15010041 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19831 LA MAR DR CONTRACTOR:CUPERTINO ROOF,INC PERMIT NO: 15010041
OWNER'S NAME:
SAN JOSE,CA 95129 PHONE NO:(408)973-9427
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
/ RE-ROOF 26 SQ;TEAR OFF SHAKES,INSTALL LIFE TIME
License Class Lic.# t� !� �p� SHINGLES CLASS A
Contractor C V Foe-+I-X9 Date /-- 11 —/
I hereby affirm that I am licensed under I provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
C5ansation,as provided for by Section 3700 of the Labor Code,for the
ance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$12000
Ind will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:36910030 00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS WOM LAST CALLED INSPECT ON.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the IN;
Date:
granting of this permit. Additionally,the applicant understands and will comply Issued by:
with - oint source regulations per the Cupertino Municipal Code,Section
9 18.
�I
CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance Witiulbe Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti n 5505,25533,and 25534. j
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9 18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 19831 lamar DATE: 01/08/2015 REVIEWED BY: Mendez
APN: BP#: *VALUATION: 1$12,000
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 SFDWLROO
WORK re-roof 26 s • tear off shakes install life time shingles class a
SCOPE
FEE ID ROOF AREA
s.f.
1REROOFFRES 2,600
� �
Wl,o Plan Che",k Phrnrh. Ilkn't C'heed: 1_/'e,% PiOn,C hs�&
Wc—h, Fee: 11,1 ih.Pe:rmi7 Fee: Istec i,e,�
C)tirn� :ale h. I sr�. Other Numb 7rrsr). E3
oilier L u l %tEsj,.
-leper. hastz f°ee: F'Itarrth hrri�. J'ec: }-lec If p
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-053 Eft. 711/13) FEE QTY/FEE MISC ITEMS
S7,af lol. P(`P"c"!
(PermJit Fee:q $442.00
t}c'rnfi7Fee:
(",oilsrtcrcia<n 71rv:
Work Without Permit? 0 Yes 0 No $0.00
I X"tfi'E'� /I{t'7,tiYdt'YIZd 17ti71 1`ees: �
Strong Motion Fee: 1BSEISMICR $1.56 Select an Administrative Item
Bldg;Stds Commission Fee: 1BCBSC $1.00
$444.56 $0.00 TOTAL FEE: $444.56
Revised: 01/06/2015