
VER'S NAME: PERhIIT ISSUE DATE
POLLOCK JEFFREY J AND BRENDA 121 W VIASHINGTON AVE #205 11/13/2007
PHONET SAMTARY NO. CONTROL NO.
(408 ) 7�:6-2075
ARCHITECtYENG1NEER: BUiLpING PERMITINFO
BLDG E[.ECf PLUMB MECH
� 0 0 �
u p � LICENSED CONTRAGTOR oECURnnoN Job Description
� � I hcreby affirm �hat I am liccnsed undcr pmvisions oC Chapur 9(commencing
z� wiih Sccdon 7000) of Division 3 of thc Business and Protcssions Code, snd my Iicensc is RMV S H� �KE , P;DD � S B 1/ 2"� 3 � S Q� 3 � L B F LT , C LA S S
�� y in fu0 force and effe�_ ; �* ��. y G L Gf A
� ? Licenac 1 L
n F Da� �/ / Conlrattnr �� �"'— �
� ARCNiTECTSDECLARATION COMP SF[INGLES
1 undcrsund my plans shall bc wcd az public �ecords
ul <
d
; �. y Liccnsed Prufcssional
: y � OWNER-BUILDER DECLARATION
I hercby affirtn Ihat 1 am excmp� Crom 1hc Cantractors Liccnac Law for thc
y p O Collowing rcuon. (Sccdon 7()31.5, Business and Profcssians Codc: Any ciry or counry
K° � which rcquiros a pertnit to consuuc4 altcr, im{xovc, dcmoiish, or �epair any auucwrc
y Z } prior to i�s iseuancc, alw icquims Wc appliean� for such permit to filc a signcd su�cmcni
_< that hc is licenscd pursuant to �hc pmvisions o( thc Conuactor's licensc Iaw (Chaptcr 9 Sq. Ft. Floor Area Valuation
� F- �(commencing wiih Section 7000) o( Division 3 of ihe Business and Profcssions Cade) or $14 0 0 0
y �.. that he ia exempt thuefrom and Ne bssis for d�e allcged exempdon. Any violadon o[
Section 7031.5 by airy applicant for a pem+it subjects ihe applicant to a civil penalty of Number Oceupaney Type
not mo�e �han five hundted dollars (5500). 3 5 9 2 3 0( i 3��
� I, u owner ot tl�e properry. a my cmployces with wages az the'v solc compensadon,
wiU do �he work md ihe s�cucture is not intended ar ollered far sale (Sec. 7044. Businesa Re uired Ins ections
snd Profesvona Code: The Contrutor's License Law dors not apply �o m owner of 9 P
property who builds or improves Ihercon, and who daes such work himseltor Uuough hia
own employces, provided �hat such improvemen�s arc not in�ended or ollered (or sale. I[.
however, the buiiding or impmvemenl ia sold within one year of compledon, ihe owner-
builder will have the burden o[ pinving lhat he did not build or imprave for puryose of
sakJ.
Q I. u owner of the property. sm esclusively contracting with licenxd rnnvactors W
wnsuuct the projea (Sec. 7044. Business and Professions Cade:) The Contnctor's Li- ,
cense I�w docs not apply w an ow�r of property who builds or impmves �henwn, and ,
who convacLS for such projects with a eonvactor(s) ticenxd pursuant w �he Convacror's
Licenae Law.
rl ! am exempt under Sec. . B� P C for this rcuon
� Date
WORKER'S COMPENSATION DECLARATION
I hemby �rm under penalty of perjury one of the following declaraGons:
❑ I hsve and will mainuin a CertiGcaee o[ Consent to xlf-insurc (or Worker's Compen-
sarion, as provided for by Secdon 3700 of �he labor Code, far the pedormance of the •
work (or which this pertnit is istucd.
❑ I havc and will muntain Worlcefs Compensation Insunnce, u mquired hy Scction
3700 of the I�bor Code, Car the pedormance of �he work for wdich �hi.i pern�it is issued.
My Worke�s Compensa�ion Insunnce carticr and Poliry numbu are:
Grtier. sT�%� �li�Ld PoliryNo.:ZPS �� r �
CEKfIF[CATE OF EXFMP7iON FROM WORKERS'
COMPENSATIONINSURANCE •
(Chis section necd irot bc completcd if tde permit is for onc hundred dollars (5100)
or Icss.) •
i cenify ihat in thc perfamanu of Ihc work for which ihis permit u issced, 1 shall not
ampioy any person in any manncr so u w bccomc mbject to �he Workcrs' Compensauon
Laws of Caiifomia Datc
AppGcam
NOTICE TO APPLICAM: If, afmr making �his CcniCw�c of Excmplion, you shoulJ
become subject to the Worlcer'� Compensation provisions of �he Labor Code, you must
� O forlhwith comply with such provisions or this permi� shall bc dcemcd revokcd.
Z ""' CONSTRUGTION LENDING AGENCY
(. �- I he�eby �rm that there is a conswctian Icnding agcncy for �hc perfortnancc u(
LYi •� ihc work Cor which Utis permit is iuued (Sce. 3097, Civ. C.)
W A Lendcr's Namc - •
a z Lcnde�s Address
() 0 I cectify �hat I have rcad �his appliution and siatc �at ihe above informauun is
w� corten. I agree to comply wi�h all city and cowry oniinances a�d sute laws relating to
0 U building conswcuon, and hereby amhori�t �eprcscntarivcs of ihis city w cntcr upnn ihc
� W ahove-mcntioned pmpcny tor inspenion purposes
a (Wc) agrce to save, indcmnify and kecp harmless �he Ciry o[ Cupertino against
„H � Iiabilitia, judgmcnts, costs and expenses which may in any way accn�c against said City
V Z in consequence o[ U�c granting of ihis permiG Date / l
■"� APPLICAM UNDERSTANDS AND WILL COMPLY WITH ALL NON-PO1M Issued by / '/ �'
SOURCE R ONS.
'�' ' �' � ��� Z— Re-roofs
Signuurea(ApplicanUContractor � Datc
HAZARDOUS MATER[ALS DISCLOSURE Type of R oof
�II thc applicant or futurc building accupant storc or handlc ha•rardous ma�cria!
lefincd by thc Cupertino Municipal Codc. Chapicr 9.12, and the Hcalth and SaCcty
�. Section 25532(a)? All roofs �hall be inspected prior to any roofing material being installed.
❑Ycs ❑No
�II thc applicant or futwc building accupant usc cyuipmcnt or Jcvices which If a roof i� installed without first obtaining an inspection, I agree to remove
emit ha•rardous air contaminants u dcfincd by the Bay Arca Air Quslity Managcmen� all new m aterials for inspeczion.
Disuict?
❑ Ycs ❑ Nu
1 havc rcad ihe he�ardous maicrials rcquiremcn�s undcrChap�cr6.95 of thc Califor- `'�-- ��� ,� ////�/� �
nia Hcal� & Safcty Cadc, Sections 25505, 25533 arid 25534. I undcrsiand ihat if ihc building ---- �
docs no� curtcnUy havc a �enan4 Uwt it is my rcsponsibility to nouCy ihe occupant nf �he
� Wns�n m� n� m�� �;a�w su�� are c�r�a� or o�N�ry. Signature of Applicant Date
�^ � � �' ��' 3 /� 7
Owncr or authori�ed agcnl o,� All roof coverings to be Class ��B ar better
. �`lll ��a�l
CITY OF C UPERTINO
�s� �I�.Q�F
CUPE�TtNC) PERMIT APPL][CATION FORM
APN # Date:
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Building Address:
cf ` Z D /� > l� liv //?/ L't/ �
Owner's Name: Phone #:
� r�� l"� �� ��'/� ���- 2sz-� s �
Contractor: License #:
G/ZOe�o /Z dI �/ivG` l il/e �Sy�Z°�
Contact: Cupertino Business License #:
�hilNClr� o
Type of Rc�of Covering:
E�cisting: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
j� Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify) �I��Jf�
Number of existing coverings ❑ Provide I.C.B.O. Report #
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu��ertino's Tear Off Policy: ❑
Job Description: � D�' 3 � 1c � �`'� 1 �z � �
�2 E tiQ v t' si/�9� � P � T v �✓ O S� �� �vs �• �� a h�v r i i i v� f - �i�� c l C�_r
Residential (� Commercial ❑
Fire Zone: Yes ❑ No �f Confirmed with Planning D�t. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
j(.� GlBp, % dz ,� — n-a 0�/ w 'G" '� -.�
Qty. if Fee Grou
Applicable Fee ID Fee Description P
BPERMFEE 131dg Permit Fees BIJILDING
BENERGY Energy BUILDING
�' BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
CITY OF CUPERTINO
2 ITEMS OF 2 PERMI�' RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: B1}:: Lot:
APN ......... 35�►23003.00
DATE ISSUED.......: 11,'13/2007
RECEIPT #.........: BS()00003215
REFERENCE ID # ...: 07:_10061
SITE ADDRESS .....: 75::0 KIRWIN LN
SUBDIVISION .......
CITY .............. CU]�ERTINO
IMPACT AREA .......
OWNER ............: POI�LOCK JEFFREY J AND BRENDA J
ADDRESS ........... 75:'.0 KIRWIN LN
CITY/STATE/ZIP ...: CU]'ERTINO CA, 95014-4337
RECEIVED FROM ....: FRi�I�TCISCO R GONZALE
CONTRACTOR .......: GOIdZALEZ, FRANCISCO LIC # 22795
COMPANY ..........: GR()MO ROOFING INC
ADDRESS ..........: 12:_ W WASHINGTON AVE #205
CITY/STATE/ZIP ...: SUIINYVALE, CA 94086
TELEPHONE ........: (41)$)746-2075
FEE ID UNIT QUANTITY ��MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 14,000.00 212.76 0.00 212.76 0.00
BSEISMICRE VALUATION 14,000.00 1.40 0.00 1.40 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 214.16 0.00 214.16 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 214.16 MC
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TOTAL RECEIPT : 214.16
Community Development
.�`� � ,
,� C pe�rtino CA 95014
:-� '�:
Telephone (408) 777-3228
CITY OF Fax (408) 777-3333
CUPEI�,TINO
Buildin De artment
JOB ADDRESS: PERMIT #�.� O � � l
7szo ,��2�. i�v z�
OWNER'S NAME: J�Ff �v Lk v C� PHONE # y��) 7YG �- Lv '7 s
GENERAL CONTRACTOR r2 D�r v .Lv e � i� c i.v � FAX #
I am not using any subcontractors:
Si gnature Date
Please check a licable subcontractors and com��lete the followin information:
SUBCONTRACTOR BUSIl`JESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
IIectrical
Excavation
Fencing
Flooring: Carpeting
Linolewn / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
� Roo� �-,�o.�� �������-�- �ti�_ �s'y� zy
Septic Tank
Sheet Metal
Sheet Rock
Tile
• ��� " _ � U �
Owner/Contractor Signature Date